California’s Top Hospital Lobbyist Cements Influence in Covid Crisis

SACRAMENTO — As intensive care units filled and coronavirus cases surged over the holidays, Carmela Coyle invoked a World War II-era quote attributed to British Prime Minister Winston Churchill to rally her own troops: “If you’re going through hell, keep going.”

Coyle is head of the California Hospital Association, and her “troops” are the highly paid hospital executives she represents. Throughout the pandemic, as in the December memo in which she quoted Churchill, she has employed battlefield rhetoric to galvanize their massive political and financial clout.

That’s because Coyle believes hospitals are quite simply “in battle conditions” — a sentiment she has impressed upon the state’s top health care officials.

While Coyle, 60, is unknown to many Californians, she is a power player in the state Capitol, one whose profile and influence have grown in the past year. She has used her position as president and CEO of the association to lobby for the multibillion-dollar hospital industry, including asking officials to temporarily relax guidelines intended to safeguard patients and workers.

Along the way, she has been granted personal access to Gov. Gavin Newsom and other top officials, helping shape the state’s response to covid-19.

“Having spent many, many hours embedded with the Governor’s team in the state’s Office of Emergency Services, everyone is working 18-plus hours a day,” she wrote to hospital executives in March, “and the dedication to supporting what hospitals need to do their jobs is impressive.”

Though she hasn’t won every battle, Coyle has scored some big wins for the industry.

She successfully petitioned the Newsom administration to relax nurse-to-patient ratios and allow health care workers exposed to the coronavirus to continue to work — critical but contentious rule changes intended to keep hospitals staffed that were approved over union objections.

When hospitals started to fill with covid patients last summer, Newsom agreed with Coyle that hospitals could care for them while also performing moneymaking elective surgeries, which hospitals had voluntarily canceled in the spring.

Newsom invited her to a July press briefing to explain that logic to the public. At the briefing, he described Coyle as an “outstanding partner” and a leader with a “seriousness of purpose.”

“I just can’t thank her enough, more publicly than I have in the past, but I need to repeat it yet again,” Newsom said. “We’re all being put to the test, particularly our hospital system at this moment.”

That Coyle, a relative newcomer to Sacramento politics, is such an influential advocate in the Capitol comes partly with the job. She represents more than 400 hospitals that provide not just critical care, but also jobs to Californians in every corner of the state.

In the first three quarters of 2019, California’s hospitals earned about $101.7 billion in net patient revenue, according to financial data filed with the Office of Statewide Health Planning and Development. During the same time last year, they earned about $97.6 billion — representing a 4% decline — despite the loss of elective surgeries and a drop in emergency room visits early in pandemic.

The California Hospital Association is a health care heavyweight in Sacramento, along with the doctors’ lobby, the dialysis industry and others. It spent nearly $5.3 million on lobbying from Jan. 1, 2019, to Sept. 30, 2020, and $4.3 million to support state and local political campaigns, according to filings with the California secretary of state’s office.

In 2019, the association paid Coyle $1.4 million, it said.

“The hospitals are such a big player that you have to be working with them,” especially during a public health outbreak, said David Panush, a Sacramento health care policy consultant who worked in state government for 35 years.

Coyle also has the ear of Mark Ghaly, secretary of the state Health and Human Services Agency. Ghaly and Coyle have corresponded often since March — sometimes multiple times a day — by phone and email about the state’s response to the pandemic, according to emails obtained by California Healthline.

For instance, in March, Coyle shared a letter with Ghaly that she had sent to hospital executives, in which she warned them — and by extension, him — that “we are in battle conditions, and it’s all hands on deck to turn the tide.”

In other letters and emails, Coyle pressed Ghaly to allow health care workers exposed to the virus to continue working as long as they didn’t show symptoms. Newsom later issued the rule in an executive order.

“Nurses are the heartbeat of the hospital,” said Stephanie Roberson, government relations director of the California Nurses Association — whose leaders, unlike Coyle, have not been invited into the governor’s state operations center since it was activated in March. “Instead, we have someone who basically represents the opposite of nursing interests standing alongside the governor discussing the importance of public health.”

In a recent statement, Ghaly said the pandemic has required the state to work not only with hospitals but also with doctors, nurses, public health departments, nursing homes, laboratories and emergency services agencies to save lives.

“I am grateful to Carmela and our hospital partners for their tremendous work, particularly during this current surge when hospitals are overwhelmed with patients and intensive care units are filled,” Ghaly said.

It took the administration six months to direct hospitals to test health care workers for covid at least once a week after requiring nursing homes to do so — a testament, critics say, to the hospital industry’s political and economic impact.

“The association exists to increase profits for hospitals, increase the bottom line,” said Sal Rosselli, president of the National Union of Healthcare Workers. The union lobbied for the mandatory testing rule, which took effect in December. “That’s why they oppose every patient care advocacy issue, every worker issue.”

Coyle countered that hospitals have no choice but to make trade-offs while they provide crisis care. She emphasized that the hospitals’ requests for exemptions are temporary.

“If we don’t flex some of these requirements, it means that people will not get the care they need and, worse, people may die,” she said at a news conference earlier this month.

Coyle, a Minnesota native, is known for her intelligence and the expertise she has honed working on health care policy for more than 30 years.

As head of the Maryland Hospital Association for nine years before she took the California job in 2017, Coyle built a reputation as a consensus builder even as she looked out for her constituency. For instance, she cultivated relationships with Maryland’s congressional delegation and lobbied it for federal funding in 2014 to help the state’s hospitals prepare for and treat Ebola patients, most of whom were American health care workers who had contracted the virus in Africa.

“She really understood the old maxim that there’s no such thing as permanent friends or permanent enemies. There are only permanent interests,” said Stan Dorn, a senior fellow at the advocacy group Families USA, who previously served on a Maryland commission on health care costs with Coyle. “She understood that it’s good to have good relationships with everybody because you never know, day after tomorrow, who is going to be important to your cause.”

Along with her credentials comes a strong streak of determination. After Coyle graduated from Minnesota’s Carleton College with degrees in economics and Spanish literature, she worked at a Washington, D.C., flower shop until the Congressional Budget Office offered her a two-year internship. She had called to check on her application every Friday for three months.

Coyle “was raised to know” such perseverance as she grew up in a working-class family, the daughter of a Colombian immigrant father.

“Kids teased me and called me names when I was a kid, my father being dark-skinned and having a heavy accent,” Coyle said. “I was dark-skinned as well, and they just thought we were so strange.”

Laughed at for the way her father spoke, Coyle today unabashedly harnesses the power of language to sway government officials and public opinion — and to marshal her own hospital forces to lobby “with one voice.”

#SB977 would give California’s AG unprecedented decision-making authority over your health care. Tell #CAleg to support access to quality health care. #NoOnSB977

— California Hospital Association (@CalHospitals) August 31, 2020

In the waning days of last year’s legislative session, Coyle warned hospital executives of the battles before them in the Capitol: bills that would come with hefty costs to hospitals should they pass.

In the end, the industry succeeded in blocking a bill that would have made it harder for hospitals to consolidate. But they didn’t get legislative approval to delay seismic retrofits at hospitals, as they had wanted. Lawmakers also passed a bill opposed by hospitals that requires them to maintain a 45-day stockpile of personal protective equipment, which Coyle had argued was unreasonable given that it has been in short supply.

“They’re not all-powerful, but certainly they’re influential,” said state Sen. Richard Pan (D-Sacramento), who chairs the Senate Health Committee. “And during covid, they’re taking care of patients. They’re the ones saving the lives of people who are intubated.”

When Coyle readied her troops for the legislative fights, she acknowledged they weren’t going to win every battle. She borrowed another World War II quote, this time from Gen. Douglas MacArthur, to explain to hospital executives that they may need to compromise.

“In war, you win or lose, live or die,” she wrote. “And the difference is just an eyelash.”

California Healthline correspondent Angela Hart and KHN data editor Elizabeth Lucas contributed to this report.


To compile total contributions from the California Hospital Association, California Healthline analyzed filings from two committees, both controlled by the association: the California Hospitals Committee on Issues and the California Hospital Association PAC.

To assess California hospitals’ net patient revenue, California Healthline analyzed quarterly financial data reported to the Office of Statewide Health Planning and Development. We summed the “total net patient revenue” for all hospitals that filed reports in each of the first three quarters of 2019 and 2020, and excluded any that reported only sporadically (representing less than 1% of revenue).

This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.


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Vaccine Ramp-Up Squeezes Covid Testing and Tracing

This story also ran on Los Angeles Times. It can be republished for free.

California Gov. Gavin Newsom, under growing pressure to jump-start a faltering covid-19 vaccine rollout, jetted to Los Angeles on Jan. 15 to unveil a massive new vaccination site at Dodger Stadium that is expected eventually to inoculate 12,000 people a day.

The city-run venue had been the biggest covid testing site in the U.S., administering over 1 million tests in its nearly eight months of operation — and over 10,000 a day during the recent surge. Its redeployment to the cause of vaccination, Newsom declared, provides “an extraordinary world-class site for a world-class logistics operation.”

That effort came with a trade-off: When the city of Los Angeles ended covid tests at Dodger Stadium and closed another testing site to help staff the new vaccination center, it removed, at least temporarily, about one-third of all government-run testing in Los Angeles County — the nation’s largest county, with a population of 10 million, and one of the biggest covid hot spots.

Sites operated by the city, county or state account for just over one-third of all covid tests in L.A. County, said Dr. Clemens Hong, who heads the county’s testing operations.

Diminished testing capacity could lead to longer waits for appointments, which means infected people could potentially expose others for a longer time before learning they have the virus.

But L.A. Mayor Eric Garcetti said that has not happened so far. In what he called an instance of “perfect timing,” infection rates in L.A. County have declined since Dodger Stadium switched to vaccinations, and demand for tests has dropped by half to two-thirds, the mayor said Thursday. “We are meeting the need — actually exceeding the need.”

Still, he acknowledged that converting the stadium had been a risk – one the city took because “the vaccines will prevent and heal and finally resolve this.”

Many health experts agree that prioritizing vaccination over testing is the right move.

“The best way out of our current crisis is masks, few contacts per day and vaccines, so it makes sense to create lots more access points for vaccinations even if it means a bit less testing,” said Dr. Bob Kocher, a senior fellow at the University of Southern California’s Schaeffer Center for Health Policy & Economics and a former member of the state’s COVID-19 Testing Task Force.

But with covid caseloads still high despite their recent decline from peak levels, and mutant strains of the virus threatening to fuel new outbreaks, some senior public health officials say testing remains an equally vital part of the effort to contain — and ultimately suppress — the pandemic.

And it could become even more important in the coming months, as the inoculation campaign gains steam, since the tests could prove a valuable tool for assessing how well the vaccines are working.

“It’s hard to say right now, given how many people are sick with covid, that vaccine is more important,” said Hong. “It’s hard to balance those two against each other, because we really just need a lot of both.”

Balancing vaccinations with testing and other covid-related tasks is a significant challenge for public health officials across California and the nation, because those functions draw on many of the same resources — especially the staff needed for administration and record-keeping.

At vaccination sites, keeping good records is essential for planning from day to day how many doses to pull out of the freezer. “It’s got to be done right, or else you screw up when the second dose is,” said Dr. George Rutherford, an epidemiologist at the University of California-San Francisco.

Sara Bosse, public health director of Madera County, noted that counties across the state have asked Newsom for $400 million in the current budget year to help defray the costs of setting up vaccination sites, including facility costs, security, data entry staffers and clinicians to give the shots and watch for adverse side effects. They are also seeking $280 million for covid testing and $440 million for contact tracing and non-group housing to protect covid-vulnerable residents.

“I think that many counties are prioritizing vaccination, and based on the resources they have, they may pull from various parts of the covid response such as contact tracing or testing,” Bosse said. The funding, she said, would help county health officials avoid “those difficult decisions where we have to pull from one part of the covid response to prop up the next.”

There could also be federal help on the way: President Joe Biden has announced plans to establish 100 federally supported vaccination centers and allocate $50 billion to expand testing.

In Madera County, a poor rural area of 160,000 people that stretches from the Central Valley into the Sierra Nevada, the state has largely taken over covid testing, allowing the county to focus its resources on vaccinations, Bosse said.

The big challenge on that front, she said, is having enough trained health personnel to run the vaccination sites. The county recently heard from 85 trained clinicians willing to volunteer for the vaccine effort, “which is going to be a game changer for us,” Bosse said.

In Los Angeles, the city has the means to add testing capacity elsewhere and beef up mobile testing, Garcetti said. It had been considering a testing site at Pierce College in the San Fernando Valley, “which it looks like we won’t need to open,” the mayor said.

The city, county and state are also discussing the possibility of a partnership to expand testing at Exposition Park in South L.A.

In San Diego County, health officials expect to face a challenge due to the competition for staffing between vaccination and testing, and they are hiring to meet the need, said Sarah Sweeney, a spokesperson for the county’s Health and Human Services Agency. The county hasn’t yet converted testing venues to vaccination sites but expects to do so after vaccine supplies increase, she said.

San Bernardino County health officials are committed to maintaining testing at current volumes even as they ramp up vaccinations, said Corwin Porter, the director of public health. But he conceded that doing both at the same time “is a struggle” because “we don’t have enough vaccine and we don’t have enough staff.”

The county is holding hiring events every week and working with multiple partners to find additional resources, “because we are trying not to pull anything out of testing or contact tracing,” Porter said.

Beyond the resource question, another big challenge confronts health officials: “There is an issue of divided attention,” said L.A. County’s Hong. “Now we have two big things to deal with — three if you include contact tracing. I think we will have to be thoughtful about our strategy.”

Once a broad swath of the population has been vaccinated, which could take many months, testing volume will likely drop off sharply, said UCSF’s Rutherford.

“I don’t see hundreds of thousands of tests a day anymore once we get well up on vaccinations,” he said. “You’ll be testing thousands of people to find tens of cases.”

In the meantime, L.A. County will likely add questions to its testing appointment website asking people about their vaccination status, Hong said. “That way we can track what’s happening in people who are vaccinated.”

Ongoing covid outbreaks may require increased testing, particularly in poorer communities of color, which have been hit hardest by the pandemic — and where hesitancy to be vaccinated is likely to be more widespread, said Hong. “So the bottom line is that testing is not going away.”

This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.


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Trump’s Pardons Included Health Care Execs Behind Massive Frauds

At the last minute, President Donald Trump granted pardons to several individuals convicted in huge Medicare swindles that prosecutors alleged often harmed or endangered elderly and infirm patients while fleecing taxpayers.

“These aren’t just technical financial crimes. These were major, major crimes,” said Louis Saccoccio, chief executive officer of the National Health Care Anti-Fraud Association, an advocacy group.

The list of some 200 Trump pardons or commutations, most issued as he vacated the White House this week, included at least seven doctors or health care entrepreneurs who ran discredited health care enterprises, from nursing homes to pain clinics. One is a former doctor and California hospital owner embroiled in a massive workers’ compensation kickback scheme that prosecutors alleged prompted more than 14,000 dubious spinal surgeries. Another was in prison after prosecutors accused him of ripping off more than $1 billion from Medicare and Medicaid through nursing homes and other senior care facilities, among the largest frauds in U.S. history.

“All of us are shaking our heads with these insurance fraud criminals just walking free,” said Matthew Smith, executive director of the Coalition Against Insurance Fraud. The White House argued all deserved a second chance. One man was said to have devoted himself to prayer, while another planned to resume charity work or other community service. Others won clemency at the request of prominent Republican ex-attorneys general or others who argued their crimes were victimless or said critical errors by prosecutors had led to improper convictions.

Trump commuted the sentence of former nursing home magnate Philip Esformes in late December. He was serving a 20-year sentence for bilking $1 billion from Medicare and Medicaid. An FBI agent called him “a man driven by almost unbounded greed.” Prosecutors said that Esformes used proceeds from his crimes to make a series of “extravagant purchases, including luxury automobiles and a $360,000 watch.”

Esformes also bribed the basketball coach at the University of Pennsylvania “in exchange for his assistance in gaining admission for his son into the university,” according to prosecutors.

Fraud investigators had cheered the conviction. In 2019, the National Health Care Anti-Fraud Association gave its annual award to the team responsible for making the case. Saccoccio said that such cases are complex and that investigators sometimes spend years and put their “heart and soul” into them. “They get a conviction and then they see this happen. It has to be somewhat demoralizing.”

Tim McCormack, a Maine lawyer who represented a whistleblower in a 2007 kickback case involving Esformes, said these cases “are not just about stealing money.”

“This is about betraying their duty to their patients. This is about using their vulnerable, sick and trusting patients as an ATM to line their already rich pockets,” he said. He added: “These pardons send the message that if you are rich and connected and powerful enough, then you are above the law.”

The Trump White House saw things much differently.

“While in prison, Mr. Esformes, who is 52, has been devoted to prayer and repentance and is in declining health,” the White House pardon statement said.

The White House said the action was backed by former Attorneys General Edwin Meese and Michael Mukasey, while Ken Starr, one of Trump’s lawyers in his first impeachment trial, filed briefs in support of his appeal claiming prosecutorial misconduct related to violating attorney-client privilege.

Trump also commuted the sentence of Salomon Melgen, a Florida eye doctor who had served four years in federal prison for fraud. That case also ensnared U.S. Sen. Robert Menendez (D-N.J.), who was acquitted in the case and helped seek the action for his friend, according to the White House.

Prosecutors had accused Melgen of endangering patients with needless injections to treat macular degeneration and other unnecessary medical care, describing his actions as “truly horrific” and “barbaric and inhumane,” according to a court filing.

Melgen “not only defrauded the Medicare program of tens of millions of dollars, but he abused his patients — who were elderly, infirm, and often disabled — in the process,” prosecutors wrote.

Prosecutors said the scheme raked in “a staggering amount of money.” Between 2008 and 2013, Medicare paid the solo practitioner about $100 million. He took in an additional $10 million from Medicaid, the government health care program for low-income people, $62 million from private insurance, and approximately $3 million in patients’ payments, prosecutors said.

In commuting Melgen’s sentence, Trump cited support from Menendez and U.S. Rep. Mario Diaz-Balart (R-Fla.). “Numerous patients and friends testify to his generosity in treating all patients, especially those unable to pay or unable to afford healthcare insurance,” the statement said.

In a statement, Melgen, 66, thanked Trump and said his decision ended “a serious miscarriage of justice.”

“Throughout this ordeal, I have come to realize the very deep flaws in our justice system and how people are at the complete mercy of prosecutors and judges. As of today, I am committed to fighting for unjustly incarcerated people,” Melgen said. He denied harming any patients.

Faustino Bernadett, a former California anesthesiologist and hospital owner, received a full pardon. He had been sentenced to 15 months in prison in connection with a scheme that paid kickbacks to doctors for admitting patients to Pacific Hospital of Long Beach for spinal surgery and other treatments.

“As a physician himself, defendant knew that exchanging thousands of dollars in kickbacks in return for spinal surgery services was illegal and unethical,” prosecutors wrote.

Many of the spinal surgery patients “were injured workers covered by workers’ compensation insurance. Those patient-victims were often blue-collar workers who were especially vulnerable as a result of their injuries,” according to prosecutors.

The White House said the conviction “was the only major blemish” on the doctor’s record. While Bernadett failed to report the kickback scheme, “he was not part of the underlying scheme itself,” according to the White House.

The White House also said Bernadett was involved in numerous charitable activities, including “helping protect his community from COVID-19.” “President Trump determined that it is in the interests of justice and Dr. Bernadett’s community that he may continue his volunteer and charitable work,” the White House statement read.

Others who received pardons or commutations included Sholam Weiss, who was said to have been issued the longest sentence ever for a white collar crime — 835 years. “Mr. Weiss was convicted of racketeering, wire fraud, money laundering, and obstruction of justice, for which he has already served over 18 years and paid substantial restitution. He is 66 years old and suffers from chronic health conditions,” according to the White House.

John Davis, the former CEO of Comprehensive Pain Specialists, the Tennessee-based chain of pain management clinics, had spent four months in prison. Federal prosecutors charged Davis with accepting more than $750,000 in illegal bribes and kickbacks in a scheme that billed Medicare $4.6 million for durable medical equipment.

Trump’s pardon statement cited support from country singer Luke Bryan, said to be a friend of Davis’.

These treatments “involved sticking needles in their eyes, burning their retinas with a laser, and injecting dyes into their bloodstream.”

“Notably, no one suffered financially as a result of his crime and he has no other criminal record,” the White House statement reads.

“Prior to his conviction, Mr. Davis was well known in his community as an active supporter of local charities. He is described as hardworking and deeply committed to his family and country. Mr. Davis and his wife have been married for 15 years, and he is the father of three young children.”

CPS was the subject of a November 2017 investigation by KHN that scrutinized its Medicare billings for urine drug testing. Medicare paid the company at least $11 million for urine screenings and related tests in 2014, when five of CPS’ medical professionals stood among the nation’s top such Medicare billers.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.


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California Is Overriding Its Limits on Nurse Workloads as Covid Surges

This story is from a reporting partnership that includes KQED, NPR and KHN. It can be republished for free.

California’s telemetry nurses, who specialize in the electronic monitoring of critically ill patients, normally take care of four patients at once. But ever since the state relaxed California’s mandatory nurse-to-patient ratios in mid-December, Nerissa Black has had to keep track of six.

And these six patients are really sick: Many of them are being treated simultaneously for a stroke and covid-19, or a heart attack and covid. With more patients than usual needing more complex care, Black said she’s worried she’ll miss something or make a mistake.

“We are given 50% more patients and we’re expected to do 50% more things with the same amount of time,” said Black, who has worked at the Henry Mayo Newhall Hospital in Valencia, California, for seven years. “I go home and I feel like I could have done more. I don’t feel like I’m giving the care to my patients like a human being deserves.”

As covid patients continue to flood California emergency rooms, hospitals are increasingly desperate to find enough staffers to care for them all. The state is asking nurses to tend to more patients simultaneously than they typically would, watering down what many nurses and their unions consider their most sacrosanct job protection: a law existing only in California that puts legal restrictions on the nurse-to-patient ratio.

“We need to temporarily — very short-term, temporarily — look a little bit differently in terms of our staffing needs,” said Gov. Gavin Newsom, after he quietly allowed hospitals to adjust their nurse-to-patient ratios on Dec. 11. Usually, California law requires a hospital to first get approval from the state before tinkering with those ratios; Newsom’s move gave hospitals presumptive approval to work outside the ratio rules immediately.

Since then, 188 hospitals, mainly in Southern California, have been operating under the new pandemic ratios: They can require ICU nurses to care for three patients instead of two. Emergency room and telemetry nurses may now be asked to care for six patients instead of four. Medical-surgical nurses are looking after seven patients instead of five.

Nurses have taken to the streets in protest, holding physically distanced demonstrations across the state, shouting and carrying posters that read: “Ratios Save Lives.” The union, the California Nurses Association, says the staffing shortage is a result of bad hospital management, of taking a reactive approach to staffing rather than proactive — laying nurses off over the summer, then not hiring or training enough for winter.

“What we’re seeing in these hospitals is their just-in-time response to a pandemic that they never prepared for — just-in-time staffing, just-in-time resources, not staffing up, calling nurses in on a shift at the very last minute — to boost profits,” said Stephanie Roberson, government relations director for the California Nurses Association. “And we’re seeing how nurses are being stretched even thinner.”

But hospitals say this is an unprecedented crisis that has spiraled beyond their control. In the current surge, four times as many Californians are testing positive for the coronavirus compared with the summer’s peak. As many as 7,000 new patients could soon be coming to California hospitals every day, according to Carmela Coyle, who heads the California Hospital Association.

“This is catastrophic and we cannot dodge this math,” she said. “We are simply out of nurses, out of doctors, out of respiratory therapists.”

The state has asked the federal government for staff, including 200 medical personnel from the Department of Defense, and it’s tried to reactivate the California Health Corps, an initiative to recruit retired health workers to come back to work. But that has yielded few people with the qualifications needed to care for hospitalized covid patients.

Hiring contract nurses from temporary staffing agencies or other states is all but impossible right now, Coyle said.

“Because California surged early during the summer and other parts of the United States then surged afterward,” she said, “those travel nurses are taken.

The next step for hospitals is to try “team nursing,” Coyle said — pulling nurses from other departments, like the operating room, for example, and partnering them with experienced critical care nurses to help care for covid patients.

Joanne Spetz, an economics professor who studies health care workforce issues at the University of California-San Francisco, said hospitals should have started training nurses for team care over the summer, in anticipation of a winter surge, but they didn’t, either because of costs — hospitals lost a lot of revenue from canceled elective surgeries that could have paid for that training — or because of excessive optimism.

California was doing so well,” she said. “It was easy for all of us to believe that we kind of got it under control, and I think there was a lot of belief that we would be able to maintain that.”

The California Nurses Association has good reason to be defensive regarding the integrity of the patient-ratio law, Spetz said. It took 10 years of lobbying and activism before the bill passed the state legislature in 1999, then several more years to overcome multiple court challenges, including one from then-Gov. Arnold Schwarzenegger.

“I’m always kicking their butt, that’s why they don’t like me,” Schwarzenegger famously said of nurses, drawing broad ire from the nurses union and its allies.

Nurses prevailed in the court of public opinion and in law; rules that put a legal cap on the number of patients per nurse finally took effect in 2004. But the long battle made nurses fiercely protective of their win. They’ve even accused hospitals of using the pandemic to try to roll back ratios for good.

“This is the exercise of disaster capitalism at its finest, where [hospital administrators] are completely maximizing their opportunity to take advantage of this crisis,” Roberson said.

Hospitals deny they want to change the ratio law permanently, and Spetz said it’s unlikely they’d succeed if they tried. The public can see that nurses are overworked and burned out by the pandemic, she said, so there would be little support for cutting back their job protections once it’s over.

“To go in and say, ‘Oh, you clearly did so well without ratios when we let you waive them, so let’s just eliminate them entirely,’ I think, would be just adding insult to moral injury,” Spetz said.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.


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CVS and Walgreens Under Fire for Slow Pace of Vaccination in Nursing Homes

The effort to vaccinate some of the country’s most vulnerable residents against covid-19 has been slowed by a federal program that sends retail pharmacists into nursing homes — accompanied by layers of bureaucracy and logistical snafus.

As of Thursday, more than 4.7 million doses of the Pfizer-BioNTech and Moderna covid vaccines had been allocated to the federal pharmacy partnership, which has deputized pharmacy teams from Walgreens and CVS to vaccinate nursing home residents and workers. Since the program started in some states on Dec. 21, however, they have administered about one-quarter of the doses, according to the Centers for Disease Control and Prevention.

Across the country, some nursing home directors and health care officials say the partnership is actually hampering the vaccination process by imposing paperwork and cumbersome corporate policies on facilities that are thinly staffed and reeling from the devastating effects of the coronavirus. They argue that nursing homes are unique medical facilities that would be better served by medical workers who already understand how they operate.

Mississippi’s state health officer, Dr. Thomas Dobbs, said the partnership “has been a fiasco.”

The state has committed 90,000 vaccine doses to the effort, but the pharmacies had administered only 5% of those shots as of Thursday, Dobbs said. Pharmacy officials told him they’re having trouble finding enough people to staff the program.

Dobbs pointed to neighboring Alabama and Louisiana, which he says are vaccinating long-term care residents at four times the rate of Mississippi.

“We’re getting a lot of angry people because it’s going so slowly, and we’re unhappy too,” he said.

Many of the nursing homes that have successfully vaccinated willing residents and staff members are doing so without federal help.

For instance, Los Angeles Jewish Home, with roughly 1,650 staff members and 1,100 residents on four campuses, started vaccinating Dec. 30. By Jan. 11, the home’s medical staff had administered its 1,640th dose. Even the facility’s chief medical director, Noah Marco, helped vaccinate.

The home is in Los Angeles County, which declined to participate in the CVS/Walgreens program. Instead, it has tasked nursing homes with administering vaccines themselves, and is using only Moderna’s easier-to-handle product, which doesn’t need to be stored at ultracold temperatures, like the Pfizer vaccine. (Both vaccines require two doses to offer full protection, spaced 21 to 28 days apart.)

By contrast, Mariner Health Central, which operates 20 nursing homes in California, is relying on the federal partnership for its homes outside of L.A. County. One of them won’t be getting its first doses until next week.

“It’s been so much worse than anybody expected,” said the chain’s chief medical officer, Dr. Karl Steinberg. “That light at the end of the tunnel is dim.”

Nursing homes have experienced some of the worst outbreaks of the pandemic. Though they house less than 1% of the nation’s population, nursing homes have accounted for 37% of deaths, according to the COVID Tracking Project.

Facilities participating in the federal partnership typically schedule three vaccine clinics over the course of nine to 12 weeks. Ideally, those who are eligible and want a vaccine will get the first dose at the first clinic and the second dose three to four weeks later. The third clinic is considered a makeup day for anyone who missed the others. Before administering the vaccines, the pharmacies require the nursing homes to obtain consent from residents and staffers.

Despite the complaints of a slow rollout, CVS and Walgreens said they’re on track to finish giving the first doses by Jan. 25, as promised.

“Everything has gone as planned, save for a few instances where we’ve been challenged or had difficulties making contact with long-term care facilities to schedule clinics,” said Joe Goode, a spokesperson for CVS Health.

Dr. Marcus Plescia, chief medical officer at the Association of State and Territorial Health Officials, acknowledged some delays through the partnership, but said that’s to be expected because this kind of effort has never before been attempted.

“There’s a feeling they’ll get up to speed with it and it will be helpful, as health departments are pretty overstretched,” Plescia said.

But any delay puts lives at risk, said Dr. Michael Wasserman, the immediate past president of the California Association of Long Term Care Medicine.

“I’m about to go nuclear on this,” he said. “There should never be an excuse about people not getting vaccinated. There’s no excuse for delays.”

Bringing in Vaccinators

Nursing homes are equipped with resources that could have helped the vaccination effort — but often aren’t being used.

Most already work with specialized pharmacists who understand the needs of nursing homes and administer medications and yearly vaccinations. These pharmacists know the patients and their medical histories, and are familiar with the apparatus of nursing homes, said Linda Taetz, chief compliance officer for Mariner Health Central.

“It’s not that they aren’t capable,” Taetz said of the retail pharmacists. “They just aren’t embedded in our buildings.”

If a facility participates in the federal program, it can’t use these or any other pharmacists or staffers to vaccinate, said Nicole Howell, executive director for Ombudsman Services of Contra Costa, Solano and Alameda counties.

But many nursing homes would like the flexibility to do so because they believe it would speed the process, help build trust and get more people to say yes to the vaccine, she said.

Howell pointed to West Virginia, which relied primarily on local, independent pharmacies instead of the federal program to vaccinate its nursing home residents.

The state opted against the partnership largely because CVS/Walgreens would have taken weeks to begin shots and Republican Gov. Jim Justice wanted them to start immediately, said Marty Wright, CEO of the West Virginia Health Care Association, which represents the state’s long-term care facilities.

The bulk of the work is being done by more than 60 pharmacies, giving the state greater control over how the doses were distributed, Wright said. The pharmacies were joined by Walgreens in the second week, he said, though not as part of the federal partnership.

“We had more interest from local pharmacies than facilities we could partner them up with,” Wright said. Preliminary estimates show that more than 80% of residents and 60% of staffers in more than 200 homes got a first dose by the end of December, he said.

Goode from CVS said his company’s participation in the program is being led by its long-term care division, which has deep experience with nursing homes. He noted that tens of thousands of nursing homes — about 85% nationally, according to the CDC — have found that reassuring enough to participate.

“That underscores the trust the long-term care community has in CVS and Walgreens,” he said.

Vaccine recipients don’t pay anything out-of-pocket for the shots. The costs of purchasing and administering them are covered by the federal government and health insurance, which means CVS and Walgreens stand to make a lot of money: Medicare is reimbursing $16.94 for the first shot and $28.39 for the second.

Bureaucratic Delays

Technically, federal law doesn’t require nursing homes to obtain written consent for vaccinations.

But CVS and Walgreens require them to get verbal or written consent from residents or family members, which must be documented on forms supplied by the pharmacies.

Goode said consent hasn’t been an impediment so far, but many people on the ground disagree. The requirements have slowed the process as nursing homes collect paper forms and Medicare numbers from residents, said Tracy Greene Mintz, a social worker who owns Senior Care Training, which trains and deploys social workers in more than 100 facilities around California.

In some cases, social workers have mailed paper consent forms to families and waited to get them back, she said.

“The facilities are busy trying to keep residents alive,” Greene Mintz said. “If you want to get paid from Medicare, do your own paperwork,” she suggested to CVS and Walgreens.

Scheduling has also been a challenge for some nursing homes, partly because people who are actively sick with covid shouldn’t be vaccinated, the CDC advises.

“If something comes up — say, an entire building becomes covid-positive — you don’t want the pharmacists coming because nobody is going to get the vaccine,” said Taetz of Mariner Health.

Both pharmacy companies say they work with facilities to reschedule when necessary. That happened at Windsor Chico Creek Care and Rehabilitation in Chico, California, where a clinic was pushed back a day because the facility was awaiting covid test results for residents. Melissa Cabrera, who manages the facility’s infection control, described the process as streamlined and professional.

In Illinois, about 12,000 of the state’s roughly 55,000 nursing home residents had received their first dose by Sunday, mostly through the CVS/Walgreens partnership, said Matt Hartman, executive director of the Illinois Health Care Association.

While Hartman hopes the pharmacies will finish administering the first round by the end of the month, he noted that there’s a lot of “headache” around scheduling the clinics, especially when homes have outbreaks.

“Are we happy that we haven’t gotten through round one and West Virginia is done?” he asked. “Absolutely not.”

KHN correspondent Rachana Pradhan contributed to this report.

This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.


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Journalists Examine How Covid Polarizes Communities

California Healthline senior correspondent Anna Maria Barry-Jester discussed public health backlash on WABE’s “Did You Wash Your Hands?” on Jan. 5.

KHN Colorado correspondent Rae Ellen Bichell dissected how covid-19 exacerbates tensions between counties in Colorado on NPR’s “Weekend Edition” on Jan. 9.

KHN chief Washington correspondent Julie Rovner talked about mental health care and the pandemic on WAMU/NPR’s “1A” on Jan. 11.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.


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In Search of a Baby, I Got Covid Instead

As a health care journalist in Los Angeles reporting on the pandemic, I knew exactly what I needed to do once I landed in the hospital with covid pneumonia: write my goodbye emails.

I’d seen coverage of some final covid messages during this terrible year. They were usually directed to spouses, but my No. 1 concern was how to explain my own death to my 3-year-old, Marigold, whom we call “Goldie.” How much of me would she remember, and how would she make peace with what happened to me, when I could barely believe it myself?

After the emergency room doctor confirmed pneumonia in both of my lungs on Dec. 17, I was whisked upstairs to the hospital’s covid unit, where I got a blood thinner injection, infusions of steroids and remdesivir, and continued on the supplemental oxygen they had started in the ER.

Immediately after the treatments, my mind was clearer and more focused than it had been in the nine days since my husband, daughter and I had all received positive covid results (and when my raging fevers began). As I lay in my hospital bed, my roommate’s TV blaring, I started thinking about my daughter’s understanding of death. A lapsed evangelical married to a Jewish man, I had adopted his family’s perspective on the afterlife — that discussing it wasn’t very important — but had also inadvertently abdicated the death discussion to Hollywood.

Goldie’s afterlife education began with the movie “Coco,” about the Mexican Day of the Dead, in which families put pictures of their ancestors on a home altar, or ofrenda. Then came “Over the Moon,” in 2020, about a little girl in China who loses her mom to illness and struggles to accept a new stepmother, all while her mom’s spirit visits her in the form of a crane.

That prompted her first question about my death.

“Are you going to die like Fei Fei’s mom did?” Goldie asked me in November, before I got sick. I told her at the time that no one knows when they’re going to die, but that I would love her with all of my heart for as long as I lived.

After that, Goldie would sometimes randomly declare, “I don’t think you’re going to die,” or she would ask if we could all die together, at the same time — to which I’d say, “Sure!”

My covid symptoms started Dec. 7, and we got our positive results back the next morning. Thankfully, my husband and daughter had almost no symptoms except stuffy noses and a day of low fever. But I started off with a fever that would burn me up to 104 degrees, over and over again. Tylenol and Advil could bring it down only to 100 or 101. I would cry as the painful fevers reached their peak and wondered if God had been preparing Goldie all along this year for my eventual death.

My breathing problems began eight days later. The scariest moment during that time was when I was in the middle of a shower (much needed after days of sweaty fevers) and realized I was gasping for air. I punched the shower curtains out of my way and ran to my bed, where I could lie on my stomach and get my oxygen levels up again. As I lay there, hyperventilating, soaking wet, with shampoo still in my hair, the pulse oximeter monitor registered 67, before inching back up to 92. I began thinking of what I wanted to say to Goldie in my final letter to her, but I was too weak to type it out.

Two more uterine procedures led to a successful embryo transfer, but a miscarriage put me in the ER on Oct. 8. By then, Los Angeles County had seen 278,665 cases and 6,726 deaths — horrifying numbers that I monitored and reported on as a health journalist, but data points I couldn’t, or wouldn’t, use to alter the decision-making in my own life.

With four miscarriages now under my belt and no more viable embryos left to use, my husband, Simon, and I decided we’d give in vitro fertilization one final try. I started my injections for an egg retrieval in late November, and by the time the procedure rolled around on Dec. 3, L.A. was well into its scary, almost vertical holiday season ascent, posting 7,854 new cases that day — up fivefold from a month earlier.

A close friend was supposed to start her IVF injections at the same time, but she decided to postpone at the last minute because covid cases were so high in our area. By that point, we were so driven in our pursuing of pregnancy that I was startled to hear her say that, as the thought had never even crossed my mind.

I have no way of knowing for sure if I was exposed to the virus sometime during this last fertility treatment. The surgical center is located on a large medical campus that also hosts a covid-19 testing drive-thru in the garage where we parked. We waited, masks on, for almost an hour outside the building, which we thought was a safer choice than the fertility clinic waiting room, but that actually put us in proximity to a lot of sick people waiting for rides home.

I also had to remove my mask just before the actual egg retrieval, because I was under anesthesia and the doctors needed quick access to my mouth in case I needed a breathing tube.

Five days after the egg retrieval, we found out we were covid-positive. I called the clinic right away to warn them; the fertility doctor told me a few days later that none of her staffers had gotten sick. And also that none of the eggs they retrieved from me had developed properly. We had no embryos to use.

Of course, as anyone who has done fertility treatments knows, all the dangers and risks we undertook would have been “worth it” if it had worked. Because it didn’t work for us, I felt defeated and foolish.

In sum, we wanted to give Goldie a sibling, but attempting to do so may have been what threatened her mother’s life. This thought haunts me and will stay with me forever, even though I’ll never know how exactly the virus entered our home.

Our nanny, who also experienced covid symptoms and tested positive three days before us, could have picked it up at the supermarket. We could have gotten it from her or while walking around our neighborhood or playing in the park. But the act of choosing, over and over again, to engage in fertility treatments as the pandemic raged on, fills me with doubt and remorse.

This was all too much to put in my goodbye letter to Goldie. Instead, this is some of what I wrote:

Around Halloween, you and I were eating breakfast together and I asked you how your life was going, and if there were any improvements I could make for you. You said, with absolute seriousness, “I’m afraid of ghosts.”

Now that I’m a ghost, I hope there’s less reason to be afraid.

Please put my picture on the ofrenda once a year. I’ll always be in your heart and in your memories. I will try to visit you too. But not in a spooky way, just a gentle way.

I will always love you. Thank you so much for being born to us. You made everything better.

After finishing my goodbye letter, I went to sleep. In the morning, I woke up, got a second infusion of steroids and remdesivir, and then was released home with oxygen tanks and an oxygen concentrator. I stayed in bed, on oxygen, for another week before my lungs were strong enough for me to stand and walk on my own. We had a wonderful Christmas morning together opening presents during a Zoom call with my family. Other than fatigue, I am now almost back to normal.

After the holidays, I sat down with Goldie for breakfast as we usually do. Feeling morose about how the year had turned out, I asked, dreading her response, if she would like to have a baby brother or sister one day.

She put her hand on my neck and pressed her forehead into mine, a face-to-face embrace that we call a “pumpkin hug.”

“No, Mom,” she said. “I want it to be just you and me, forever.”

I took a deep breath, and then sighed with relief.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.


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California Counties ‘Flying the Plane as We Build It’ in a Plodding Vaccine Rollout


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In these first lumbering weeks of the largest vaccination campaign in U.S. history, Dr. Julie Vaishampayan has had a battlefront view of a daunting logistical operation.

Vaishampayan is the health officer in Stanislaus County, an almond-growing mecca in California’s Central Valley that has recorded about 40,000 cases of covid-19 and lost 700 people to the illness. Her charge is to see that potentially lifesaving covid shots make it into the arms of 550,000 residents.

And like her dozens of counterparts across the state, she is improvising as she goes.

From week to week, Vaishampayan has no idea how many new doses of covid vaccines will be delivered until just days before they arrive, complicating advance planning for mass inoculation clinics. The inoculation clinics themselves can be a bureaucratic slog, as county staffers verify the identities and occupations of people coming in for shots to ensure strict compliance with the state’s multitiered hierarchy of eligibility. In these early days, the county also has provided vaccines to some area hospitals so they can inoculate health care workers, but the state system for tracking whether and how those doses are administered has proven clumsy.

With relatively little help from the federal government, each state has built its own vaccination rollout plan. In California, where public health is largely a county-level operation, the same departments managing testing and contact tracing for an out-of-control epidemic are leading the effort. That puts an already beleaguered workforce at the helm of yet another time-consuming undertaking. A lack of resources and limited planning by the federal and state governments have made it that much harder to get operations up and running.

“We are flying the plane as we are building it,” said Jason Hoppin, a spokesperson for Santa Cruz County. ”All of these logistical pieces are just a huge puzzle to work out.”

It’s a massive enterprise. Counties must figure out who falls where in the state’s multitiered system for eligibility, locate vaccination sites, hire vaccinators, notify workforce groups when they are eligible, schedule appointments, verify identities, then track distribution and immunizations administered.

Some of that burden has been eased by a federal program that is contracting with major pharmacies Walgreens and CVS to vaccinate people living in nursing homes and long-term care facilities, as well as a California mechanism that allows some large multicounty health care providers to order vaccines directly. As of this week, some smaller clinics and doctors’ offices also can get vaccine directly from the state.

But much of the job falls on health departments, the only entities required by law to protect the health of every Californian. And they are doing it amid pressures from the state to prevent people from skipping the line and a public eager to know why the rollout isn’t happening faster.

As of Monday, only a third of the nearly 2.5 million doses allocated to California counties and health systems had been administered, according to the most recent state data available. Gov. Gavin Newsom has acknowledged the rollout has “gone too slowly.” Health directors counter it’s the best that could be expected given the short planning timeline, limited vaccine available and other strictures.

“I would not call this rollout slow,” said Kat DeBurgh, executive director of the Health Officers Association of California. “This isn’t the same as a flu vaccine clinic where all you have to do is roll up your sleeve and someone gives you a shot.”

It has been one month since the first vaccines arrived in California, and just over five weeks since the state first outlined priority groups for vaccinations, then passed the ball to counties to devise ways to execute the plan.

Like most states, California opened its rollout with strict rules about the order of distribution. The first phase prioritized nursing home residents and hospital staffs before expanding to other broad categories of health care workers. In the weeks after the vaccines first arrived, state officials made clear that providers could be penalized if they gave vaccinations to people not in those initial priority groups.

Multiple counties said there had been little in the way of line-skipping, but stray reports in the media or complaints sent directly to community officials need to be chased down, wasting precious public health resources. The same goes for reports of vaccine doses being thrown away. One of the vaccines in circulation, once removed from ultra-cold storage, must be used within five days or discarded.

State officials have since loosened their rules, telling counties and providers to do their best to adhere to the tiers, but not to waste doses. On Jan. 7, California officials told counties they could vaccinate anyone in “phase 1a,” expanding beyond the first priority group of nursing homes and hospitals to nearly everyone in a health-related job. Once that wide-ranging category is finished, counties were supposed to move to “phase 1b,” which unfolds with its own set of tiers, starting with people 75 and older, educators, child care workers, providers of emergency services, and food and agricultural workers before expanding to all people 65 and older.

Mariposa and San Francisco both said they would be vaccinating people in the first 1b categories this week. That means residents will start seeing inequities among counties, said DeBurgh, noting that some counties had not yet received enough vaccine doses to cover health care workers while others are nearly finished. Stanislaus County, for example, had received approximately 16,000 first doses as of Jan. 9, but estimates it has between 35,000 and 40,000 health care workers phase 1a.

And the orders are changing yet again, forcing counties to pivot. On Tuesday, U.S. Health and Human Services Secretary Alex Azar said the Trump administration would begin releasing more of its vaccine supply, holding onto fewer vials for second doses; and he encouraged states to open up vaccinations to everyone age 65 and older. In response, California officials said Wednesday that once counties are done with phase 1a, people 65 and older are in the next group eligible for vaccines.

Some local health directors expressed dismay at the prospect, saying they welcome the influx of vaccines but need to prioritize people 75 and older who represent the bulk of hospitalizations. They also noted that states already offering broader access have had their own challenges, including flooded health department phone lines, crashed websites and fragile seniors camping out overnight in hopes of securing their place in line.

While sensible in theory, California’s phased approach to the rollout has proved cumbersome when it comes to verifying that people showing up for shots fall under the umbrella groups deemed eligible. In Stanislaus, for example, 6,600 people qualify as in-home support workers. Someone from another county department has to sit with health department staffers to verify their eligibility, since the health department doesn’t have access to official data on who is a qualified member of the group.

Complicating matters, about half the county’s in-home workers are caring for a family member, and many are bringing that person with them to get vaccinated. The county is required to turn those family members away if they don’t meet the eligibility criteria, Vaishampayan said.

A range of other hiccups hampered the rollout. Across the state, uptake of vaccination slowed to a crawl from Christmas to New Year’s. Health workers, particularly those who do not work in hospitals, were on vacation and enjoying a few days off with family after a tough year, several county officials said. Many chose not to get vaccinated during that time.

Others are choosing not to get vaccinated at all. Across the state, health care workers are declining vaccinations in large numbers. The health officer for Riverside County has said 50% of hospital workers there have declined the vaccine.

And in Los Angeles and Sonoma, officials described software challenges that prevented them from quickly enrolling doctors’ offices to receive vaccines and perform injections.

Still, statewide, officials said they were confident that the pace would pick up in the coming days, as more doses arrive, data snags get sorted out and more vaccination sites come on board. Los Angeles County announced this week it would convert Dodger Stadium and a Veterans Affairs site from mass testing sites into mass vaccination clinics. Similar plans are underway at Petco Park in San Diego and the Disneyland Resort in Orange County. Officials hope Dodger Stadium alone can handle up to 12,000 people a day.

The move solves one problem, but potentially exacerbates another: The two Los Angeles sites have been testing 87,000 people a week, according to Dr. Christina Ghaly, Los Angeles County Department of Health Services director. That will put new constraints on testing, even as covid cases in the nation’s most populous county continue to rise and hospitals are beyond capacity.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.


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How Much Arsenic in Rice Is Too Much?

What are some strategies to reduce arsenic exposure from rice?

Those who are exposed to the most arsenic in rice are those who are exposed to the most rice, like people who are eating plant-based, gluten-free, or dairy-free. So, at-risk populations are not just infants and pregnant women, but also those who may tend to eat more rice. What “a terrible irony for the health conscious” who are trying to avoid dairy and eat lots of whole foods and brown rice—so much so they may not only suffer some theoretical increased lifetime cancer risk, but they may actually suffer arsenic poisoning. For example, a 39-year-old woman had celiac disease, so she had to avoid wheat, barley, and rye, but she turned to so much rice that she ended up with sky-high arsenic levels and some typical symptoms, including “diarrhea, headache, insomnia, loss of appetite, abnormal taste, and impaired short-term memory and concentration.” As I discuss in my video How Much Arsenic in Rice Is Too Much, we, as doctors, should keep an eye out for signs of arsenic exposure in those who eat lots of rice day in and day out.

As you can see at 1:08 in my video, in its 2012 arsenic-in-rice exposé, Consumer Reports recommended adults eat no more than an average of two servings of rice a week or three servings a week of rice cereal or rice pasta. In its later analysis, however, it looked like “rice cereal and rice pasta can have much more inorganic arsenic—a carcinogen—than [its] 2012 data showed,” so Consumer Reports dropped its recommendation down to from three weekly servings to a maximum of only two, and that’s only if you’re not getting arsenic from other rice sources. As you can see from 1:29 in my video, Consumer Reports came up with a point system so people could add up all their rice products for the week to make sure they’re staying under seven points a week on average. So, if your only source of rice is just rice, for example, then it recommends no more than one or two servings for the whole week. I recommend 21 servings of whole grains a week in my Daily Dozen, though, so what to do? Get to know sorghum, quinoa, buckwheat, millet, oatmeal, barley, or any of the other dozen or so common non-rice whole grains out there. They tend to have negligible levels of toxic arsenic.

Rice accumulates ten times more arsenic than other grains, which helps explain why the arsenic levels in urine samples of those who eat rice tend to consistently be higher than those who do not eat rice, as you can see at 2:18 in my video. The FDA recently tested a few dozen quinoa samples, and most had arsenic levels below the level of detection, or just trace amounts, including the red quinoas that are my family’s favorite, which I was happy about. There were, however, still a few that were up around half that of rice. But, overall, quinoa averaged ten times less toxic arsenic than rice. So, instead of two servings a week, following the Consumer Reports recommendation, you could have 20. You can see the chart detailing the quinoa samples and their arsenic levels at 2:20 in my video.

So, diversifying the diet is the number-one strategy to reduce exposure of arsenic in rice. We can also consider alternatives to rice, especially for infants, and minimize our exposure by cooking rice like pasta with plenty of extra water. We found that a 10:1 water-to-rice ratio seemed best, though the data suggest the rinsing doesn’t seem to do much. We can also avoid processed foods sweetened with brown rice syrup. Is there anything else we can do at the dining room table while waiting for federal agencies to establish some regulatory limits?

What if you eat a lot of fiber-containing foods with your rice? Might that help bind some of the arsenic? Apparently not. In one study, the presence of fat did seem to have an effect, but in the wrong direction: Fat increased estimates of arsenic absorption, likely due to the extra bile we release when we eat fatty foods.

We know that the tannic acid in coffee and especially in tea can reduce iron absorption, which is why I recommend not drinking tea with meals, but might it also decrease arsenic absorption? Yes, by perhaps 40 percent or more, so the researchers suggested tannic acid might help, but they used mega doses—17 cups of tea worth or that found in 34 cups of coffee—so it isn’t really practical.

What do the experts suggest? Well, arsenic levels are lower in rice from certain regions, like California and parts of India, so why not blend that with some of the higher arsenic rice to even things out for everybody?


Another wonky, thinking-outside-the-rice-box idea involves an algae discovered in the hot springs of Yellowstone National Park with an enzyme that can volatize arsenic into a gas. Aha! Researchers genetically engineered that gene into a rice plant and were able to get a little arsenic gas off of it, but the rice industry is hesitant. “Posed with a choice between [genetically engineered] rice and rice with arsenic in it, consumers may decide they just aren’t going to eat any rice” at all.

This is the corresponding article to the 11th in a 13-video series on arsenic in the food supply. If you missed any of the first ten videos, watch them here:

You may also be interested in Benefits of Turmeric for Arsenic Exposure.

Only two major questions remain: Should we moderate our intake of white rice or should we minimize it? And, are there unique benefits to brown rice that would justify keeping it in our diet despite the arsenic content? I cover these issues in the final two videos: Is White Rice a Yellow-Light or Red-Light Food? and Do the Pros of Brown Rice Outweigh the Cons of Arsenic?.

In health,

Michael Greger, M.D.

PS: If you haven’t yet, you can subscribe to my free videos here and watch my live presentations:

California Budget Reflects ‘Pandemic-Induced Reality,’ Governor Says


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SACRAMENTO, Calif. — The coronavirus pandemic doomed Gov. Gavin Newsom’s ambitious plans last year to combat homelessness, expand behavioral health services and create a state agency to control soaring health care costs.

But even as the pandemic continues to rage, California’s Democratic governor said Friday he plans to push forward with those goals in the coming year, due to a rosier budget forecast buoyed by higher tax revenue from wealthy Californians who have fared relatively well during the crisis.

Newsom’s $227.2 billion budget blueprint also prioritizes billions to safely reopen K-12 schools shuttered by the pandemic, $600 payments for nearly 4 million low-income Californians — in addition to federal stimulus payments — and coronavirus relief grants and tax credits for hard-hit small businesses.

However, his 2021-22 fiscal year spending plan does not include additional public health money for local health departments steering California’s pandemic response, which have been chronically underfunded. He vowed to support cities and counties by boosting state testing and contact tracing capacity, speeding vaccination efforts and funding state-run surge hospitals that take overflow patients.

Newsom said Friday his budget reflects a “pandemic-induced reality” with investments aimed at spurring California’s economic recovery by helping businesses and people living in poverty. Wealth and income disparities, he added, “must be addressed.”

But Democrats in control of the state legislature, county leaders and social justice groups say that will be difficult to achieve because Newsom’s spending plan does not sufficiently fund health and social safety-net programs.

And without additional public health money, local leaders worry California will not be able to adequately control the spread of the virus.

“County public health is drowning,” said Graham Knaus, executive director of the California State Association of Counties. “We are triaging right now between testing, contact tracing and vaccination, and it’s impacting the response to the pandemic.”

Newsom’s budget proposal is the first step in a months-long negotiation process with the Democratic-controlled legislature, which has until June 15 to adopt the state budget that takes effect July 1. Lawmakers have become increasingly frustrated with the governor’s response to the pandemic, including his unilateral spending decisions in response to the emergency. Newsom is also facing a burgeoning recall effort, backed by heavyweight Republicans such as former San Diego Mayor Kevin Faulconer, who is considering challenging Newsom in the 2022 California gubernatorial election.

Newsom said he expects to make some tough calls on spending even though the state anticipates a $15 billion budget surplus for the coming fiscal year, largely because a state fiscal analysis projected deficits in subsequent years.

“While we are enjoying the fruits of a lot of one-time energy and surplus, it’s not permanent and we have to be mindful of over-committing,” Newsom said, explaining why he didn’t include funding to expand Medicaid to more unauthorized immigrants.

Some lawmakers say they will nonetheless press Newsom to use higher-than-expected revenues — and perhaps seek new taxes — to expand health coverage to more Californians.

The following health care proposals factor heavily into Newsom’s 2021-22 budget proposal.

Covid Relief

Newsom committed $4.4 billion in his budget to vaccine distribution, increased testing, contact tracing and other short-term pandemic expenses. Because that spending is related to the public health emergency, the state expects at least 75% to be reimbursed by the federal government and insurance payments.

He also proposed $52 million to fund costs at state-run surge hospitals, including support staff. And he is asking lawmakers to sign off on a covid relief package that would provide funding before the start of the fiscal year in July. It would include $2 billion to help school districts reopen classrooms to in-person instruction beginning in February by paying for protective equipment, ventilation systems and adequate testing. It would also commit billions to economic recovery, such as stimulus payments for individuals, and grants and tax credits for struggling small businesses.

Newsom also wants to increase the budget for the Department of Industrial Relations by $23 million to fund up to 113 additional workplace inspectors at the California Division of Occupational Safety and Health to police health order violations at businesses and enforce workplace safety laws.

Transforming Medi-Cal

Spending for Medi-Cal, the state’s Medicaid program for low-income residents, is expected to grow in the coming year because of the economic impact of the pandemic — as is its enrollment. The program has roughly 13 million enrollees, or about one-third of the state population.

In the coming year, Newsom will also press forward with a major overhaul of Medi-Cal, through a project called CalAIM, to provide new benefits emphasizing mental health care and substance use treatment, and pay for some nontraditional costs such as housing assistance. The hope is the program would divert homeless and other vulnerable people away from expensive emergency room care and keep them out of jail.

State Medi-Cal officials estimate the program would cost $1.1 billion for the first year. The state is working with the federal Centers for Medicare & Medicaid Services to obtain approval for the program.

Newsom also wants to expand Medi-Cal benefits to cover over-the-counter cold medicine and blood glucose monitors for people with diabetes. His budget includes $95 million for a major expansion of telehealth services that would permanently provide higher payments for virtual doctor visits.

Controlling Health Care Costs

Newsom is proposing a new state agency, the Office of Health Care Affordability, which he said would help control health care costs. He budgeted $63 million over the next three years for the office, which would set health care cost targets for the health care industry — along with financial penalties for failing to meet future targets.

Powerful health industry groups said they are still assessing whether they will support the proposal. But some expressed concern last year when Newsom floated the idea. Doctors and hospitals routinely fight proposals in Sacramento that might limit their revenue.

Newsom acknowledged Friday the task would be “tough.”

Battling Homelessness and Food Insecurity

Newsom is proposing a one-time infusion of $1.75 billion to battle homelessness.

Of that, Newsom said, $750 million would help counties purchase hotels and transform them into permanent housing for chronically homeless people. Another $750 million would allow counties to purchase facilities to treat people with mental illness or substance use disorders. And $250 million would help counties purchase and renovate homes for low-income older people.

Newsom’s budget also includes $30 million to help overwhelmed food banks and emergency food assistance programs.

Lawmakers said they plan to negotiate for even more funding for homelessness and safety-net programs.

“We absolutely need to significantly increase our investment to address homelessness because the need is so intense,” said Assembly member David Chiu (D-San Francisco). “And I don’t think there’s a single legislator who isn’t incredibly concerned about the food insecurity we’re seeing: lines around the block for food banks in what should be the wealthiest state in the country.”

Expanding Health Coverage

Newsom did not include money in his proposed budget to expand Medi-Cal to unauthorized immigrants age 65 and older. He had previously promised to fund the proposal, estimated to cost $350 million per year once fully implemented, but he said Friday the state cannot afford to commit to ongoing costs with a projected budget deficit starting in fiscal year 2022-23. California already offers full Medicaid benefits for income-eligible unauthorized immigrants up to age 26.

Some lawmakers and health care advocates countered that providing health insurance for undocumented immigrants would save lives and reduce costs, especially during the pandemic, and vowed to continue to fight for the expansion.

“To say we are disappointed is describing it very lightly,” said Orville Thomas, a lobbyist with the California Immigrant Policy Center. “These are Californians dying and getting sick at disproportionate rates during covid.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.


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‘Peer Respites’ Provide an Alternative to Psychiatric Wards During Pandemic

Mia McDermott is no stranger to isolation. Abandoned as an infant in China, she lived in an orphanage until a family in California adopted her as a toddler. She spent her adolescence in boarding schools and early adult years in and out of psychiatric hospitals, where she underwent treatment for bipolar disorder, anxiety and anorexia.

The pandemic left McDermott feeling especially lonely. She restricted social interactions because her fatty liver disease put her at greater risk of complications should she contract covid-19. The 26-year-old Santa Cruz resident stopped regularly eating and taking her psychiatric medications, and contemplated suicide.

When McDermott’s thoughts grew increasingly dark in June, she checked into Second Story, a mental health program based in a home not far from her own, where she finds nonclinical support in a peaceful environment from people who have faced similar challenges.

Second Story is what is known as a “peer respite,” a welcoming place where people can stay when they’re experiencing or nearing a mental health crisis. Betting that a low-key wellness approach, coupled with empathy from people who have “been there,” can help people in distress recover, this unorthodox strategy has gained popularity in recent years as the nation grapples with a severe shortage of psychiatric beds that has been exacerbated by the pandemic.

Peer respites allow guests to avoid psychiatric hospitalization and emergency department visits. They now operate in at least 14 states. California has five, in the San Francisco Bay Area and Los Angeles County.

“When things are really tough and you need extra support but you don’t need hospitalization, where’s that middle ground?” asked Keris Myrick, founder of Hacienda of Hope, a peer respite in Long Beach, California.

People with serious mental illness are more likely to experience emotional distress in the pandemic than the general population, said Dr. Benjamin Druss, a psychiatrist and professor at Emory University’s public health school, elaborating that they tend to have smaller social networks and more medical problems.

That was the case with McDermott. “I don’t have a full-on relationship with my family. My friends are my family,” she said. She yearned to “give them a hug, see their smile or stand close and take a selfie.”

The next best thing was Second Story, located in a pewter-gray split-level, five-bedroom house in Aptos, a quaint beach community near McDermott’s Santa Cruz home.

Peer respites offer people in distress short-term (usually up to two weeks), round-the-clock emotional support from peers — people who have experienced mental health conditions and are trained and often certified by states to support others with similar issues — and activities like arts, meditation and support groups.

“You can’t tell who’s the guest and who’s the staff. We don’t wear uniforms or badges,” said Angelica Garcia-Guerrero, associate director of Hacienda of Hope’s parent organization.

Peer respites are free for guests but rarely covered by insurance. States and counties typically pick up the tab. Hacienda of Hope’s $900,000 annual operating costs are covered by Los Angeles County through the Mental Health Services Act, a policy that directs proceeds from a statewide tax on people who earn more than $1 million annually to behavioral health programs.

In September, California Gov. Gavin Newsom signed a bill that would establish a statewide certification process for mental health peer providers by July 2022.

For now, however, peer respite staff members in California are not licensed or certified. Peer respites typically don’t offer clinical care or dispense psychiatric drugs, though guests can bring theirs. Peers share personal stories with guests but avoid labeling them with diagnoses. Guests must come — and can leave — voluntarily. Some respites have few restrictions on who can stay; others don’t allow guests who express suicidal thoughts or are homeless.

Peer respite is one of several types of programs that divert people facing behavioral health crises from the hospital, but the only one without clinical involvement, said Travis Atkinson, a consultant at TBD Solutions, a behavioral health care company. The first peer respites arose around 2000, said Laysha Ostrow, CEO of Live & Learn, which conducts behavioral health research.

The approach seems to be expanding. Live & Learn counts 33 peer respites today in the U.S., up from 19 six years ago. All are overseen and staffed by people with histories of psychiatric disorders. About a dozen other programs employ a mix of peers and laypeople who don’t have psychiatric diagnoses, or aren’t peer-led, Atkinson said.

Though she had stayed at Second Story several times over the past five years, McDermott hesitated to return during the pandemic. However, she felt reassured after learning that guests were required to wear a mask in common areas and get a covid test before their stay. To ensure physical distancing, the respite reduced capacity from six to five guests at a time.

During her two-week stay, McDermott played with the respite’s two cats and piano — activities she found therapeutic. But most helpful was talking to peers in a way she couldn’t with her mental health providers, she said. In the past, McDermott said, she had been involuntarily admitted to a psychiatric hospital after she expressed suicidal thoughts. When she shared similar sentiments with Second Story peers, they offered to talk, or call the hospital if she wanted.

“They were willing to listen,” she said. “But they’re not forceful about helping.”

By the end of the visit, McDermott said that she felt understood and her loneliness and suicidal feelings had waned. She started eating and taking her medications more consistently, she said.

The small number of studies on respites have found that guests had fewer hospitalizations and accounted for lower Medicaid spending for nearly a year after a respite stay than people with similar conditions who did not stay in a respite. Respite visitors spent less time in the hospital and emergency room the longer they stayed in the respite.

Financial struggles and opposition from neighbors have hindered the growth of respites, however. Live & Learn said that although five peer respites have been created since 2018, at least two others closed because of budget cuts.

Neighbors have challenged nearby respite placements in a few instances. Santa Cruz-area media outlets reported in 2019 that Second Story neighbors had voiced safety concerns with the respite. Neighbor Tony Crane told California Healthline that guests have used drugs and consumed alcohol in the neighborhood, and he worried that peers are not licensed or certified to support people in crisis. He felt it was too risky to let his children ride their bikes near the respite when they were younger.

In a written response, Monica Martinez, whose organization runs Second Story, said neighbors often target community mental health programs because of concerns that “come from misconceptions and stigma surrounding those seeking mental health support.”

Many respites are struggling with increased demand and decreased availability during the pandemic. Sherry Jenkins Tucker, executive director of Georgia Mental Health Consumer Network, said its four respites have had to reduce capacity to enable physical distancing, despite increased demand for services. Other respites have temporarily suspended stays because of the pandemic.

McDermott said her mental health had improved since staying at Second Story in June, but she still struggles with isolation amid the pandemic. “Holidays are hard for me,” said McDermott, who returned to Second Story in November. “I really wanted to be able to have Thanksgiving with people.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.


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San Francisco Wrestles With Drug Approach as Death and Chaos Engulf Tenderloin

This story also ran on Los Angeles Times. It can be republished for free.

SAN FRANCISCO — In early 2019, Tom Wolf posted a thank-you on Twitter to the cop who had arrested him the previous spring, when he was homeless and strung out in a doorway with 103 tiny bindles of heroin and cocaine in a plastic baggie at his feet.

“You saved my life,” wrote Wolf, who had finally gotten clean after that bust and 90 days in jail, ending six months of sleeping on scraps of cardboard on the sidewalk.

Today, he joins a growing chorus of people, including the mayor, calling for the city to crack down on an increasingly deadly drug trade. But there is little agreement on how that should be done. Those who demand more arrests and stiffer penalties for dealers face powerful opposition in a city with little appetite for locking people up for drugs, especially as the Black Lives Matter and Defund the Police movements push to drastically limit the power of law enforcement to deal with social problems.

Drug overdoses killed 621 people in the first 11 months of 2020, up from 441 in all of 2019 and 259 in 2018. San Francisco is on track to lose an average of nearly two people a day to drugs in 2020, compared with the 178 who had died by Dec. 20 of the coronavirus.

As in other parts of the country, most of the overdoses have been linked to fentanyl, the powerful synthetic opioid that laid waste to the eastern United States starting in 2013 but didn’t arrive in the Bay Area until about five years later. Just as the city’s drug scene was awash with the lethal new product — which is 50 times stronger than heroin and sells on the street for around $20 for a baggie weighing less than half a gram — the coronavirus pandemic hit, absorbing the attention and resources of health officials and isolating drug users, making them more likely to overdose.

The pandemic is contributing to rising overdose deaths nationwide, according to the Centers for Disease Control and Prevention, which reported last month that a record 81,000 Americans died of an overdose in the 12 months ending in May.

“This is moving very quickly in a horrific direction, and the solutions aren’t matching it,” said Supervisor Matt Haney, who represents the Tenderloin and South of Market neighborhoods, where nearly 40% of the deaths have occurred. Haney, who has hammered City Hall for what he sees as its indifference to a life-or-death crisis, is calling for a more coordinated response.

“It should be a harm reduction response, it should be a treatment response — and yes, there needs to be a law enforcement aspect of it too,” he said.

Tensions within the city’s leadership came to a head in September, when Mayor London Breed supported an effort by City Attorney Dennis Herrera to clean up the Tenderloin by legally blocking 28 known drug dealers from entering the neighborhood.

But District Attorney Chesa Boudin, a progressive elected in 2019 on a platform of police accountability and racial justice, sided with activists opposing the move. He called it a “recycled, punishment-focused” approach that would accomplish nothing.

People have died on the Tenderloin’s needle-strewn sidewalks and alone in hotel rooms where they were housed by the city to protect them from covid-19. Older Black men living alone in residential hotels are dying at particularly high rates; Blacks make up around 5% of the city’s population but account for a quarter of the 2020 overdoses. Last February, a man was found hunched over, ice-cold, in the front pew at St. Boniface Roman Catholic Church.

The only reason drug deaths aren’t in the thousands, say health officials, is the outreach that has become the mainstay of the city’s drug policy. From January to October, 2,975 deaths were prevented by naloxone, an overdose reversal drug that’s usually sprayed up the nose, according to the DOPE Project, a city-funded program that trains outreach workers, drug users, the users’ family members and others.

“If we didn’t have Narcan,” said program manager Kristen Marshall, referring to the common naloxone brand name, “there would be no room at our morgue.”

The city is also hoping that this year state lawmakers will approve safe consumption sites, where people can do drugs in a supervised setting. Other initiatives, like a 24-hour meth sobering center and an overhaul of the city’s behavioral health system, have been put on hold because of pandemic-strained resources.

Efforts like the DOPE Project, the country’s largest distributor of naloxone, reflect a seismic shift over the past few years in the way cities confront drug abuse. As more people have come to see addiction as a disease rather than a crime, there is little appetite for locking up low-level dealers, let alone drug users — policies left over from the “war on drugs” that began in 1971 under President Richard Nixon and disproportionately punished Black Americans.

In practice, San Francisco police don’t arrest people for taking drugs, certainly not in the Tenderloin. On a sunny afternoon in early December, a red-haired young woman in a beret crouched on a Hyde Street sidewalk with her eyes closed, clutching a piece of foil and a straw. A few blocks away, a man sat on the curb injecting a needle into a thigh covered with scabs and scars, while two uniformed police officers sat in a squad car across the street.

Last spring, after the pandemic prompted a citywide shutdown, police stopped arresting dealers to avoid contacts that might spread the coronavirus. Within weeks, the sidewalks of the Tenderloin were lined with transients in tents. The streets became such a narcotics free-for-all that many of the working-class and immigrant families living there felt afraid to leave their homes, according to a federal lawsuit filed by business owners and residents. It accuses City Hall of treating less wealthy ZIP codes as “containment zones” for the city’s ills.

The suit was settled a few weeks later after officials moved most of the tents to designated “safe sleeping sites.” But for many, the deterioration of the Tenderloin, juxtaposed with the gleaming headquarters of companies like Twitter and Uber just blocks away, symbolizes San Francisco’s starkest contradictions.

Mayor Breed, who lost her younger sister to a drug overdose in 2006, has called for a crackdown on drug dealing.

The Federal Initiative for the Tenderloin was one such effort, announced in 2019. It aims to “reclaim a neighborhood that is being smothered by lawlessness,” U.S. Attorney David Anderson said at a recent virtual news conference held to announce a major operation in which the feds arrested seven people and seized 10 pounds of fentanyl.

Law enforcement agencies have blamed the continued availability of cheap, potent drugs on lax prosecutions. Boudin, however, said his office files charges in 80% of felony drug cases, but most involve low-level dealers whom cartels can easily replace in a matter of hours.

He pointed to a 2019 federal sting that culminated in the arrest of 32 dealers — mostly Hondurans who were later deported — after a two-year undercover operation involving 15 agencies.

“You go walk through the Tenderloin today and tell me if it made a difference,” said Boudin.

His position reflects a growing “progressive prosecutor” movement that questions whether decades-old policies that focus on putting people behind bars are effective or just. In May, the killing of George Floyd by the Minneapolis police energized a nationwide police reform campaign. Cities around the country, including San Francisco, have promised to redirect millions of dollars from law enforcement to social programs.

“If our city leadership says in one breath that they want to defund the police and are for racial and economic justice and in the next talk about arresting drug dealers, they’re hypocrites and they’re wrong,” said Marshall, the leader of the DOPE Project.

But Wolf, 50, believes a concerted crackdown on dealers would send a message to the drug networks that San Francisco is no longer an open-air illegal drug market.

Like hundreds of thousands of other Americans who’ve succumbed to opiate misuse, he began with a prescription for the painkiller oxycodone, in his case following foot surgery in 2015. When the pills ran out, he made his way from his tidy home in Daly City, just south of San Francisco, to the Tenderloin, where dealers in hoodies and backpacks loiter three or four deep on some blocks.

When he could no longer afford pills, Wolf switched to heroin, which he learned how to inject on YouTube. He soon lost his job as a caseworker for the city and his wife threw him out, so he became homeless, holding large quantities of drugs for Central American dealers, who sometimes showed him photos of the lavish houses they were having built for their families back home.

Looking back, he wishes it hadn’t taken six arrests and three months behind bars before someone finally pushed him toward treatment.

“In San Francisco, it seems like we’ve moved away from trying to urge people into treatment and instead are just trying to keep people alive,” he said. “And that’s not really working out that great.”

This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.


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In Los Angeles and Beyond, Oxygen Is the Latest Covid Bottleneck

As Los Angeles hospitals give record numbers of covid patients oxygen, the systems and equipment needed to deliver the life-sustaining gas are faltering.

It’s gotten so bad that Los Angeles County officials are warning paramedics to conserve it. Some hospitals are having to delay releasing patients as they don’t have enough oxygen equipment to send home with them.

“Everybody is worried about what’s going to happen in the next week or so,” said Cathy Chidester, director of the L.A. County Emergency Medical Services Agency.

Oxygen, which makes up 21% of the Earth’s air, isn’t running short. But covid damages the lungs, and the crush of patients in hot spots such as Los Angeles, the Navajo Nation, El Paso, Texas, and in New York last spring have needed high concentrations of it. That has stressed the infrastructure for delivering the gas to hospitals and their patients.

The strain in those areas is caused by multiple weak links in the pandemic supply chain. In some hospitals that pipe oxygen to patients’ rooms, the massive volume of cold liquid oxygen is freezing the equipment needed to deliver it, which can block the system.

“You can completely — literally, completely — shut down the entire hospital supply if that happens,” said Rich Branson, a respiratory therapist with the University of Cincinnati and editor-in-chief of the journal Respiratory Care.

There is also pressure on the availability of both the portable cylinders that hold oxygen and the concentrators that pull oxygen from the air. And in some cases, vendors that supply the oxygen have struggled to get enough of the gas to hospitals. Even nasal cannulas, the tubing used to deliver oxygen, are now running low.

“It’s been nuts, absolutely nuts,” said Esteban Trejo, general manager of Syoxsa, an industrial and medical gas distributor based in El Paso. He provides oxygen to several temporary hospitals set up specifically to treat people with covid.

In November, he said, he was answering calls in the middle of the night from contractors worried about oxygen supplies. At one point, when the company’s usual supplier fell through, they were hauling oxygen from Houston, which is a more than 10-hour drive each way.

Branson has been sounding the alarm about logistical limitations on critical care since the SARS pandemic nearly 20 years ago, when he and others surveyed experts about the specific equipment and infrastructure needed during a future pandemic. Oxygen was near the top of the list.

Oxygen as Cold as Neptune

Last spring, New York, New Jersey and Connecticut faced a challenge similar to what is now unfolding in Los Angeles, said Robert Karcher, a vice president of contract services for Acurity, a group purchasing organization that worked with many hospitals during that surge.

To take up less space, oxygen is often stored as a liquid around minus 300 degrees Fahrenheit, about as cold as the surface of Neptune. But as covid patients filling ICUs were given oxygen through ventilators or nasal tubes, some hospitals began to see ice form over the equipment that converts liquid oxygen into a gas.

When a hospital draws more and more liquid oxygen from those tanks, the super-cold liquid can seep further into the vaporizing coils where liquid oxygen turns to gas.

Branson said some ice is normal, but a lot of ice can cause valves on the device to freeze in place. And the ice can restrict airflow in the pipes sending the oxygen into patients’ rooms, Karcher said. To combat this, hospitals could switch to a backup vaporizer if they had one, hose down iced vaporizers or move patients to cylinder-delivered oxygen. But that puts additional strain on the hospitals’ cylinder oxygen supply, as well as the medical gas supplier, Karcher said.

Hospitals in New York began to panic in the spring because the icing of the vaporizer was much greater than they had seen before, he added. It got so bad, he said, that some hospitals worried they’d have to close their ICUs.

“They thought they were in imminent danger of their tank piping shutting down,” he said. “We came pretty close in a couple of our hospitals. It was a rough few weeks.”

The strain on Los Angeles health care infrastructure could be worse given the now-common treatment of putting patients on oxygen using high-flow nasal cannulas. That requires more of the gas pumped at a higher rate than with ventilators.

“I don’t know of any system that is really set to triple patient volumes — or 10 times the oxygen delivery,” Chidester said of the L.A. County hospitals. “They’re having a hard time keeping up.”

The Oxygen Shortage Doom Loop

In and around Los Angeles, the Army Corps of Engineers has so far surveyed 11 hospitals for freezing oxygen pipe issues. The hospitals are a mix of older facilities and smaller suburban hospitals seeing such high demand amid skyrocketing cases in the area, said Mike Petersen, a Corps spokesperson.

One of the worst examples he saw included pipes that looked like a home freezer that had not been defrosted in some time.

The problem gets worse for hospitals that have had to convert regular hospital rooms to intensive care units. ICU pipes are bigger than those leading to other parts of a hospital. When rooms get repurposed as pop-up ICUs, the pipes can simply be too narrow to deliver the oxygen that covid patients need. And so, Chidester said, the hospitals switch to large cylinders of oxygen. But vendors are having a hard time refilling those quickly enough.

Even smaller cylinders and oxygen concentrators are in short supply amid the surge, she said. Those patients who could be sent home with an oxygen cylinder are left stuck in a hospital waiting for one, taking up a much-needed bed.

‘Extreme Rurality’

In early December, doctors serving the Navajo Nation said they needed more of everything: the oxygen itself and the equipment to get oxygen to patients both in the hospital and recovering at home.

“We’ve never reached capacity before — until now,” said Dr. Loretta Christensen, chief medical officer for the Navajo Area Indian Health Service, in mid-December. Its hospitals serve a patient population in the southwestern U.S. that’s spread across an area bigger than West Virginia.

The buildings are aging, and they aren’t built to house a large number of critical patients, said Christensen. As the number of patients on high-flow oxygen climbed, several facilities started to notice their oxygen flow weaken. They thought something was broken, but when engineers took a look, Christensen said, it became clear the system was just not able to provide the amount of high-flow oxygen patients needed.

She said a hospital in Gallup, New Mexico, put in new filters to maximize oxygen flow. After delays from snowy weather, a hospital serving the northern part of the Navajo Nation managed to hook up a second oxygen tank to boost capacity.

But medical facilities in the area are always a little on edge.

“Honestly, we worry about supply a lot out here because — and I call it extreme rurality — you just can’t get something tomorrow,” said Christensen. “It’s not like being in an urban area where you can say, ‘Oh, I need this right now.’”

Because of the small size of certain hospitals and the difficulty of getting to some of them, Christensen said, Navajo facilities aren’t attractive to big vendors, so they rely on local vendors, which may prove more vulnerable to supply chain hiccups.

Tséhootsooí Medical Center in Fort Defiance, Arizona, has at times had to keep patients in the hospital and transfer incoming patients to other facilities because it couldn’t get the oxygen cylinders needed to send recovering patients home.

Tina James-Tafoya, covid incident commander at Fort Defiance Indian Hospital Board, which runs the center, said at-home oxygen is out of the question for some patients. Oxygen concentrators require electricity, which some patients don’t have. And for patients who live in hogans, homes often heated with a wood stove, the use of oxygen cylinders is a hazard.

“It’s really interesting and eye-opening for me to see that something that seems so simple like oxygen has so many different things tied to it that will hinder it getting to the patient,” she said.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.


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States threaten to crackdown on providers amid Covid-19 vaccine distribution

In an effort to ensure the efficient and orderly distribution of the Covid-19 vaccine, governors from New York, California and Florida are warning that they will take action against providers who are conducting vaccinations too slowly or healthcare workers who undercut priority guidelines.

Arsenic in Rice Milk, Rice Krispies, and Brown Rice Syrup

I recommend people switch away from using rice milk

For kids and teens, the amount of arsenic flowing through their bodies was found to be about 15 percent higher for each quarter cup of rice consumed per day, and a similar link was found in adults. A study of pregnant women found that consuming about a half cup of cooked rice per day could raise urine arsenic levels as much as drinking a liter of arsenic-contaminated water at the current upper federal safety limit. These findings “suggest that many people in the United States may be exposed to potentially harmful levels of arsenic through rice consumption.” which I explore in my video Arsenic in Rice Milk, Rice Krispies, and Brown Rice Syrup.

Do you know where Americans get most of their rice arsenic? From Rice Krispies, though brown rice crisps cereal may have twice as much, as I discuss in my video Arsenic in Rice Milk, Rice Krispies, and Brown Rice Syrup.

“Organic brown rice syrup (OBRS) is used as a sweetener in organic food products as an alternative to high-fructose corn syrup.” Big mistake, as organic brown rice syrup products “may introduce significant concentrations” of toxic arsenic into people’s diets. For example, two energy chews sweetened with brown rice syrup might hit the provisional upper daily arsenic intake based on the water standards.

“Toddler formulas with added organic brown rice syrup have 20 times higher levels of inorganic [toxic] arsenic than regular formulas,” and in older children, thanks to brown rice syrup, a few cereal bars a day “could pose a very high cancer risk.”

What about rice milk? A consensus statement of both the European and North American societies for pediatric nutrition recommends the “avoidance of rice drinks for infants and young children,” and, generally, toxic “inorganic arsenic intake in infancy and childhood should be as low as possible.”

To this end, the United Kingdom has banned the consumption of rice milk for young children, a notion with which Consumer Reports concurred, recommending no servings a week of rice milk for children and no more than half a cup a day for adults, as you can see at 1:56 in my video.

The arsenic in various brands of rice milk ranges wildly—in fact, there’s a 15-fold difference between the highest and lowest contamination, suggesting manufacturers could make low arsenic rice milk if they wanted. As you can see at 2:16 in my video, Consumer Reports found rice drinks from Pacific and Rice Dream brands were right about average, though, for Rice Dream, it appears the vanilla or chocolate flavors may be lower. It doesn’t seem we have anything to worry about with rice vinegar, but rice pasta and rice cakes end up similar to pure rice in terms of arsenic levels, which makes sense because that’s pretty much what they are—pure rice. However, pasta is boiled, so we’d expect the levels to be cut 40 to 60 percent, like when you boil and drain rice.

If you just couldn’t live without rice milk for some reason, you could make your own using lower arsenic rice, like brown basmati from India, Pakistan, or California, but then your homemade rice milk might have even less nutrition, as most of the commercial brands are at least fortified. Better options might be soy, oat, hemp, or almond milk, though you don’t want kids to be drinking too much almond milk. There have been a few case reports of little kids drinking four cups a day and running into kidney stone problems due to its relatively high oxalate content, which averages about five times more than soy milk. More on oxalates in my video series starting with Oxalates in Spinach and Kidney Stones: Should We Be Concerned?

I have about 40 videos that touch on soy milk, discussing such topics as how it may normalize development in girls and reduce breast cancer risk, as well reduce prostate cancer risk in men. Some of the latest science on soy milk includes an association with better knee x-rays, suggesting protection from osteoarthritis, and an interventional study suggesting improved gut health by boosting the growth of good bacteria. However, drinking 3 quarts a day, which is 10 to 12 daily cups, for a year may inflame your liver, but two cups a day can have an extraordinary effect on your cholesterol, causing a whopping 25 percent drop in bad cholesterol after just 21 days.

An ounce and a half of almonds, about a handful, each day, can drop LDL cholesterol 13 percent in six weeks and reduce abdominal fat, though a cup of almond milk only contains about ten almonds, which is less than a third of what was used in the study. So, it’s not clear if almond milk helps much, but there was a study on oat milk compared to rice milk. As you can see at 4:37 in my video, five weeks of oat milk lowered bad cholesterol, whereas rice milk didn’t, and even increased triglycerides and may bump blood pressure a bit. However, the oat milk only dropped LDL about 5 percent and that was with three cups a day. As plant-based alternatives go, it appears soy milk wins the day.

So, why drink rice milk at all when there are such better options? There really isn’t much nutrition in rice milk. In fact, there are case reports of severe malnutrition in toddlers whose diets were centered around rice milk due to multiple food allergies. Infants and toddlers have increased protein requirements compared to adults, so if the bulk of a child’s diet is rice milk, coconut milk, potato milk, or almond milk, they may not get enough, as you can see at 5:23 in my video. In fact, cases of kwashiorkor—that bloated-belly protein- and calorie-deficient state of malnutrition—due to rice milk have been reported in Ethiopia…and Atlanta, Georgia, because literally 99 percent of the child’s diet was rice milk. So, these malnutrition cases were not because they drank rice milk, but rather because they drank rice milk nearly exclusively. I just use these examples to illustrate the relative lack of nutrition in rice milk. If you’re going to choose a milk alternative, you might as well go for one that has less arsenic—and more nutrition.

I have released several videos on soy milk, but only one on almond milk video so far: Prostate Cancer and Organic Milk vs. Almond Milk. I plan on producing many more on choosing between various milk options, so stay tuned.

If you’ve missed any of the useful material on dietary arsenic I’ve also shared, please see:

The final four videos in this series take all of this information and try to distill it into practical recommendations:

In health,

Michael Greger, M.D.

PS: If you haven’t yet, you can subscribe to my free videos here and watch my live presentations:


As the Terror of COVID Struck, Health Care Workers Struggled to Survive. Thousands Lost the Fight.

This story also ran on The Guardian. It can be republished for free.

Workers at Garfield Medical Center in suburban Los Angeles were on edge as the pandemic ramped up in March and April. Staffers in a 30-patient unit were rationing a single tub of sanitizing wipes all day. A May memo from the CEO said N95 masks could be cleaned up to 20 times before replacement.

Patients showed up COVID-negative but some still developed symptoms a few days later. Contact tracing took the form of texts and whispers about exposures.

By summer, frustration gave way to fear. At least 60 staff members at the 210-bed community hospital caught COVID-19, according to records obtained by KHN and interviews with eight staff members and others familiar with hospital operations.

The first to die was Dawei Liang, 60, a quiet radiology technician who never said no when a colleague needed help. A cardiology technician became infected and changed his final wishes — agreeing to intubation — hoping for more years to dote on his grandchildren.

Few felt safe.

Ten months into the pandemic, it has become far clearer why tens of thousands of health care workers have been infected by the virus and why so many have died: dire PPE shortages. Limited COVID tests. Sparse tracking of viral spread. Layers of flawed policies handed down by health care executives and politicians, and lax enforcement by government regulators.

All of those breakdowns, across cities and states, have contributed to the deaths of more than 2,900 health care workers, a nine-month investigation by over 70 reporters at KHN and The Guardian has found. This number is far higher than that reported by the U.S. government, which does not have a comprehensive national count of health care workers who’ve died of COVID-19.

The fatalities have skewed young, with the majority of victims under age 60 in the cases for which there is age data. People of color have been disproportionately affected, accounting for about 65% of deaths in cases in which there is race and ethnicity data. After conducting interviews with relatives and friends of around 300 victims, KHN and The Guardian learned that one-third of the fatalities involved concerns over inadequate personal protective equipment.

Many of the deaths occurred in New York and New Jersey, and significant numbers also died in Southern and Western states as the pandemic wore on.

Workers at well-funded academic medical centers — hubs of policymaking clout and prestigious research — were largely spared. Those who died tended to work in less prestigious community hospitals like Garfield, nursing homes and other health centers in roles in which access to critical information was low and patient contact was high.

Garfield Medical Center and its parent company, AHMC Healthcare, did not respond to multiple calls or emails regarding workers’ concerns and circumstances leading to the worker deaths.

So as 2020 draws to a close, we ask: Did so many of the nation’s health care workers have to die?

New York’s Warning for the Nation

The seeds of the crisis can be found in New York and the surrounding cities and suburbs. It was the region where the profound risks facing medical staff became clear. And it was here where the most died.

As the pandemic began its U.S. surge, city paramedics were out in force, their sirens cutting through eerily empty streets as they rushed patients to hospitals. Carlos Lizcano, a blunt Queens native who had been with the New York City Fire Department (FDNY) for two decades, was one of them.

He was answering four to five cardiac arrest calls every shift. Normally he would have fielded that many in a month. He remembered being stretched so thin he had to enlist a dying man’s son to help with CPR. On another call, he did chest compressions on a 33-year-old woman as her two small children stood in the doorway of a small apartment.

“I just have this memory of those kids looking at us like, ‘What’s going on?’”

After the young woman died, Lizcano went outside and punched the ambulance in frustration and grief.

The personal risks paramedics faced were also grave.

More than 40% of emergency medical service workers in the FDNY went on leave for confirmed or suspected coronavirus during the first three months of the pandemic, according to a study by the department’s chief medical officer and others.

In fact, health care workers were three times more likely than the general public to get COVID-19, other researchers found. And the risks were not equally spread among medical professions. Initially, CDC guidelines were written to afford the highest protection to workers in a hospital’s COVID-19 unit.

Yet months later, it was clear that the doctors initially thought to be at most risk — anesthesiologists and those working in the intensive care unit — were among the least likely to die. This could be due to better personal protective equipment or patients being less infectious by the time they reach the ICU.

Instead, scientists discovered that “front door” health workers like paramedics and those in acute-care “receiving” roles — such as in the emergency room — were twice as likely as other health care workers to be hospitalized with COVID-19.

For FDNY’s first responders, part of the problem was having to ration and reuse masks. Workers were blind to an invisible threat that would be recognized months later: The virus spread rapidly from pre-symptomatic people and among those with no symptoms at all.

In mid-March, Lizcano was one of thousands of FDNY first responders infected with COVID-19.

At least four of them died, city records show. They were among the 679 health care workers who have died in New York and New Jersey to date, most at the height of the terrible first wave of the virus.

“Initially, we didn’t think it was this bad,” Lizcano said, recalling the confusion and chaos of the early pandemic. “This city wasn’t prepared.”

Neither was the rest of the country.

An Elusive Enemy

The virus continued to spread like a ghost through the nation and proved deadly to workers who were among the first to encounter sick patients in their hospital or nursing home. One government agency had a unique vantage point into the problem but did little to use its power to cite employers — or speak out about the hazards.

Health employers had a mandate to report worker deaths and hospitalizations to the Occupational Safety and Health Administration.

When they did so, the report went to an agency headed by Eugene Scalia, son of conservative Supreme Court Justice Antonin Scalia who died in 2016. The younger Scalia had spent part of his career as a corporate lawyer fighting the very agency he was charged with leading.

Its inspectors have documented instances in which some of the most vulnerable workers — those with low information and high patient contact — faced incredible hazards, but OSHA’s staff did little to hold employers to account.

Beaumont, Texas, a town near the Louisiana border, was largely untouched by the pandemic in early April.

That’s when a 56-year-old physical therapy assistant at Christus Health’s St. Elizabeth Hospital named Danny Marks called in sick with a fever and body aches, federal OSHA records show.

He told a human resources employee that he’d been in the room of a patient who was receiving a breathing treatment — the type known as the most hazardous to health workers. The CDC advises that N95 respirators be used by all in the room for the so-called aerosol-generating procedures. (A facility spokesperson said the patient was not known or suspected to have COVID at the time Marks entered the room.)

Marks went home to self-isolate. By April 17, he was dead.

The patient whose room Marks entered later tested positive for COVID-19. And an OSHA investigation into Marks’ death found there was no sign on the door to warn him that a potentially infected patient was inside, nor was there a cart outside the room where he could grab protective gear.

The facility did not have a universal masking policy in effect when Marks went in the room, and it was more than likely that he was not wearing any respiratory protection, according to a copy of the report obtained through a public records request. Twenty-one more employees contracted COVID by the time he died.

“He was a beloved gentleman and friend and he is missed very much,” Katy Kiser, Christus’ public relations director, told KHN.

OSHA did not issue a citation to the facility, instead recommending safety changes.

The agency logged nearly 8,700 complaints from health care workers in 2020. Yet Harvard researchers found that some of those desperate pleas for help, often decrying shortages of PPE, did little to forestall harm. In fact, they concluded that surges in those complaints preceded increases in deaths among working-age adults 16 days later.

One report author, Peg Seminario, blasted OSHA for failing to use its power to get employers’ attention about the danger facing health workers. She said issuing big fines in high-profile cases can have a broad impact — except OSHA has not done so.

“There’s no accountability for failing to protect workers from exposure to this deadly virus,” said Seminario, a former union health and safety official.

More ‘Lost on the Frontline’ Stories

Desperate for Safety Gear

There was little outward sign this summer that Garfield Medical Center was struggling to contain COVID-19. While Medicare has forced nursing homes to report staff infections and deaths, no such requirement applies to hospitals.

Yet as the focus of the pandemic moved from the East Coast in the spring to Southern and Western states, health care worker deaths climbed. And behind the scenes at Garfield, workers were dealing with a lack of equipment meant to keep them safe.

Complaints to state worker-safety officials filed in March and April said Garfield Medical Center workers were asked to reuse the same N95 respirator for a week. Another complaint said workers ran out of medical gowns and were directed to use less-protective gowns typically provided to patients.

Staffers were shaken by the death of Dawei Liang. And only after his death and a rash of infections did Garfield provide N95 masks to more workers and put up plastic tarps to block a COVID unit from an adjacent ward. Yet this may have been too late.

The coronavirus can easily spread to every corner of a hospital. Researchers in South Africa traced a single ER patient to 119 cases in a hospital — 80 among staff members. Those included 62 nurses from neurology, surgical and general medical units that typically would not have housed COVID patients.

By late July, Garfield cardiac and respiratory technician Thong Nguyen, 73, learned he was COVID-positive days after he collapsed at work. Nguyen loved his job and was typically not one to complain, said his youngest daughter, Dinh Kozuki. A 34-year veteran at the hospital, he was known for conducting medical tests in multiple languages. His colleagues teased him, saying he was never going to retire.

Kozuki said her father spoke up in March about the rationing of protective gear, but his concerns were not allayed.

The PPE problems at Garfield were a symptom of a broader problem. As the virus spread around the nation, chronic shortages of protective gear left many workers in community-based settings fatally exposed. Nearly 1 in 3 family members or friends of around 300 health care workers interviewed by KHN or The Guardian expressed concerns about a fallen workers’ PPE.

Health care workers’ labor unions asked for the more-protective N95 respirators when the pandemic began. But Centers for Disease Control and Prevention guidelines said the unfitted surgical masks worn by workers who feed, bathe and lift COVID patients were adequate amid supply shortages.

Mary Turner, an ICU nurse and president of the Minnesota Nurses Association, said she protested alongside nurses all summer demanding better protective gear, which she said was often kept from workers because of supply-chain shortages and the lack of political will to address them.

“It shouldn’t have to be that way,” Turner said. “We shouldn’t have to beg on the streets for protection during a pandemic.”

At Garfield, it was even hard to get tested. Critical care technician Tony Ramirez said he started feeling ill on July 12. He had an idea of how he might have been exposed: He’d cleaned up urine and feces of a patient suspected of having COVID-19 and worked alongside two staffers who also turned out to be COVID-positive. At the time, he’d been wearing a surgical mask and was worried it didn’t protect him.

Yet he was denied a free test at the hospital, and went on his own time to Dodger Stadium to get one. His positive result came back a few days later.

As Ramirez rested at home, he texted Alex Palomo, 44, a Garfield medical secretary who was also at home with COVID-19, to see how he was doing. Palomo was the kind of man who came to many family parties but would often slip away unseen. A cousin finally asked him about it: Palomo said he just hated to say goodbye.

Palomo would wear only a surgical mask when he would go into the rooms of patients with flashing call lights, chat with them and maybe bring them a refill of water, Ramirez said.

Ramirez said Palomo had no access to patient charts, so he would not have known which patients had COVID-19: “In essence, he was helping blindly.”

Palomo never answered the text. He died of COVID-19 on Aug. 14.

And Thong Nguyen had fared no better. His daughter, a hospital pharmacist in Fresno, had pressed him to go on a ventilator after seeing other patients survive with the treatment. It might mean he could retire and watch his grandkids grow up. But it made no difference.

“He definitely should not have passed [away],” Kozuki said.

Nursing Homes Devastated

During the summer, as nursing homes recovered from their spring surge, Heather Pagano got a new assignment. The Doctors Without Borders adviser on humanitarianism had been working in cholera clinics in Nigeria. In May, she arrived in southeastern Michigan to train nursing home staffers on optimal infection-control techniques.

Federal officials required worker death reports from nursing homes, which by December tallied more than 1,100 fatalities. Researchers in Minnesota found particular hazards for these health workers, concluding they were the ones most at risk of getting COVID-19.

Pagano learned that staffers were repurposing trash bin liners and going to the local Sherwin-Williams store for painting coveralls to backfill shortages of medical gowns. The least-trained clinical workers — nursing assistants — were doing the most hazardous jobs, turning and cleaning patients, and brushing their teeth.

She said nursing home leaders were shuffling reams of federal, state and local guidelines yet had little understanding of how to stop the virus from spreading.

“No one sent trainers to show people what to do, practically speaking,” she said.

As the pandemic wore on, nursing homes reported staff shortages getting worse by the week: Few wanted to put their lives on the line for $13 an hour, the wage for nursing assistants in many parts of the U.S.

The organization GetusPPE, formed by doctors to address shortages, saw almost all requests for help were coming from nursing homes, doctors’ offices and other non-hospital facilities. Only 12% of the requests could be fulfilled, its October report said.

And a pandemic-weary and science-wary public has fueled the virus’s spread. In fact, whether or not a nursing home was properly staffed played only a small role in determining its susceptibility to a lethal outbreak, University of Chicago public health professor Tamara Konetzka found. The crucial factor was whether there was widespread viral transmission in the surrounding community.

“In the end, the story has pretty much stayed the same,” Konetzka said. “Nursing homes in virus hot spots are at high risk and there’s very little they can do to keep the virus out.”

The Vaccine Arrives

From March through November, 40 complaints were filed about the Garfield Medical Center with the California Department of Public Health, nearly three times the statewide average for the time. State officials substantiated 11 complaints and said they are part of an ongoing inspection.

For Thanksgiving, AHMC Healthcare Chairman Jonathan Wu sent hospital staffers a letter thanking “frontline healthcare workers who continue to serve, selflessly exposing themselves to the virus so that others may cope, recover and survive.”

The letter made no mention of the workers who had died. “A lot of people were upset by that,” said critical care technician Melissa Ennis. “I was upset.”

By December, all workers were required to wear an N95 respirator in every corner of the hospital, she said. Ennis said she felt unnerved taking it off. She took breaks to eat and drink in her car.

Garfield said on its website that it is screening patients for the virus and will “implement infection prevention and control practices to protect our patients, visitors, and staff.”

On Dec. 9, Ennis received notice that the vaccine was on its way to Garfield. Nationwide, the vaccine brought health workers relief from months of tension. Nurses and doctors posted photos of themselves weeping and holding their small children.

At the same time, it proved too late for some. A new surge of deaths drove the toll among health workers to more than 2,900.

And before Ennis could get the shot, she learned she would have to wait at least a few more days, until she could get a COVID test.

She found out she’d been exposed to the virus by a colleague.

Shoshana Dubnow and Anna Sirianni contributed to this report.Video by Hannah NormanWeb production by Lydia Zuraw

This story is part of “Lost on the Frontline,” an ongoing project from The Guardian and Kaiser Health News that aims to document the lives of health care workers in the U.S. who die from COVID-19, and to investigate why so many are victims of the disease. If you have a colleague or loved one we should include, please share their story.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.


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California’s COVID Enforcement Strategy: Education Over Citations

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SACRAMENTO, Calif. — Nearly six months since Gov. Gavin Newsom promised to target businesses that are flagrantly violating public health orders to control the spread of COVID-19, California regulators have issued just 424 citations and suspended two business licenses as of Monday, according to data from 10 state regulatory and law enforcement agencies.

Instead of strictly penalizing businesses for violations, the Democratic governor and businessman with a portfolio of wineries, bars and restaurants under the brand name PlumpJack, has relied on educating owners about infectious disease mandates. State agencies have contacted establishments primarily by email, sending them 1.3 million messages since July 1 to urge them to comply with state and local public health rules.

Enforcement at bars and restaurants where alcohol is served, identified by the Centers for Disease Control and Prevention as among the highest-risk environments for COVID transmission, has been limited, data shows. The state Department of Alcoholic Beverage Control, which can issue criminal misdemeanor citations, fine businesses and revoke liquor licenses, has issued just 45 citations against bars and 119 against restaurants since July. No fines have been issued or licenses revoked for the 94,000 businesses it regulates.

By comparison, the state of New York — with half the population of California and far fewer eating and drinking establishments — has issued 1,867 fines against bars and restaurants and temporarily suspended 279 business liquor licenses from June 18 to Dec. 8.

“The reality is it’s not enough to send an email and say ‘Wear a mask,’” said Dr. Kirsten Bibbins-Domingo, a professor of epidemiology and biostatistics at the University of California-San Francisco. “We see workplace violations that we know are major sources of transmission. We have to be willing to enforce or there’s no point in doing these things.”

Like much of the country, both California and New York, the nation’s two most populous Democratic-led states, have put primary responsibility for enforcing public health mandates on cities and counties. Newsom and New York Gov. Andrew Cuomo have bolstered local enforcement efforts by forming statewide task forces to go after businesses that repeatedly violate or ignore public health rules, such as mask mandates and business closures.

But California has been less aggressive than New York in targeting and penalizing bad actors. Newsom and state agencies have instead relied on tough talk and persuasion, emphasizing “personal responsibility,” informing businesses about their responsibilities — and giving them plenty of time to comply.

“I’m not coming out with a fist. We want to come out with an open heart,” Newsom said July 1. “We have, I think, a responsibility at the same time to go after people that are thumbing their nose, that are particularly being aggressive and reticent to do anything.”

The state’s lenient enforcement policy has put enormous responsibility and pressure on cities and counties struggling to gain compliance with COVID measures. Local government leaders are preparing for deep budget cuts and can’t find resources to undertake a coherent enforcement strategy of their own. Many are also fighting intense political battles over mask mandates, curfews and other COVID safety measures.

As a result, some counties enforce the rules and some don’t. And because the state hasn’t stepped in to assist with adequate enforcement, some local officials say, businesses are often free to ignore the rules, allowing the virus to run rampant.

“It would be nice to have some air support from the governor,” said Nevada City Councilman Doug Fleming, who backs the city’s new ordinance imposing fines for violating the state mask mandate. “He’s kind of forcing local jurisdictions to enforce his rules without any air support.”

California is experiencing a COVID surge as never before, setting records almost daily for infections and deaths. Hospitals across the state are running dangerously low on intensive care beds, with the state reporting 2.5% ICU capacity as of Monday.

Most of California is under a mandatory stay-at-home order, which prohibits indoor and outdoor dining and requires closure of a wide swath of businesses, from barbershops to wineries. Retail operations are limited to 20% capacity and churches must hold services outside.

Yet across the state, many people continue to flout the rules, keeping businesses open and refusing to wear masks in public. Pastors Jim and Cyndi Franklin, for instance, continue to hold indoor Sunday sermons at the Cornerstone Church in Fresno. Bars in Los Angeles County were packed with maskless football fans on a recent Sunday. And the owners of Calla Lily Crepes in Nevada City have repeatedly refused to close or require masks despite more than 20 warnings and attempts by Nevada County to gain compliance.

As ICUs run out of capacity, this Huntington Beach, CA scene was posted by a resident noting that today’s Green Bay/ Detroit game can be seen on overhead TVs.

— Margot Roosevelt (@margotroosevelt) December 14, 2020

“We are free thinkers. I hope I’m not stepping out too far by saying we strongly question the masks, but we do,” said Rebecca Sweet Engstrom, who owns the restaurant with her husband, Darren Engstrom. “We feel that it should be people’s choice.”

Newsom in July threatened to withhold money from cities and counties that refuse to enforce public health orders. To date, the state has withheld federal funding from two cities in the Central Valley, Atwater and Coalinga, for allowing businesses to remain open in defiance of state and local health orders.

The governor has also directed 10 state agencies to police egregious violators of state and local health orders, primarily businesses, to protect workers and the public. State enforcement officials have issued few harsh penalties, they argue, because most businesses are complying — and the state doesn’t want to be punitive.

In interviews, regulators described long hours of back-breaking work to inform business owners about the rapidly changing COVID restrictions and enforcement rules.

“We’re not trying to get into an adversarial situation here,” said Erika Monterroza, chief spokesperson for the state Department of Industrial Relations, which oversees Cal/OSHA, the agency responsible for regulating workplace safety and employer public health mandates.

Cal/OSHA issued 219 COVID-related citations to 90 employers from Aug. 25 to Dec. 14, accompanied by about $2.2 million in proposed fines, according to department data. The penalties ranged from $475 on Sept. 30 against a Taco Bell in Anaheim for failing to require employees to maintain 6 feet of physical distance, to $108,000 on Oct. 29 against Apple Bistro in Placerville for not requiring masks indoors and for not providing adequate physical distance between employees and guests. The department is investigating about 1,700 other cases.

The state Board of Barbering and Cosmetology, which regulates about 54,000 salons and barbershops, has levied just two citations and suspended two licenses, both held by Primo’s Barbershop in Vacaville, which has “very adamantly” opposed state health orders, said Matt Woodcheke, a spokesperson for the state Department of Consumer Affairs, which oversees the board.

No citations have been issued for COVID-related public health violations by California’s 280 state parks, nor by the California Highway Patrol.

Regulators said they have felt tremendous angst trying to get businesses to follow rapidly changing rules, but they aim for voluntary compliance and don’t want to cause businesses to go under.

“This is extremely difficult and we don’t want to do it,” said Luke Blehm, an acting supervising agent in charge for the state Department of Alcoholic Beverage Control. “We are all compassionate and empathetic and it’s a very hard thing to tell somebody that they’ve got to close and they may lose everything because of these rules they have to comply with.”

The state Department of Public Health, which is not one of the 10 task force agencies but assists them, has not issued fines or citations for health order violations, even though it is the primary agency responsible for issuing statewide mandates, according to spokesperson Corey Egel.

In New York, by contrast, Cuomo has leaned on political leaders and law enforcement agencies to aggressively police violations of COVID public health rules and has publicly admonished sheriffs who refuse to enforce violations. He ordered a statewide crackdown on bars and restaurants as cases surged this summer after contact-tracing data indicated drinking and dining were a major source of community spread, said Cuomo spokesperson Jack Sterne.

In hard-hit counties and towns where political leadership rebuffed enforcement, the Cuomo administration deployed COVID strike teams composed of state inspectors — in some cases, retrained Department of Motor Vehicles employees — to police business violations of public health rules. Cuomo argues it has made a difference.

“Compliance on bars has increased dramatically from when we started,” he said in September, “because if you know someone is going to check, if you know there’s monitoring, people tend to increase compliance.”

In California, some counties are enforcing COVID restrictions. San Diego County is dedicating six sheriff’s deputies to the cause and fines repeat violators up to $1,000.

“We’re supportive of enforcement here,” said San Diego County Sheriff’s Lt. Ricardo Lopez. “COVID-19 is exploding and our view is, let’s get this over with as fast as possible.”

But elsewhere, county health officers pushing for stricter enforcement face intense political opposition from their bosses and law enforcement agencies. Sacramento County, for example, dropped its plan to impose fines this month after confronting resistance from businesses. Sacramento County Sheriff Scott Jones also has refused to enforce mask and other public health mandates.

Dr. Georges Benjamin, executive director of the American Public Health Association, said the state, ideally, should develop a consistent statewide enforcement system that starts with warnings and a strong public messaging campaign, then moves to graduated fines if noncompliance continues.

Until that happens, local leaders say, the patchwork of rules and enforcement strategies is causing confusion and chaos.

“People are continuing to disobey,” said Dr. Olivia Kasirye, Sacramento County’s health officer. “Some people are outright angry with us, asking why aren’t we doing something, but all we can do is refer problems to the state enforcement agencies.”

This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.


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‘Nine Months Into It, the Adrenaline Is Gone and It’s Just Exhausting’


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In March, during the first week of the San Francisco Bay Area’s first-in-the-nation stay-at-home order, KHN spoke with emergency department physicians working on the front lines of the burgeoning COVID-19 pandemic. At the time, these doctors reported dire shortages of personal protective equipment and testing supplies. Health officials had no idea how widespread the virus was, and some experts warned hospitals would be overwhelmed by critically ill patients.

In the end, due to both the early sweeping shutdown order and a state-sponsored effort to bolster the supply chain, Bay Area hospitals were able to avert that catastrophe. The region so far has fared much better than most other U.S. metro regions when it comes to rates of COVID infection and death. Even so, with intensive care unit capacity dwindling to critical levels statewide, San Francisco on Thursday issued another drastic order, announcing a mandatory 10-day quarantine for anyone returning to the city who has spent time outside the region.

Amid this fierce second surge, we circled back last week to check in with Dr. Jeanne Noble, director of the COVID response at the University of California-San Francisco medical center emergency department, to get her reflections on the Bay Area’s experience. She explained how even as her hospital has made so many improvements, including recently launching universal testing so that everyone who comes to the emergency room is tested for COVID-19, the lockdown and burnout are wearing on her and her colleagues. The conversation has been edited for length.

Q: How are you doing at UCSF right now? 

We’re OK in terms of our numbers. We have our ICU capacity; today’s numbers are 74% occupied. Acute care is a little bit tighter; the emergency department is seeing an increase in patients. [Editor’s note: As of Sunday, ICU capacity had dropped to 13%.]

We did have a period of time before this last surge where we often had a few days with no COVID patients. That was great. That ended in late September. This morning we have 11 patients on ventilators in the ICU.

I think we’re the first hospital in the state for universal testing. Everyone who comes to the ER gets tested. I’ve been working on this for months, but it’s new this week. Now we have testing, so we don’t have to do so much guesswork.

Q: When we spoke during the week of the first stay-at-home order, back in March, you were very worried. How do things compare now?

The supply [of masks] is just much better than it was back in March. In March, we had furloughed engineers from our local museum, the Exploratorium, making us face shields, and we started a makers lab in the library across the street to make supplies. It doesn’t feel like that this time around. We have a longer horizon.

I think in terms of our COVID care and our hospital capacity, we are fine. But my own sort of perspective on all of this is: When are we going to be done with this? Because even though things are smoother — we have PPE, we have testing — it’s a tremendous amount of work and stress. Frankly, the fact that my children have not been in school since March is one of my major sources of stress.

We’re all working way more than we ever have before. And nine months into it, the adrenaline is gone and it’s just purely exhausting.

Q: Can you tell me more about that, the physical and emotional toll on the hospital staff?

We don’t allow eating in the ED anymore, so we don’t have break rooms. Especially if you’re the supervising doctor, you need to do this elaborate handoff to another doctor if you need to eat. You know, it’s 10 hours into your shift and you want a cup of coffee.

The hassles and the discomforts. Wearing an N95 day after day is really uncomfortable. A lot of us have ulcers on our noses. They become painful.

And the lack of being able to socialize with colleagues is hard. The ED has always been a pretty intense environment. That’s offset by this closeness and being a team. All of this emotional intensity, treating people day after day at these incredible junctures in their lives — a lot of the camaraderie and morale comes from being able to debrief together. When you’re not supposed to be closer than a few feet from one another and you don’t take off your masks, it’s a lot of strain.

People are much less worried about coming home to their families. It hasn’t been the fomite disease we were all worried about initially, worried we’d give our kids COVID from our shoes. But there’s still the concern. Every time you get a runny nose or a sore throat you need to get tested, and you worry about what if you infected your family.

Q: So will you and your colleagues be able to take a break over the holidays?

We’ll see what happens. We’re just now starting to feel like we’re seeing the post-Thanksgiving numbers. But I think that even without having to do extra shifts in the ED, certainly for someone like me doing COVID response, there’s always a huge number of issues to work through. We just got the monoclonal antibodies, which is great, but that’s a whole new workflow.

I think what is going to bother people the most is that we are in lockdown. Kind of longing for that relaxation and time with family that we’re all kind of craving.

Q: It sounds like things are hard, but the hospital is in a relatively good place.

I was deployed to the Navajo Nation and helped with their surge in May in Gallup, New Mexico, and that is much, much harder than what we’ve faced in the Bay Area. In Gallup, at Indian Health Service, they were incredible in just the can-do attitude with way fewer resources than we have here. As of this summer, they had had the worst per capita surge in the country. They redesigned their ED essentially by cutting every room in half, hanging plastic on hooks you would use to hang your bicycle wheel. They hung thick plastic and right there doubled their capacity of patients they could see.

Our tents at UCSF are these blue medical tents with HVAC systems, heaters, negative pressure. They are really nice. There they had what looked like beach cabanas — open walls with just a tent overhead. In March and April they were taking care of patients in the snow. In the summer, it was hot and windy. When I was there, almost every single one of my patients had COVID.

That level of intensity was not something we had to go through in the Bay Area. Not to say that it’s easy [here]; I just told you all the ways it’s hard. But everything is relative. In terms of the COVID landscape, we have been very lucky.

Q: The Bay Area was early to close and has had stricter regulations than many parts of the country. As someone directly affected, what do you think of the response?

I think that we have benefited from early closures, unquestionably, when we did our shelter-in-place in March and probably saved 80,000 lives. It was really a tremendous and a bold move.

We’ve done some things well and other things not so well. We were very late to implement closures in a targeted fashion. Restaurants and dining reopened this summer, and a lot of us couldn’t figure out why indoor dining was open. Why is indoor dining something we need to even be considering when we’ve just barely flattened our curve? It was very predictable that cases would go up when dining happened. And they did.

We need to evaluate what is more important for our society and well-being, and to say what is the risk associated with that activity. Schools are of high social value. And [the closures are] really hard for kids. We’re seeing a lot of adolescents with suicidal ideation brought to the emergency department, which is related to school closure. I would put dining and restaurants as being of minimal social importance and very high risk.

We could have done this better. Closing [down society] when numbers go up is reasonable and that saves lives. But I think we know enough that it should not be an across-the-board closing. I mean, with this latest order, they temporarily closed parks. And we’ve been telling people to go outside. It’s like, what? Are you kidding?

This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.


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No More ICU Beds at the Main Public Hospital in the Nation’s Largest County as COVID Surges


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She lay behind a glass barrier, heavily sedated, kept alive by a machine that blew oxygen into her lungs through a tube taped to her mouth and lodged at the back of her throat. She had deteriorated rapidly since arriving a short time earlier.

“Her respiratory system is failing, and her cardiovascular system is failing,” said Dr. Luis Huerta, a critical care expert in the intensive care unit. The odds of survival for the patient, who could not be identified for privacy reasons, were poor, Huerta said.

The woman, in her 60s, was among 50 patients so ill with COVID-19 that they required constant medical attention this week in ICUs at Los Angeles County+USC Medical Center, a 600-bed public hospital on L.A.’s Eastside. A large majority of them had diabetes, obesity or hypertension.

An additional 100 COVID patients, less ill at least for the moment, were in other parts of the hospital, and the numbers were growing. In the five days that ended Wednesday, eight COVID patients at the hospital died — double the number from the preceding five days.

As COVID patients have flooded into LAC+USC in recent weeks, they’ve put an immense strain on its ICU capacity and staff — especially since non-COVID patients, with gunshot wounds, drug overdoses, heart attacks and strokes, also need intensive care.

No more ICU beds were available, said Dr. Brad Spellberg, the hospital’s chief medical officer.

Similar scenes — packed wards, overworked medical staffers, harried administrators and grieving families — are playing out in hospitals across the state and the nation.

In California, only 4.1% of ICU beds were available as of Wednesday. In the 11-county Southern California region, just 0.5 % of ICU beds were open, and in the San Joaquin Valley, none were.

The county of Los Angeles, the nation’s largest, was perilously close to zero capacity.

County health officials reported Wednesday that the number of daily new COVID cases, deaths and hospitalizations had all soared beyond their previous highs for the entire pandemic.

LAC+USC has had a heavy COVID burden since the beginning of the pandemic, largely because the low-income, predominantly Latino community it serves has been hit so hard. Latinos represent about 39% of California’s population but have accounted for nearly 57% of the state’s COVID cases and 48% of its COVID deaths, according to data updated this week.

Many people who live near the hospital have essential jobs and “are not able to work from home. They are going out there and exposing themselves because they have to make a living,” Spellberg said. And, he said, “they don’t live in giant houses where they can isolate themselves in a room.”

The worst cases end up lying amid a tangle of tubes and bags, in ICU rooms designed to prevent air and viral particles from flowing out into the hall. The sickest among them, like the woman described above, need machines to breathe for them. They are fed through nose tubes, their bladders draining into catheter bags, while intravenous lines deliver fluids and medications to relieve pain, keep them sedated and raise their blood pressure to a level necessary for life.

To take some pressure off the ICUs, the hospital this week opened a new “step-down” unit, for patients who are still very sick but can be managed with a slightly lower level of care. Spellberg said he hopes the unit will accommodate up to 10 patients.

Hospital staff members have also been scouring the insurance plans of patients to see if they can be transferred to other hospitals. “But at this point, it’s become almost impossible, because they’re all filling up,” Spellberg said.

Two weeks ago, a smaller percentage of COVID patients in the ER were showing signs of severe disease, which meant fewer needed to be admitted to the hospital or the ICU than during the July surge. That was helping, as Spellberg put it, to keep the water below the top of the levee.

But not anymore.

“Over the last 10 days, it is my distinct impression that the severity has worsened again, and that’s why our ICU has filled up quickly,” Spellberg said Monday.

The total number of COVID patients in the hospital, and the number in its ICUs, are now well above the peak of July — and both are nearly six times as high as in late October. “This is the worst it’s been,” Spellberg said. And it will only get worse over the coming weeks, he added, if people travel and gather with their extended families over Christmas and New Year’s as they did for Thanksgiving.

“Think New York in April. Think Italy in March,” Spellberg said. “That’s how bad things could get.”

They are already bad enough. Nurses and other medical staffers are exhausted from long months of extremely laborious patient care that is only getting more intense, said Lea Salinas, a nurse manager in one of the hospital’s ICU units. To avoid being short-staffed, she’s been asking her nurses to work overtime.

Normally, ICU nurses are assigned to two patients each shift. But one really sick COVID patient can take up virtually the entire shift — even with help from other nurses. Jonathan Magdaleno, a registered nurse in the ICU, said he might have to spend 10 hours during a 12-hour shift at the bedside of an extremely ill patient.

Even in the best case, he said, he typically has to enter a patient’s room every 30 minutes, because the bags delivering medications and fluids empty at different rates. Every time nurses or other care providers enter a patient’s room, they must put on cumbersome protective gear — then take it off when they leave.

One of the most delicate and difficult tasks is a maneuver known as “proning,” in which a patient in acute respiratory distress is flipped onto his or her stomach to improve lung function. Salinas said it can take a half-hour and require up to six nurses and a respiratory therapist, because tubes and wires have to be disconnected, then reconnected — not to mention the risks involved in moving an extremely fragile person. And they must do it twice, because every proned patient needs to be flipped back later in the day.

For some nurses, working on the COVID ward at LAC+USC feels very personal. That’s the case for Magdaleno, a native Spanish speaker who was born in Mexico City. “I grew up in this community,” he said. “Even if you don’t want to, you see your parents, you see your grandparents, you see your mom in these patients, because they speak the language.”

He planned to spend Christmas only with members of his own household and urged everyone else to do the same. “If you lose any member of your family, then what’s the purpose of Christmas?” he asked. “Is it worth it going to the mall right now? Is it worth even getting a gift for somebody who’s probably going to die?”

That the darkest hour of the pandemic should come precisely at the moment when COVID vaccines are beginning to arrive is especially poignant, said Dr. Paul Holtom, chief epidemiologist at LAC+USC.

“The tragic irony of this is that the light is at the end of the tunnel,” he said. “The vaccine is rolling out as we speak, and people just need to keep themselves alive until they can get the vaccine.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.


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Hospitals sue drug companies over discount program

The lawsuit follows action by at least a half-dozen drug companies to rein in what they see as waste and abuse in the program, overseen by the Department of Health and Human Services. Meanwhile, the Hospital plaintiffs have a potentially powerful ally in the person picked to head the department under the incoming Biden administration.

Alzheimer’s Inc.: Colleagues Question Scientist’s Pricey Recipe Against Memory Loss

This story also ran on Daily Beast. It can be republished for free.

When her husband was diagnosed with early-stage Alzheimer’s disease in 2015, Elizabeth Pan was devastated by the lack of options to slow his inevitable decline. But she was encouraged when she discovered the work of a UCLA neurologist, Dr. Dale Bredesen, who offered a comprehensive lifestyle management program to halt or even reverse cognitive decline in patients like her husband.

After decades of research, Bredesen had concluded that more than 36 drivers of Alzheimer’s cumulatively contribute to the loss of mental acuity. They range from chronic conditions like heart disease and diabetes to vitamin and hormonal deficiencies, undiagnosed infections and even long-term exposures to toxic substances. Bredesen’s impressive academic credentials lent legitimacy to his approach.

Pan paid $4,000 to a doctor trained in Bredesen’s program for a consultation and a series of extensive laboratory tests, then was referred to another doctor, who devised a stringent regimen of dietary changes that entailed cutting out all sugars, eating a high-fat, low-carbohydrate diet and adhering to a complex regimen of meditation, vigorous daily exercise and about a dozen nutritional supplements each day (at about $200 a month). Pan said she had extensive mold remediation done in her home after the Bredesen doctors told her the substance could be hurting her husband’s brain.

But two years passed, she said, and her husband, Wayne, was steadily declining. To make matters worse, he had lost more than 60 pounds because he didn’t like the food on the diet. In April, he died.

“I imagine it works in some people and doesn’t work in others,” said Pan, who lives in Oakton, Virginia. “But there’s no way to tell ahead of time if it will work for you.”

Bredesen wrote the best-selling 2017 book “The End of Alzheimer’s” and has promoted his ideas in talks to community groups around the country and in radio and TV appearances like “The Dr. Oz Show.” He has also started his own company, Apollo Health, to market his program and train and provide referrals for practitioners.

Unlike other self-help regimens, Bredesen said, his program is an intensely personalized and scientific approach to counteract each individual’s specific deficits by “optimizing the physical body and understanding the molecular drivers of the disease,” he told KHN in a November phone interview. “The vast majority of people improve” as long as they adhere to the regimen.

Bredesen’s peers acknowledge him as an expert on aging. A former postdoctoral fellow under Nobel laureate Stanley Prusiner at the University of California-San Francisco, Bredesen presided over a well-funded lab at UCLA for more than five years. He has been on the UCLA faculty since 1989 and also founded the Buck Institute for Research on Aging in Marin County. He has written or co-authored more than 200 papers.

But colleagues are critical of what they see as his commercial promotion of a largely unproven and costly regimen. They say he strays from long-established scientific norms by relying on anecdotal reports from patients, rather than providing evidence with rigorous research.

“He’s an exceptional scientist,” said George Perry, a neuroscientist at the University of Texas-San Antonio. “But monetizing this is a turnoff.”

“I have seen desperate patients and family members clean out their bank accounts and believe this will help them with every ounce of their being,” said Dr. Joanna Hellmuth, a neurologist in the Memory and Aging Center at UCSF. “They are clinging to hope.”

Many of the lifestyle changes Bredesen promotes are known to be helpful. “The protocol itself is based on very low-quality data, and I worry that vulnerable patients and family members may not understand that,” said Hellmuth. “He trained here” — at UCSF — “so he knows better.”

The Bredesen package doesn’t come cheap. He has built a network of practitioner-followers by training them in his protocol — at $1,800 a pop — in seminars sponsored by the Institute for Functional Medicine, which emphasizes alternative approaches to managing disease. Apollo Health also offers two-week training sessions for a $1,500 fee.

Once trained in his ReCODE Protocol, medical professionals charge patients upward of $300 for a consultation and as much as $10,500 for eight- to 15-month treatment packages. For the ReCODE protocol, aimed at people already suffering from early-stage Alzheimer’s disease or mild cognitive decline, Apollo Health charges an initial $1,399 fee for a referral to a local practitioner that includes an assessment and extensive laboratory tests. Apollo then offers $75-per-month subscriptions that provide cognitive games and online support, and links to another company that offers dietary supplements for an additional $150 to $450 a month. Insurance generally covers little of these costs.

Apollo Health, founded in 1998 and headquartered in Burlingame, California, also offers a protocol geared toward those who have a family history of dementia or want to prevent cognitive decline.

Bredesen estimates that about 5,000 people have done the ReCODE program. The fees are a bargain, Bredesen said, if they slow decline enough to prevent someone from being placed in a nursing home, where yearly costs can climb past $100,000 annually.

Bredesen and his company are tapping into the desperation that has grown out of the failure of a decades-long scientific quest for effective Alzheimer’s treatments. Much of the research money in the field has narrowly focused on amyloid — the barnacle-like gunk that collects outside nerve cells and interferes with the brain’s signaling system — as the main culprits behind cognitive decline. Drugmakers have tried repeatedly, and thus far without much success, to invent a trillion-dollar anti-amyloid drug. There’s been less emphasis in the field on the lifestyle choices that Bredesen stresses.

“Amyloids sucked up all the air in the room,” said Dr. Lon Schneider, an Alzheimer’s researcher and a professor of psychiatry and behavioral sciences at the Keck School of Medicine at USC.

Growing evidence shows lifestyle changes help delay the progress of the mind-robbing disease. An exhaustive Lancet report in August identified a long list of risk factors for dementia, including excessive drinking, exposure to air pollution, obesity, loss of hearing, smoking, depression, lack of exercise and social isolation. Controlling these factors — which can be done on the cheap — could delay or even prevent up to 40% of dementia cases, according to the report.

Bredesen’s program involves all these practices, with personalized bells and whistles like intermittent fasting, meditation and supplements. Bredesen’s scientific peers question whether data supports his micromanaged approach over plain-vanilla healthy living.

Bredesen has published three papers showing positive results in many patients following his approach, but critics say he has fallen short of proving his method’s effectiveness.

The papers lack details on which protocol elements were followed, or the treatment duration, UCSF’s Hellmuth said. Nor do they explain how cognitive tests were conducted or evaluated, so it’s difficult to gauge whether improvements were due to the intervention, to chance variations in performance or an assortment of other variables, she said.

Bredesen shrugs off the criticism: “We want things to be in an open-access journal so everybody can read it. These are still peer-reviewed journals. So what’s the problem?”

Another problem raised about Bredesen’s enterprise is the lack of quality control, which he acknowledges. Apollo-trained “certified practitioners” can include everyone from nurses and dietitians to chiropractors and health coaches. Practitioners with varying degrees of training and competence can take his classes and hang out a shingle. That’s a painful fact for some who buy the package.

“I had the impression these practitioners were certified, but I realize they all had just taken a two-week course,” said a Virginia man who requested anonymity to protect his wife’s privacy. He said that he had spent more than $15,000 on tests and treatments for his ailing spouse and that six months into the program, earlier this year, she had failed to improve.

Bredesen said he and his staff were reviewing “who’s getting the best results and who’s getting the worst results,” and intended to cut poor performers out of the network. “We’ll make it so that you can only see the people getting the best results,” he said.

Colleagues say that to test whether Bredesen’s method works it needs to be subjected to a placebo-controlled study, the gold standard of medical research, in which half the participants get the treatment while the other half don’t.

In the absence of rigorous studies, said USC’s Schneider, a co-author of the Lancet report, “saying you can ‘end Alzheimer’s now and this is how you do it’ is overpromising and oversimplifying. And a lot of it is just common sense.”

Bredesen no longer says his method can end Alzheimer’s, despite the title of his book. Apollo Health’s website still makes that claim, however.

This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.


This story can be republished for free (details).

Immunai joins 10x Genomics program to boost drug development

Together, the two companies say can give drugmakers a better view at the cellular level of how a patient’s immune system is responding to a cerain therapy.

How to Pull Off a COVID-Era Music Festival

BEVERLY HILLS, Calif. — As the pandemic took hold and well-grooved music festivals canceled their mainstream events, Krista Selico saw an opening. She had been organizing the Helix Festival as an opportunity to give artists in the urban music community a chance to redefine the genre for themselves, as well as choose more racially diverse headliners.

The industry’s destination festivals had excluded many diverse performers and types of music, she said, adding: “Urban music is so much more than what we hear on the radio.”

Although the COVID crisis dealt a blow to entertainment events worldwide, it also gave birth to new channels of entertainment. Netflix, Fever and Secret Cinema joined forces to create the Stranger Things “drive-into experience,” an immersive drive-thru concept that leads patrons through the world of the Netflix series “Stranger Things” from the safety — and distance — of their cars. A R I Z O N A, a band signed by Atlantic Records, performed an immersive livestream concert from Nashville on Oct. 29 through mySongbird, a new live-performance streaming app. Comedian Dave Chappelle has been hosting physically distanced comedy shows and music events at Wirrig Pavilion in Yellow Springs, Ohio, since May.

And Selico’s Helix Festival seemed primed for the COVID era.

Her goal was to feature less-mainstream offerings in a protected Caribbean environment — reportedly more affordable this year because COVID-19 has greatly eaten into conventional tourism. The lineup included Noise Cans, a Bermuda-born DJ based in the U.S. known as Collas who fuses Caribbean carnival music with electronic dance, Nigerian-American Afrobeats star Davido, and contemporary R&B/hip-hop artist Ty Dolla $ign.

“It’s called Helix Festival because we’re talking about our DNA,” said Selico, a University of Southern California graduate and health care administrator in Los Angeles. The festival was scheduled for October and sales were hot, with tickets in the $1,800-$3,000 price range.

Of course, with the pandemic spreading, Selico realized that festival patrons would see more health and safety precautions implemented. That could mean limited-capacity tickets with potentially higher price tags, suggesting that, in turn, artists and promoters would have to offer more of an experience in exchange for those sales.

At USC, Selico majored in cultural arts, with an emphasis in classical voice. She loved singing opera but felt shut out of the operatic world due to race. As a Black woman, she said, she felt pressured to fit into the limited mainstream molds Black artists are often pressed into: mainly hip-hop and R&B. She created Helix Festival to elevate and broaden the urban music menu.

Selico had been planning the luxury, urban music festival for two years before the pandemic hit. Because the festival was designed to be high-end, boasting private accommodations for attendees, she and her crew pushed forward with planning and promoting through the summer months, even as established festivals were canceling (many not offering refunds). “We’ll be on lockdown for two weeks, then two weeks turns into two months … but the ticket sales continued and no one’s asking for refunds,” she said.

Some large festivals such as Tomorrowland — a two-week-long Belgian electronic dance music festival — went fully virtual using streaming services, but Selico’s was planned for overseas, on an island — Jamaica — with a low COVID case count. And at an expansive resort — the Bahia Principe Grand in Runaway Bay — where safe outdoor enjoyment and social distancing seemed plausible.

The festival’s COVID-19 precautions were developed using the same protocols established by Jamaica’s Ministry of Tourism, Ministry of Health & Wellness (MoHW), the Jamaica Tourist Board and the Tourism Product Development Co. From intake to departure, Selico said, coronavirus precautions would be in place.

She knew she would have to orchestrate her first festival with more precautions than any prior such event and less of a fun-filled, devil-may-care attitude: “If someone gets dehydrated and passes out, we’ve got to test them for everything now,” she said.

Because of the setting, Selico reasoned that COVID-era safety adjustments wouldn’t seem onerous. Even before the pandemic, a luxury component of Helix was private beach “pods” for patrons spaced at least 6 feet apart for lounging on the beach. And “everything is digital,” she said. There would be no exchange of physical money or tickets at Helix Festival, similar to procedures restaurants across America are adopting, along with doing away with physical menus.

She put extra safeguards in place:

  • Attendees would be required to submit negative COVID test results 48 hours before arrival and, in lieu of rum punch, would be greeted with temperature checks at the airport, at other transit points and before entering the festival grounds. Face masks would be required on all trips to and from the airport and resort.
  • If an attendee exhibited COVID-19 symptoms, the Helix Festival site stated, they would be moved into a designated isolation room at the venue for screening by a COVID-19 Safety Point Person — an employee designated to conduct spot checks, which the Jamaican government now requires of both the hotel and festival organizers. The MoHW would be contacted and, if necessary, the attendee would be put into mandatory quarantine.
  • During concerts, guests would be seated in every other seat in all open seating areas, while groups who arrive together could sit next to one another. A minimum distance of 6 feet would be maintained between patrons and performers on designated stage areas, an easy feat considering the Helix Festival’s main stage was to be set on the ocean in the middle of a small bay on the resort.
  • For an even more enhanced luxury experience, and elevated social distancing, guests could purchase such upgrades as a VIP cabana for up to six people, or for $6,000 guests could rent a private catamaran — the festival’s version of box seats — for up to 10 people, docked around the floating stage.

When patrons weren’t getting their urban music palates expanded by acts on the main stage, themed events would feature visual artists, fire dancers and even a hologram light show presented by Chad Knight, a 3D designer with Nike. These activities — including any water sports — would be limited to follow social distancing requirements, the festival’s site stated.

According to the festival site, no food or beverages would be sold on festival grounds — another break from pre-COVID music festivals. Prepaid top-shelf liquor and snack boxes would be prepackaged and individually sealed before distribution at check-in. Hand-sanitizer stations would be strategically placed throughout the festival grounds, as well as touchless waste bins.

As of Dec. 10, Jamaica — the fourth-most-populous country in the Caribbean — had seen over 11,509 COVID-19 cases and 270 deaths, according to the government’s ministry of health and wellness website. Currently, travelers to Jamaica must apply for travel authorization through the Jamaica Tourist Board, including an upload of the results from a valid PCR test performed no more than seven days from their arrival date.

With the average ticket pricing starting at around $2,000 and no sure way to guarantee attendees would be permitted across the Jamaican border or quarantined, in late August Selico decided to postpone the festival until fall 2021. Tickets to the nearly sold-out event were refunded at 100%. “We’re going to add more artists. We’re going to be able to expand on this health care aspect,” Selico said.

And, since COVID-19 is likely to be around for a while, vaccine or not, she is confident she has developed the expertise to be a pandemic-friendly festival promoter. “I think this is the model for festivals going forward,” Selico said.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.


This story can be republished for free (details).

Which Rice Has the Least Amount of Arsenic: Black, Brown, Red, White, or Wild?

Brown rice contains more arsenic than white rice, but the arsenic in brown rice is less absorbable, so how does it wash out when you compare the urine arsenic levels of white-rice eaters to brown-rice eaters?

Arsenic in rice is a cause for concern, according to a consensus statement by the European and North American societies for pediatric nutrition. At the very least, “in areas of the world where rice consumption is high in all ages, authorities should be prompted to declare which of the rice [types] have the lowest arsenic content and are, therefore, the least harmful for use during infancy and childhood.” I look into the arsenic content of different rices in my video Which Rice Has Less Arsenic: Black, Brown, Red, White, or Wild?.

Extensive recent testing by the FDA found that long grain white rice, which is what most people eat, appears to have more arsenic than medium or short grain rice, but this may be because most of the shorter grains are produced in California, which has significantly less contaminated rice paddies than those in the South, such as in Texas or Arkansas, where most of the long grain rice is grown. So, it’s less long grain versus short grain than white rice versus brown rice, as the mean concentration of inorganic arsenic in parts per billion of long grain white rice is 102.0 and 156.5 in short, medium, and long grain brown rice, as you can see at 0:54 in my video.

What about some of the naturally pigmented varieties like red rice or black rice, which may be even healthier than brown? As you can see at 1:08 in my video, they may contain even less arsenic than white rice. One sample of black rice from China that was purchased in Kuwait had higher levels for total arsenic, so the toxic inorganic portion may only be half that, putting it on par with U.S. brown rice. The study’s red rice sample from Sri Lanka was even more extraordinary, with less than a fifth of the arsenic of the Chinese black rice. But, the Sri Lankan red rice sample had a ridiculous high amount of cadmium, evidently attributed to the cadmium content of widely used Sri Lankan fertilizers.

Colored rice samples purchased mostly in the United States were better than brown or white, and a dozen samples of red rice purchased in Europe were as bad, or even worse, as brown rice. I was hoping that wild rice would have little or no arsenic because it’s a totally different plant, but an average of eight samples showed it to be nearly comparable to white, though the wild rice samples contained only half as much toxic arsenic as brown rice.

As you can see at 2:06 in my video, the arsenic found in a daily serving of white rice carries 136 times the acceptable cancer risk, but brown rice is even riskier at 162. Brown rice averages two-thirds more toxic arsenic than white rice. But, is that just because brown rice tends to be a different strain or grown in different places? No. If you take the exact same batch of brown rice and measure the arsenic levels before and after polishing it to white, you do get a significant drop in arsenic content.

It’s not what you eat, though. It’s what you absorb. The arsenic in brown rice appears to be less bioavailable than the arsenic in white rice. The texture of brown rice may cut down on the release of arsenic from the grain, or perhaps the bran in brown rice helps bind it up. Regardless, taking bioavailability into account, the difference in arsenic levels in white versus brown rice may be a third more, rather than 70 percent more, as you can see at 2:57 in my video. This estimate, however, was based on an in vitro gastrointestinal fluid system in which researchers strung together beakers and tubes to mimic our gut, with one flask containing stomach acid and another intestinal juices. What happened when it was tested in humans? Yes, “evidence suggests that brown rice may contain more arsenic than white rice,” but the researchers aimed to determine how much is actually absorbed by measuring the urine levels of arsenic in white-rice eaters compared with brown-rice eaters. For the arsenic to get from the rice into your bladder, it has to be absorbed through your gut into your bloodstream.

As you can see at 3:45 in my video, the urine of thousands of American test subjects who don’t eat rice at all still contains about 8 micrograms of toxic, carcinogenic arsenic a day. It’s in the air, it’s in the water, and there’s a little bit in nearly all foods. But, eat just one food—a cup or more of white rice a day—and your arsenic exposure shoots up by 65 percent to about 13 micrograms a day.

What about those who eat a cup or more of brown rice every day, which technically contains even more arsenic? Their exposure shoots up the same 65 percent. There is no difference between the urine arsenic levels of white-rice eaters compared with brown-rice eaters. However, this was not an interventional study in which they fed people the same amount of rice to see what happened, which would have been ideal. Instead, it was a population study, so maybe the reason the levels are the same is that white-rice eaters eat more rice than do brown-rice eaters. Could that be why they ended up with the same levels? We don’t know, but it should help to put the minds of brown-rice eaters to rest. But would it be better to eat no rice at all? That’s what I’ll explore in my next few blogs.

 If you’re just joining in on this topic, check out these lead-up videos:


It seems like each of these videos just raises more questions, but don’t worry because I’ve got answers for you. See:

In health,

Michael Greger, M.D.

PS: If you haven’t yet, you can subscribe to my free videos here and watch my live presentations:


High-Poverty Neighborhoods Bear the Brunt of COVID’s Scourge

Over the course of the pandemic, COVID-19 infections have battered high-poverty neighborhoods in California on a staggeringly different scale than more affluent areas, a trend that underscores the heightened risks for low-wage workers as the state endures a deadly late-autumn surge.

A California Healthline review of local data from the state’s 12 most populous counties found that communities with relatively high poverty rates are experiencing confirmed COVID-19 infection rates two to three times as high as rates in wealthier areas. By late November, the analysis found, about 49 of every 1,000 residents in the state’s poorest urban areas — defined as communities with poverty rates higher than 30% — had tested positive for COVID-19. By comparison, about 16 of every 1,000 residents in comparatively affluent urban areas —communities with poverty rates lower than 10% — had tested positive.

Epidemiologists say the findings offer evidence of the outsize risk being shouldered by the millions of low-wage workers who live in those communities and do the jobs state and federal officials have deemed essential in the pandemic. These are the grocery store clerks, gas station cashiers, home health aides, warehouse packers, meat processors, hospital janitors and myriad other retail and service employees whose jobs keep the rest of us comfortable, clothed and fed. Those jobs cannot be done remotely.

“People are being forced to go to work, possibly not able to protect themselves adequately,” said Dr. Christian Ramers, an infectious disease specialist at Family Health Centers of San Diego. “If you are living paycheck to paycheck, it’s a very hard decision for some people, if they feel OK, to not go to work or to even quarantine if they know that they were exposed, because they need to pay rent and they need to pay the bills.”

To examine income and COVID infection rates, California Healthline obtained data showing the number of cases for each ZIP code in nine of the state’s 12 most populous counties: AlamedaFresnoKernOrangeRiversideSacramentoSan DiegoSan Francisco and Santa Clara. For three other counties that organize the data differently — Los AngelesContra Costa and San Bernardino — we obtained infection rates at the neighborhood and city level. We then cross-referenced those infection figures with U.S. census data showing poverty levels by community. Federal regulations set the poverty line for the 48 contiguous states at $26,200 in annual income for a family of four.

The analysis revealed a common pattern of COVID spread, in which neighborhoods within the same city, often just miles apart, had vastly different infection rates, with higher-poverty areas hit hardest.

For example, in the 94621 ZIP code in southern Oakland, where nearly 30% of residents live below the poverty line, there were about 54 confirmed infections per 1,000 people as of late November. Several miles north, in the 94618 ZIP code — the Rockridge and Upper Rockridge neighborhoods, where about 5% of residents live below the poverty line — there were about four confirmed infections per 1,000 people as of late November.

At Family Health Centers of San Diego, which operates dozens of primary care, dental and behavioral health clinics in San Diego County, more than 90% of patients qualify as low-income and nearly 30% don’t have insurance. Ramers said the recent surge in coronavirus cases has ripped through his patients’ communities at a quicker pace than in San Diego’s many affluent neighborhoods.

“It’s southeast San Diego, it’s El Cajon and it’s all of the South Bay communities right by the [Mexican] border,” Ramers said. “They have the lowest socioeconomic status amongst other indicators, and that is exactly where we’re seeing the hardest-hit communities with COVID.”

Ramers said he recently treated a patient who works at a sandwich shop. She developed a fever and told her boss she had possible COVID symptoms. “He said, ‘No, you have to get to work,’” Ramers said. “I started asking about what kind of PPE [personal protective equipment] does she get? She is in a crowded kitchen making sandwiches for hundreds of people, probably, and I think she got one mask every couple of days.”

Her employer ultimately gave her permission to miss work, but only after Ramers confirmed the COVID diagnosis and issued a formal doctor’s note saying she needed to stay home.

Research indicates residents of low-income neighborhoods are curtailing outings and social gatherings as much as anyone else during the pandemic — with the key exception that, unlike many white-collar workers, they have to leave home to work. Jonathan Jay, assistant professor of community health sciences at Boston University, recently co-authored a study that used smartphone data to see whether people in low-income areas were maintaining physical distance as much as people in more affluent areas.

“We didn’t find anything that would confirm the idea that lower-income people were unaware or unmotivated,” Jay said. “What we found was suggestive of their having the same level of awareness, the same level of motivation, and simply the only evidence we found to explain the difference in physical distancing was the work-related behaviors.”

Dr. Kirsten Bibbins-Domingo, professor and chair of the Department of Epidemiology and Biostatistics at the University of California-San Francisco, noted that low-wage workers also tend to live in densely crowded households. In other words, she said, it is often hard to isolate yourself if you are poor.

“If somebody has a positive test, I advise them that they should not be living with other people in their household; or, if they have to stay in the same household, that they separate to a separate room, a separate bathroom, ideally, and that people wear masks in the house,” she said.

“You can see that if their normal living environment is doubled up, tripled up, quadrupled up, that those strategies won’t work.”

Bibbins-Domingo called on community and business leaders to embrace policies that ensure essential workers get paid time off if they contract COVID-19. Legislators at the federal and state level have passed laws intended to expand the ranks of employees guaranteed paid sick leave for COVID-19, but many small businesses are exempt. She said public agencies also should consider paying for hotel rooms so people who live in crowded households can quarantine.

She praised California’s decision to tie COVID-related restrictions on activities in each county to a “health equity metric,” which ensures infection rates are low in all neighborhoods, not just wealthy ones.

“What the failure has been is to recognize that poor communities always have higher transmission during a pandemic; that we sort of expect to happen,” she said. “Knowing that is going to happen, it’s the responsibility of policymakers to actually put protections in place, to help the communities with the least resources to address the needs in the pandemic.”

Phillip Reese is a data reporting specialist and an assistant professor of journalism at California State University-Sacramento.


Data for this article came from 12 county health departments and the U.S. Census Bureau’s five-year 2014-18 American Community Survey. The Census Bureau creates geographies called ZIP Code Tabulation Areas that are based on ZIP codes but may not exactly match ZIP code boundaries. For most counties, a ZIP code is the smallest geography available for infection data released online. Infection data was obtained from county websites on Nov. 23. All counties appear to update their ZIP code data frequently but some may lag more than others. When available, the analysis used confirmed infection rates and population data provided by counties; otherwise, census data was used to calculate infection rates. The analysis excluded ZIP codes, cities and neighborhoods with fewer than 5,000 residents.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.


This story can be republished for free (details).

Law Will Allow Calif. to Produce, Distribute Biosimilars, Generics

That is the title of an article by Angela Maas in Radar on Specialty pharmacy (reprinted here). A few excerpts:

“Although state governments frequently pay for health care through programs such as Medicaid, in the past, state governments have not manufactured drugs,” says Jason Shafrin, vice president of health economics at PRECISIONheor. “Thus, this is a significant departure from the status quo. The California state government, however, does not have a robust set of government-owned drug manufacturing facilities to start making its own drug either.”

Why would manufacturers contract with California to produce drugs?

Shafrin tells AIS Health that there are two key reasons for manufacturers to contract with California. First, the drugs will be available without rebates. For this reason, “manufacturers could lower their list price but not lose much funds by simply cutting out the middleman — the pharmacy benefit managers — and avoiding having to pay rebates.”
Second, he notes that “California is a large market, and it could be the case that these ‘Made in California’ drugs would have preferred status among California payers. The bill notes that the state needs to consult with key state purchasers including Public Employees’ Retirement System, the State Department of Health Care Services, the California Health Benefit Exchange (Covered California), the State Department of Public Health, the Department of General Services, and the Department of Corrections and Rehabilitation. Getting access to all these large California payers could be lucrative if the reimbursement price is reasonable.”

Do read the whole article here.

Which Brands and Sources of Rice Have the Least Arsenic?

Arsenic levels were tested in 5,800 rice samples from 25 countries.The arsenic found in five servings of rice a week poses a hundred times the acceptable cancer risk. What did the rice industry have to say about that? When the story first broke in the media that U.S. rice had some of the highest arsenic levels in the world, the USA Rice Federation said, “Enough nonsense about arsenic already!” in the August 9, 2005, issue of USA Rice Daily, its daily newsletter. The study, in its mind, was “not only inaccurate in the highest degree, but also maliciously untrue.” One of the researchers responded, “By not addressing this problem [of arsenic] that has been ignored for decades, the U.S. cotton-belt rice industry is doing itself an injustice. “Had the problem been addressed in the past, given that it is well known that arsenic in paddy soils was a problem in the U.S….safe soils would have been identified and low grain arsenic rice varieties developed.” Instead, arsenic-resistant varieties have been developed that build up excessive levels of arsenic without dying themselves. I discuss arsenic levels in rice in my video Which Brands and Sources of Rice Have the Least Arsenic?.

Not all rice producers have been so dismissive, though. After a subsequent Consumer Reports exposé, one rice company detailed “how it is taking matters into its own hands.” Lundberg Farms started testing hundreds of samples of its rice to share the results with the FDA. “We’re committed to providing safe food,” said the CEO, “to really listening to our consumers, and dealing with this problem very openly….” Lundberg Farms isn’t just sharing its results with the FDA, but with everyone.

If you visit its website or go to 1:37 in my video, you can see it apparently followed through on its testing promise for its brown rice. Lundberg Farms use parts per million (ppm) instead of parts per billion (ppb) to make it look better than it is, but compared with the average U.S. brown rice level of 154 ppb, Lundberg does do better. In fact, at 80 ppb, its aromatic brown rice, presumably its brown basmati and brown jasmine, averages less than national white rice levels, as do, apparently, Lundberg’s red and black rices, at 90 ppb. In fact, none of its samples even reached the average U.S. brown rice level.

Consumer Reports found most other brands to be pretty comparable to the U.S. average arsenic levels in brown rice, as you can see at 2:15 in my video, including Uncle Ben’s and Walmart’s Great Value brand. Whole Foods, however, scored the worst with its 365 Everyday Value long grain brown rice, about a third higher than these others and exceeding the national average.

In the largest review to date, based on 5,800 rice samples from 25 countries, the highest total arsenic average came from the United States. U.S. studies averaged overall about double that of rice out of Asia, with the high levels in the United States blamed on “the heavy [historical] use of arsenic-based pesticides.” But arsenic levels were not the same across the United States. Yes, U.S. rice averages twice the arsenic of Asian rice and nearly all rice samples tested in upstate New York that were imported from India or Pakistan had arsenic levels lower than 95 percent of domestically produced rice. But, “[r]ice grown in the U.S. showed the widest overall range…and the largest number of outliers,” due primarily to where it was grown, as you can see at 3:01 in my video. There is significantly more arsenic in Texas and Arkansas rice than rice from California. California rice is comparable to rice produced around the rest of the world. These are presumably some of the data that led Consumer Reports to suggest brown basmati from California, India, or Pakistan might be among the safer rice choices.If the arsenic is from pesticides, would organic rice have less than conventionally grown rice? No, because arsenic pesticides were banned about 30 years ago. It’s just that 30,000 tons of arsenic chemicals had already been dumped onto cotton fields in the southern United States, “so it is understandable that arsenic residues still remain in the environment” even if you don’t add an ounce of new pesticides. That’s why the industry specifically selects for arsenic-resistant varieties of rice plants in the South. If only there were arsenic-resistant humans.

What about other brands of rice? That was the subject of Which Rice Has Less Arsenic: Black, Brown, Red, White, or Wild?.

For even more background, see:

 You may also be interested in:

Kudos to Consumers Union, the wonderful organization that publishes Consumer Reports, for its pioneering work on this and so many other topics.

In health,

Michael Greger, M.D.

PS: If you haven’t yet, you can subscribe to my free videos here and watch my live presentations:


With Becerra as HHS Pick, California Plots More Progressive Health Care Agenda

SACRAMENTO — President-elect Joe Biden didn’t back “Medicare for All” during his campaign.

Yet his choice of California Attorney General Xavier Becerra to serve in the nation’s top health care post is fueling California lawmakers’ most progressive health care dreams, including pursuing a government-run single-payer system at the state level.

“Now it’s much more real, and it energizes me in terms of pushing for single-payer now,” said state Assembly member Ash Kalra (D-San Jose), who is considering spearheading a new single-payer campaign next year — a move he argues is more plausible under the Biden-Harris administration, with Becerra at the helm of the U.S. Department of Health and Human Services.

“It’s not good enough to just say that we believe health care is a human right. We’re now obligated to act,” Kalra said.

Across California, Democrats are changing their political calculus for what could be possible if Becerra, 62, is confirmed to the powerful position. After nearly four years of battling President Donald Trump and federal policies they view as unfriendly, Gov. Gavin Newsom and other Democratic leaders welcome a strong ally who could help make California a laboratory for progressive ideas. He would set the agenda for key federal health care agencies, which have broad authority to steer more money to states and approve their ambitious health care proposals.

Becerra, whose mother emigrated from Mexico, would be the first Latino to serve in the position. He would lead a massive $1.3 trillion federal health care apparatus that oversees agencies responsible for Medicare, Medicaid, vaccines, prescription drug approval and the U.S. public health response to the coronavirus pandemic.

“It’s a game changer for us — the stale era of normalcy versus the fresh era of progress,” Newsom said Monday. “We’re going to take advantage of this moment and these relationships — not unfairly.”

A native Californian with 30 years of political experience, 24 of them in Congress, Becerra has long backed a progressive health care agenda, including single-payer, environmental justice and protecting immigrants’ access to safety-net care. He has fiercely defended the Affordable Care Act and fought to preserve reproductive rights. He has gone after deep-pocketed pharmaceutical companies, and successfully sued a large health system in California for anti-competitive practices.

Newsom said he’s already spoken to Becerra about California’s health care priorities and is “accelerating” a dramatic transformation of the state’s Medicaid program to better serve the chronically sick and those suffering from untreated mental illness.

Immigrant advocates, who are deploying a new strategy to expand the state’s Medicaid program to all income-eligible unauthorized immigrants, plan to lobby Becerra and the Biden administration for additional federal money that could help fast-track it. They also want Becerra to agree to allow young unauthorized immigrants known as “Dreamers” to purchase insurance through Covered California, the state exchange. And California Senate President Pro Tem Toni Atkins said she’s “excited” to seek renewed approval to use federal Medicaid dollars for nontraditional uses, such as combating homelessness and providing emergency housing assistance.

“We’ve had a lot less money to bank on under Trump, but Becerra at HHS bodes well for us,” said Cathy Senderling-McDonald, incoming executive director for the County Welfare Directors Association of California. “We can rethink and possibly open up more federal funding.”

Democrats are also seizing on Becerra’s past support for single-payer, which dates back to his early congressional career in the 1990s. He has described himself as a lifelong single-payer advocate, and when a reporter asked him last year whether the idea is too costly and “pie in the sky,” Becerra responded, “I love pie.”

A young XAVIER BECERRA, Biden’s pick to run HHS, lays out his health care principles as a congressman in 1994.

“We must have universal coverage. We must have portability. We must have choice of provider,” Becerra says, endorsing single-payer.

— Dan Diamond (@ddiamond) December 7, 2020

But it’s unclear whether Becerra as HHS secretary would embrace progressive — and expensive — health care ideas like single-payer. In his first public remarks on his nomination Tuesday, he touted his work helping to pass the Affordable Care Act and said on Twitter he would “build on our progress to ensure every American has access to quality, affordable health care.”

Some congressional Republicans are raising red flags about Becerra’s nomination, which must be confirmed by the U.S. Senate. They cite his anti-Trump stance and opposition to some federal policies, such as a Trump-era Obamacare rule that allows private employers with religious objections to deny workers contraceptive coverage. Becerra has sued the Trump administration 107 times, including 13 times on health care.

Although Becerra has no direct health care experience, “the court has become the arbiter of health policy, and he certainly got experience there,” said Trish Riley, executive director of the National Academy for State Health Policy.

In announcing Becerra as his Cabinet pick Tuesday, Biden described him as someone who is unafraid to take on special interests and has spent his career working to expand health care access and reduce racial health disparities. California, under Becerra’s leadership, led the defense of the federal health care law before the U.S. Supreme Court last month.

“No matter what happens in the Supreme Court, he’ll lead our efforts to build on the Affordable Care Act, to work to dramatically expand coverage and take bold steps to lower health care prescription drug costs,” Biden said at the news briefing.

In Congress, I helped pass the Affordable Care Act. As California’s Attorney General, I defended it. As Secretary of Health and Human Services, I will build on our progress and ensure every American has access to quality, affordable health care—through this pandemic and beyond.

— Xavier Becerra (@XavierBecerra) December 7, 2020

At the outset, however, Becerra would be consumed by managing the U.S. response to the coronavirus pandemic. In his new role, he would oversee the Centers for Disease Control and Prevention and the National Institutes of Health.

“The No. 1 task he’s going to be completely absorbed with is getting this pandemic under control. We need a consistent message,” said Bruce Pomer, a public health expert and chief lobbyist for the California Association of Public Health Laboratory Directors. “It’s going to be critical for the Biden administration to show people that it can be effective at keeping the American people safe.”

Becerra’s public comments Tuesday indicated the pandemic would be his top priority. “The COVID pandemic has never been as vital or as urgent as it is today,” Becerra said, adding that the economic fallout has “thrust families into crisis. Too many Americans are sick or have lost loved ones, too many have lost their jobs.”

But liberal California lawmakers and advocates say the pandemic has made their ambitious health care goals all the more urgent. And should Becerra back a progressive health agenda in California, similar proposals could follow from other states, said Mark Peterson, a professor of public policy, political science and law at UCLA.

“California has pushed the envelope on health care beyond where other states are,” he said. “And that gives more capacity for California sensibilities and ideas to get into the mix in Washington.”

This story was produced by KHN (Kaiser Health News), which publishes California Healthline, an editorially independent service of the California Health Care Foundation. KHN is not affiliated with Kaiser Permanente.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.


This story can be republished for free (details).

Dialysis Industry Spends Millions, Emerges as Power Player in California Politics

SACRAMENTO — The nation’s dialysis industry has poured $233 million into California campaigns over the past four years, establishing its leading companies as a formidable political force eager to protect their bottom line and influence state policy.

This story also ran on Los Angeles Times. It can be republished for free.

Most of the money the industry spent from Jan. 1, 2017, through Nov. 30, 2020, funded the defeat of two union-backed ballot measures that would have regulated dialysis clinics — and eaten into their profits. But the companies and their trade association also stepped up their offense, dedicating about $16.4 million to lobbying and political contributions during the same period, a California Healthline analysis of state campaign finance records shows.

Nearly every member of the legislature, Democratic Gov. Gavin Newsom and his predecessor, former Gov. Jerry Brown, the Democratic and Republican parties, and dozens of political campaigns — including some local school board and city council races — received a contribution from a dialysis company.

“These are very large, very profitable companies,” said Mark Stephens, founder of Prima Health Analytics, a health economics research and consulting firm. “They have a lot to lose. The fear would be that if some of this stuff passed in California, the union would certainly try to get similar measures on the ballot or in the legislatures in other states. The stakes are higher than just California for them.”

Staking Ground in Sacramento

California has about 600 dialysis clinics, which are visited by an estimated 80,000 patients each month, typically three times a week. At the clinics, patients are hooked up to machines that filter toxins and remove excess fluid from their blood because their kidneys can no longer do the job.

Medicare, which covers most dialysis patients, pays a base rate of $239.33 for each dialysis treatment.

DaVita and Fresenius Medical Care North America are the largest dialysis providers in the state and country, operating roughly 80% of clinics nationwide. Last year, DaVita reported $811 million in net income, on revenue of $11.4 billion. Fresenius posted $2 billion in operating income on revenue of $13.6 billion.

DaVita was responsible for about $143 million — or more than three-fifths — of the political spending in the past four years, and Fresenius gave about $68 million.

Until four years ago, the dialysis industry’s political spending was relatively modest compared with that of the hospital, physician and other health care associations so well known in Sacramento. In those days, dialysis lobbyists focused on regulatory issues and health care reimbursement rates, and companies gave minimal campaign contributions.

The industry’s transformation into one of the biggest spenders in California politics began in 2017, the first of four years in which it faced ballot or legislative threats. In 2017, a Democratic lawmaker introduced a bill that would have set strict staff ratios at dialysis clinics. The bill, SB-349, which failed, had faced opposition from the California Hospital Association, the California Chamber of Commerce and the dialysis industry.

The SEIU-United Healthcare Workers West union (SEIU-UHW) followed the next year with Proposition 8, a ballot initiative that would have capped industry profits.

DaVita and Fresenius were forced to defend their huge profits and allegations of subpar patient care, turning the competitors into allies — at least in politics.

The industry spent $111 million to successfully defeat the measure, breaking the record for spending by one side on an initiative.

“I think it’s very natural for these private chains to spend millions to make billions of profits,” said Ryan McDevitt, associate professor of economics at Duke University. “They’re lobbying to protect their profits.”

Last year, the industry fought AB-290, a bill that aimed to stop a billing practice dialysis companies use to get higher insurance reimbursements for some low-income patients. But the legislature wasn’t swayed, and Newsom signed the bill into law, which is now tied up in federal court.

And this year, the industry spent $105 million to block Proposition 23, which would have required every clinic have a physician on site and institute other patient safety protocols.

Kent Thiry, the former chairman and CEO of DaVita, said the industry had no choice but to spend heavily to defeat the ballot measures, which he said would have increased costs and harmed patient care.

“When someone does that, you have to use some of your money to defend yourself, your patients and your teammates,” Thiry said in an interview with KHN, which publishes California Healthline. “It forces companies to allocate precious resources to do something that never should have been brought up to start with.”

In an emailed statement, DaVita said it would continue to work to “educate lawmakers and defend against policy measures that are harmful to our patients.” Fresenius also defended its advocacy, saying the company needs to protect itself against special interests intent on abusing the political system. The company will “continue to support legislation that improves access to quality care and improves patient outcomes,” said Brad Puffer, a company spokesperson.

By comparison, SEIU-UHW, which sponsored the ballot measures, spent about $25 million to advocate for the initiatives, and $7.8 million on lobbying and political contributions. The union lobbies lawmakers on a wide array of health care issues

“They’ve got tons of money. We understand that,” said Dave Regan, the union’s president. “We’ve seen them spend a quarter of a billion dollars in a very short period of time. I hope they’re prepared to spend another quarter of a billion dollars, because we’re not going to go away until there’s legitimate commonsense reforms to this industry.”

From Defense to Offense

While most of dialysis companies’ political spending in California has been used to defeat ballot measures, several of the largest companies also dedicated about $16.4 million to lobbying and political contributions over the past four years.

The companies and their trade association, the California Dialysis Council, put almost three-fourths of that — nearly $12 million — into hiring veteran lobbyists to advocate for dialysis companies when lawmakers consider legislation that could affect the industry.

For instance, when Newsom took office in 2019, both DaVita and Fresenius added Axiom Advisors to their lobbying teams, paying it $737,500 since then. One of the firm’s partners is Newsom’s longtime friend Jason Kinney, whose close relationship with the governor was highlighted by the recent French Laundry dinner fiasco. Newsom came under intense criticism for attending the early November dinner at the exclusive restaurant, held to celebrate Kinney’s birthday, because he and his administration were asking Californians not to gather.

The industry has also given at least $4.6 million in contributions to political candidates and committees, both directly and to entities on behalf of a lawmaker or candidate.

All but five state senators and Assembly members who served during the 2019-20 legislative session received a direct contribution from at least one of the companies or the California Dialysis Council.

Most of the donations to individuals went to state lawmakers, but DaVita dipped into local races, too. For instance, it contributed $10,000 to a Glendale city council candidate in February, $7,700 to an El Monte school board candidate in October and $3,500 to a Signal Hill city council candidate last year.

Dialysis companies also gave to the state Democratic and Republican parties.

“They’re spreading it out. They’re doing the full gambit,” said Bob Stern, former general counsel for the California Fair Political Practices Commission, which enforces state political campaign and lobbying laws.

Legal Loopholes

State law limits how much a company or person can give to a political candidate in an election, but there are legal loopholes that allow individuals and corporate interests to give more. The dialysis industry has taken advantage of them.

Under state campaign finance rules, lawmakers can accept only $4,700 from any one person or company per election.

But some lawmakers operate “ballot measure committees” so they can accept unlimited contributions. These committees are supposed to advocate for a ballot measure, but lawmakers often use them to pay for political consultants and marketing, and to contribute to state and local initiatives they support. Candidates can also get unlimited help from donors who independently pay for campaign costs, such as mailings and digital campaign ads.

For instance, DaVita chipped in $93,505 to help pay for a direct mail campaign on behalf of state Sen. Steve Glazer (D-Orinda) in this year’s primary election. Glazer also received $55,600 from DaVita, Fresenius and the California Dialysis Council in contributions to himself and his ballot committee, Citizens for a Better California.

In some cases, lawmakers such as Glazer who netted some of the biggest contributions from dialysis companies voted with the industry. That was the case last year when the legislature approved AB-290, the bill limiting the dialysis billing practice.

Glazer voted no, as did Assembly member Adam Gray (D-Merced), whose Valley Solutions ballot measure committee had received $112,500 from DaVita and Fresenius since 2017. Gray also received $36,900 in direct contributions from Fresenius, DaVita and U.S. Renal Care.

Gray issued a statement saying campaign contributions play “zero role” in how he represents his district. Glazer did not respond to a request for comment.

Targeting Legislative Adversaries

Assembly member Reggie Jones-Sawyer’s 84-year-old mother is on dialysis. The Los Angeles Democrat and SEIU-UHW member has called for improved staffing ratios at dialysis clinics and has voted repeatedly to regulate them.

DaVita wrote a $249,000 check in October to a political committee supporting Jones-Sawyer’s opponent, Efren Martinez, another Democrat, but one the industry considered more friendly. DaVita followed up with a $15,000 check the week before the election.

Jones-Sawyer, who won the race, said he’s frustrated dialysis companies aren’t willing to make changes to improve patient safety on their own, saying it would cost them far less than the nearly quarter-billion dollars they have spent on political contributions. So for now, he said, he will continue to push to improve conditions at dialysis clinics from the Capitol, despite the industry’s growing political clout.

“I think dialysis is saying, ‘Look, we can be the 800-pound gorilla now,’” Sawyer said. “It’s not just influence for a day; it’s longevity.”

Rae Ellen Bichell and Elizabeth Lucas of KHN contributed to this report.


How California Healthline compiled data about dialysis companies’ political spending

Among the ways dialysis companies exert influence on the political process is by contributing money to campaigns; hiring lobbyists; and paying for advertising and marketing on behalf of candidates.

Opposition to ballot measures: Using the California secretary of state’s website, California Healthline downloaded the contributions made by DaVita, Fresenius Medical Care North America, U.S. Renal Care, Satellite Healthcare, Dialysis Clinic Inc. and American Renal Management to the campaign committees formed to defeat Propositions 8 and 23. This includes some non-monetary contributions.

Lobbying: We created a spreadsheet of expenses reported on lobbying disclosure forms, also available on the secretary of state’s website, by DaVita, Fresenius, U.S. Renal Care, Satellite Healthcare and the California Dialysis Council. We found details about how much the industry paid lobbying firms, what agencies it lobbied and which bills it tracked.

Political contributions: DaVita, Fresenius, U.S. Renal Care and the California Dialysis Council made direct contributions to more than 100 candidates, which we compiled from the secretary of state’s website. DaVita and Fresenius made other contributions, often large, to Democratic and Republican committees, and ballot measure committees led by lawmakers. The two companies also made contributions known as “independent expenditures” that benefited candidates’ campaigns and “behested payments,” which are donations to nonprofit organizations and charities in lawmakers’ names. Behested payments are disclosed on the California Fair Political Practices Commission website.

The SEIU-United Health Care West union uses two political committees for its giving. Its PAC contributes mostly to lawmakers and county and state Democratic parties while its Issues Committee gives to local hospital ballot measures. We did not tally spending for local hospital ballot measures for this story, but we did include contributions made by the Issues Committee to the California Democratic Party, which helps state lawmakers.

This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.


This story can be republished for free (details).

Becerra, un candidato para el HHS con habilidad política pero sin experiencia en salud

Xavier Becerra, elegido por el presidente electo Joe Biden para dirigir el Departamento de Salud y Servicios Humanos (HHS), será un secretario de la era pandémica, sin experiencia en salud pública. Si eso importa o no, depende de quién conteste.

Becerra construyó su carrera en la Cámara de Representantes de los Estados Unidos antes de convertirse en fiscal general de California. Algunos se preguntan si sus habilidades políticas y legales serían las adecuadas para conducir al HHS a través de una catástrofe de salud que está matando a miles de estadounidenses cada día.

Aunque aportará al cargo años de trabajo en legislacones y políticas de salud, nada de esto proviene de la experiencia de primera línea como ejecutivo o administrador dirigiendo programas de salud pública, gerenciando la atención de pacientes o controlando la propagación de enfermedades.

Sin embargo, más allá de la crisis inmediata de COVID-19, muchos demócratas ven a Becerra como un aliado importante para deshacer el daño que causaron los esfuerzos de la administración Trump para socavar la Ley de Cuidado de Salud a Bajo Precio (ACA); el Medicaid, que brinda cobertura a más de 70 millones de estadounidenses; la salud reproductiva; y más.

Como fiscal general de California desde 2017, Becerra ha sido una molestia para la administración Trump, presentando 107 demandas para revocar la acción federal sobre ACA, la anticoncepción, inmigración, derechos de los trabajadores, derechos LGBT, educación, protección del consumidor,  violencia con armas de fuego, y medio ambiente.

“COVID es el mayor problema sobre la mesa, pero no es el único”, dijo el doctor Georges Benjamin, director ejecutivo de la Asociación Estadounidense de Salud Pública. “Si miras su trabajo, no es tu abogado tradicional. Su trabajo en el área de la salud es sustancial. Y creo que eso cuenta”.

El martes 8 de diciembre, Biden está presentando formalmente a Becerra junto con otros candidatos para los principales puestos de salud, muchos con una profunda experiencia en salud pública.

Entre ellos se encuentra la doctora Rochelle Walensky, experta en enfermedades infecciosas de la Escuela de Medicina de Harvard, quien ejerce en el Hospital General de Massachusetts, en Boston, como próxima directora de los Centros para el Control y Prevención de Enfermedades (CDC).

Como “zar” de COVID, la elección de Biden es Jeffrey Zients, un ejecutivo de inversiones y ex funcionario de la administración Obama que dirigirá la respuesta a la pandemia desde la Casa Blanca. El doctor Vivek Murthy es el nominado a cirujano general de los Estados Unidos, cargo que ocupó en los últimos años de Obama.

Biden ha dicho que permitirá que los científicos veteranos del gobierno federal guíen su respuesta a la pandemia, en particular los de los CDC, a los que supervisa el HHS. El presidente Donald Trump marginó a la agencia, dañando su reputación como la institución de salud pública más confiable del mundo.

El hecho de que la experiencia más profunda de Becerra sea política hace que algunos observadores desconfíen.

“Creo que siempre existe el peligro de dejar que eso enturbie el juicio científico y médico sobre la mejor manera de hacer las cosas. Espero que puedan manejar eso bien”, dijo Jeffrey Morris, profesor de bioestadística en la Universidad de Pennsylvania, quien ha trabajado en temas de COVID.

Morris agregó que tuvo sentimientos encontrados sobre la elección de Becerra. “¿Cuál es el estilo de liderazgo? ¿Habrá una microgestión? Para mí, ese es el aspecto clave”.

Garry South, estratega demócrata con sede en Los Ángeles, calificó el nombramiento de Becerra de “curioso”.

“Mucha gente está levantando las cejas, incluso aquellos que están complacidos y orgullosos de que Biden eligiera a otro californiano para unirse a su administración”, dijo South. “Si los republicanos buscan apuntar a algunos de los nombrados, para rechazarlos, pueden plantear que no existe un nexo lógico entre un fiscal general estatal y el cargo de secretario de Salud y Servicios Humanos”.

Aún así, Becerra, quien como miembro del Congreso trabajó con el liderazgo demócrata de la Cámara y fue miembro del poderoso Comité de Medios y Arbitrajes, tiene más experiencia en políticas de salud y más conocimiento de los sistemas financieros y de prestación de servicios de salud del país que sus predecesores en el HHS, que tiene más de 80,000 empleados y un presupuesto de $1.3 mil millones.

Durante tres años, Becerra ha administrado el Departamento de Justicia de California, con un presupuesto de $1.1 mil millones y 4,800 empleados. Como fiscal general, ha estado profundamente involucrado en la elaboración de políticas de salud. Su oficina ha perseguido el comportamiento anticompetitivo de los hospitales. Y ha patrocinado una legislación para enfrentar a los fabricantes de medicamentos y los esquemas de pago por demora.

“Ha perseguido a intereses poderosos en la atención de salud”, dijo Anthony Wright, director ejecutivo de Health Access California, una organización sin fines de lucro.

El Departamento de Juticia de los Estados Unidos y la Comisión Federal de Comercio son las entidades que vigilan la aplicación de las leyes antimonopolio. Pero Becerra lo convirtió en una prioridad como principal fiscal de California. En mayo de 2018, presentó un caso antimonopolio contra el gigante de la atención médica sin fines de lucro Sutter Health, acusando al sistema de prácticas monopólicas que elevaban el costo de la atención médica en el norte de California.

“Este es un gran acuerdo”, dijo Becerra en una conferencia de prensa. El caso, que llevó años de trabajo del departamento y sus predecesores y millones de páginas de documentos, alegó que Sutter había comprado agresivamente hospitales y consultorios médicos en toda la región y había explotado ilegalmente ese poder de mercado con fines de lucro.

Los costos de la atención médica en el norte de California, donde Sutter domina con sus 24 hospitales, son entre un 20% y un 30% más altos que en el sur de California, incluso después de ajustar por el mayor costo de vida del norte del estado, según un estudio de 2018 del Nicholas C. Petris Center de la Universidad de California-Berkeley, que se citó en la demanda.

En diciembre de 2019, Sutter acordó pagar $575 millones para resolver el caso y prometió poner fin a una serie de prácticas que, Becerra alegó, sofocaban a la competencia.

Becerra canalizó las lecciones aprendidas del caso Sutter en un proyecto de ley antimonopolio en la Legislatura de California. En última instancia, la legislación fracasó, pero le habría dado al fiscal general el poder de revisar las fusiones o adquisiciones de un sistema de atención médica o un hospital lideradas por fondos de inversión o fondos de cobertura.

“El caso Sutter es un modelo para una política nacional que podría comenzar a restaurar la competencia por el sistema de atención médica y ahorrar a los consumidores miles de millones de dólares de inmediato”, dijo Glenn Melnick, economista de salud de la Universidad del Sur de California.

Melnick ve a Becerra como “un verdadero experto en algunos de los problemas más importantes que enfrenta nuestro sistema de atención médica, no solo en California sino a nivel nacional”.

Si el Senado lo confirma, los partidarios de Becerra dicen que aportará al trabajo una perspicacia política de sus más de dos décadas en el Capitolio, que probablemente será una ventaja para la administración Biden, mientras negocia proyectos de ley de ayuda para enfrentar la pandemia, y otras leyes de salud con un Congreso políticamente dividido.

Henry Waxman, ex miembro demócrata del Congreso de California, trabajó con casi una docena de secretarios del HHS durante su tiempo en el Comité de Energía y Comercio de la Cámara de Representantes. Dijo que no le preocupa que Becerra no tenga experiencia en el liderazgo de una vasta burocracia sanitaria. Para ser secretario del HHS, “se necesitan habilidades políticas para ver hasta dónde se puede llegar con otras personas en un contexto político”. Es por eso que la mayoría de los secretarios del HHS, republicanos y demócratas, han tenido antecedentes políticos.

Becerra “comprende las políticas y tiene un profundo compromiso con ellas”, dijo. “Creo que le irá bien”.

Los funcionarios de salud pública dicen que el trabajo que enfrenta Becerra es gigantesco.

El doctor Gary Pace, oficial de salud en la zona rural del condado de Lake, en California, dijo que Becerra tendría la tarea de reconstruir un sistema de salud pública que no funciona.

“Queremos un aliado federal que pueda brindarnos una buena orientación; algo que no hemos tenido”, dijo Pace. “Lo primero que necesitamos es que los CDC vuelvan a desempeñar un papel emblemático en la salud pública, con una guía confiable y oportuna basada en evidencia”.

Nacido en Sacramento de padres inmigrantes mexicanos, Becerra sería el primer secretario latino del HHS. Fue elegido para el Congreso a los 30 años y ha estado involucrado en la legislación nacional de salud durante las últimas dos décadas, aunque es más conocido por su participación en temas de inmigración e impuestos.

Se unió al poderoso Comité de Medios y Arbitrajes de la Cámara, que supervisa la legislación fiscal y sanitaria, en la década de 1990. El comité jugó un papel central en la redacción de lo que se convertiría en la Ley de Cuidado de Salud a Bajo Precio, en 2010.

Si bien el HHS supervisa las principales agencias de salud federales, incluidos los CDC, los Centros de Servicios de Medicare y Medicaid, la Administración de Alimentos y Medicamentos y los Institutos Nacionales de Salud, también tiene una amplia cartera de servicios sociales, incluida la supervisión del cuidado y el bienestar infantil, programas de beneficiencia, Head Start, programas para personas mayores y reasentamiento de refugiados.

Dan Mendelson, ex funcionario de salud de la administración Clinton, dijo que Becerra era una “elección inspiradora”. “Creo que el punto más importante es que este es el líder de un equipo”.

Las redactoras de California Healthline, Rachel Bluth y Samantha Young, colaboraron con esta historia.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.


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In Becerra, an HHS Nominee With Political Skill But No Front-Line Health Experience

Xavier Becerra, President-elect Joe Biden’s choice to head the Department of Health and Human Services, is set to be a pandemic-era secretary with no public health experience. Whether that matters depends on whom you ask.

Becerra built his career in the U.S. House of Representatives before becoming California’s attorney general, and some wonder whether his political and legal skills would be the right fit to steer HHS through a health catastrophe that’s killing thousands of Americans every day.

Although he would bring years of health politics and policy work to the role, none of it comes from front-line experience as an executive or administrator running public health programs, managing patient care or controlling the spread of disease.

Yet beyond the immediate COVID-19 crisis, many Democrats see Becerra as an important ally to undo what they view as years of damage from the Trump administration’s efforts to undermine the Affordable Care Act; the Medicaid program, which provides coverage for more than 70 million Americans; reproductive health; and more.

As California’s attorney general since 2017, Becerra has been a thorn in the side of the Trump administration, filing 107 lawsuits to overturn federal action on the Affordable Care Act, contraception, immigration, workers’ rights, LGBT rights, education, consumer protection, gun violence and the environment.

“COVID is the biggest issue on the table, but it is not the only issue on the table,” said Dr. Georges Benjamin, executive director of the American Public Health Association. “If you look at his body of work, he is not your traditional attorney. His body of work in the health area is substantial. And I think that counts.”

On Tuesday, Biden will formally introduce Becerra along with other candidates for top health jobs, many with deep public health experience.

They include Dr. Rochelle Walensky, an infectious disease expert at Harvard Medical School who practices at Massachusetts General Hospital in Boston, as the next director of the Centers for Disease Control and Prevention. Biden’s choice for COVID “czar” is Jeffrey Zients, a private equity executive and former Obama administration official who will steer the pandemic response from the White House. Dr. Vivek Murthy is the nominee for U.S. surgeon general, a position he held in the final Obama years.

Biden has said he will let the federal government’s longtime scientists guide his pandemic response, in particular those at the CDC, which is overseen by HHS. President Donald Trump sidelined the agency, damaging its reputation as the world’s most trusted public health institution.

That Becerra’s deepest experience is political makes some observers wary.

“I think there’s always a danger of letting that sort of cloud the scientific and medical judgment of how best to do things. I hope they can manage that well,” said Jeffrey Morris, a biostatistics professor at the University of Pennsylvania who has worked on COVID issues. He said he had mixed feelings about the Becerra selection. “What is the leadership style, and is there going to be micromanaging from the top down into these organizations? To me, that’s the key aspect.”

Garry South, a Los Angeles-based Democratic strategist, called Becerra’s appointment “curious.”

“A lot of people are raising eyebrows — even those who are pleased and proud that Biden picked another Californian to join his administration,” South said. “If Republicans are looking to target a few Biden appointees for rejection, you can expect them to make the case that there is no logical nexus between a state attorney general and serving as secretary of Health and Human Services.”

Still, Becerra, who as a member of Congress worked in the House Democratic leadership and was a member of the powerful Ways and Means Committee, has more health policy background and knowledge of U.S. health care finance and delivery systems than many previous heads of the sprawling HHS, which employs more than 80,000 people and has a $1.3 trillion budget.

For three years, Becerra has managed California’s Justice Department, with a $1.1 billion budget and 4,800 employees. As attorney general, he’s been deeply involved in crafting health policy. His office has gone after anti-competitive behavior from hospitals. And he’s sponsored legislation to take on drugmakers and pay-for-delay schemes.

“He’s gone after powerful health care interests,” said Anthony Wright, executive director of the nonprofit Health Access California.

Antitrust enforcement is more commonly handled by the U.S. Department of Justice and the Federal Trade Commission. But Becerra made it a priority as California’s top cop. In May 2018, he brought an antitrust case against nonprofit health care giant Sutter Health, accusing the system of monopolistic practices that drove up the cost of medical care in Northern California.

“This is a big ‘F’ deal,” Becerra said at a news conference unveiling the lawsuit. The case — which encompassed years of work by the department and his predecessors and millions of pages of documents — alleged that Sutter had aggressively bought up hospitals and physician practices across the region and illegally exploited that market power for profit. Health care costs in Northern California, where Sutter dominates with its 24 hospitals, are 20% to 30% higher than in Southern California, even after adjusting for Northern California’s higher cost of living, according to a 2018 study from the Nicholas C. Petris Center at the University of California-Berkeley that was cited in the complaint.

In December 2019, Sutter agreed to pay $575 million to settle the case and promised to end a host of practices that Becerra alleged stifled competition.

Becerra channeled lessons learned from the Sutter case into an antitrust bill in the California legislature. The legislation ultimately failed, but it would have given the attorney general power to review private equity- or hedge fund-led mergers or acquisitions of a health care system or hospital.

“The Sutter case is a blueprint for a national policy that could start to restore competition for the health care system and save American health care consumers billions of dollars right away,” said Glenn Melnick, a health care economist at the University of Southern California. He views Becerra as “a real expert in some of the most important issues facing our health care system, not just in California but nationally.”

If confirmed by the Senate, Becerra supporters say, he will bring to the job a political acumen from his two decades-plus on Capitol Hill that’s likely to be an asset for the Biden administration as it negotiates pandemic relief bills and other health legislation with a politically divided Congress.

Former California Democratic member of Congress Henry Waxman worked with nearly a dozen HHS secretaries during his time on the House Energy and Commerce Committee. He said he’s not worried that Becerra lacks experience leading a vast health care bureaucracy. The HHS secretary job, he said, is one “where you need political skills to see how far you can get with other people in a political context.” That’s why most HHS secretaries, Republicans and Democrats, have had political backgrounds.

Becerra “understands the policies and has a deep commitment to them,” he said. “I think he’ll do well.”

Public health officials say the job before Becerra is gigantic.

Dr. Gary Pace, the health officer in rural Lake County, California, said Becerra would be tasked with rebuilding a broken public health system.

“We want a federal partner who can give us good guidance — we haven’t had that,” Pace said. “For him, I’d say what we need first is starting to get the CDC back into a flagship public health role, with trusted and timely evidence-based guidance.”

Born in Sacramento to Mexican immigrant parents, Becerra would be the first Latino HHS secretary. He was elected to Congress in his 30s and has been involved in national health legislation during the past two decades, even though he is more widely known for his involvement in immigration and tax issues. He joined the powerful House Ways and Means Committee, which oversees tax and health legislation, in the 1990s. The committee played a central role in the drafting of what would become the Affordable Care Act in 2010.

While HHS oversees major federal health agencies, including the CDC, the Centers for Medicare & Medicaid Services, the Food and Drug Administration and the National Institutes of Health, it also has a wide-ranging human services portfolio, including oversight of child care and welfare programs, Head Start, programs for seniors and refugee resettlement.

“It’s not like any one person is going to have everything,” said Dan Mendelson, a former Clinton administration health official, who called Becerra an “inspired choice.” “I think that the most important point is that this is a leader of a team and not the be-all and end-all.”

KHN staff writers Rachel Bluth and Samantha Young contributed to this story.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.


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Xavier Becerra en sus propias palabras: “La atención de salud es un derecho”

El presidente electo Joe Biden nombró al fiscal general de California, Xavier Becerra, para dirigir el Departamento de Salud y Servicios Humanos (HHS) de los Estados Unidos. Becerra, quien sería el primer secretario latino del HHS, ha tomado algunas posiciones innovadoras en atención de salud, especialmente desde que se convirtió en fiscal general, en 2017.

Becerra ha demandado a la administración Trump docenas de veces por temas de atención médica, control de la natalidad, inmigración, cambio climático y más, con California liderando la defensa de la Ley de Cuidado de Salud a Bajo Precio (ACA) ante la Corte Suprema de Estados Unidos. Becerra también ganó un importante acuerdo legal contra Sutter Health, después de acusar al gigante de la atención de salud sin fines de lucro de usar su dominio del mercado en el norte de California para aumentar los precios de manera ilegal.

El año pasado, Becerra le dijo a KHN que sus puntos de vista han sido moldeados por su experiencia como hijo de inmigrantes mexicanos. Al describir el aborto espontáneo de su madre, dijo que todos deberían poder ir al médico: “Para mí, la atención médica es un derecho”, dijo. “He sido un defensor del pagador único toda mi vida”.

Aquí hay más de lo que le dijo a KHN sobre sus puntos de vista sobre la atención médica en los últimos años:

A principios del año pasado, Becerra le contó a Samantha Young, corresponsal política de California Healthline, sobre su experiencia como hijo de inmigrantes y cómo eso moldeó su carrera legal y política.

Hace dos años, Becerra participó del podcast “What a Health?”, que conduce Julie Rovner, corresponsal principal de KHN en Washington, en donde habló sobre su énfasis en la atención de salud como fiscal general.

El mes pasado, Becerra habló con Samantha Young sobre su defensa de la Ley de Cuidado de Salud a Bajo Precio (ACA) ante la Corte Suprema de los Estados Unidos.

Esta historia fue producida por KHN, que publica California Healthline, un servicio editorialmente independiente de la California Health Care Foundation.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.


This story can be republished for free (details).

Xavier Becerra in His Own Words: ‘Health Care Is a Right’

President-elect Joe Biden has tapped California Attorney General Xavier Becerra to lead the U.S. Department of Health and Human Services. Becerra, who would be the nation’s first Latino HHS secretary, has taken some ground-breaking positions on health care, especially since he became attorney general in 2017.

He has sued the Trump administration dozens of times on health care, birth control, immigration, climate change and more, with California leading the defense of the Affordable Care Act before the U.S. Supreme Court. Becerra has also won a major legal settlement from Sutter Health after accusing the nonprofit health care giant of using its market dominance in Northern California to illegally drive up prices.

Becerra told KHN last year that his views have been shaped by his experience as the son of Mexican immigrants. Describing his mother’s miscarriage, he said that everyone should be able to go to the doctor: “For me, health care is a right,” he said. “I’ve been a single-payer advocate all my life.”

Here’s more of what he told KHN about his views on health care in the past few years:

Early last year, Becerra told Samantha Young, California Healthline’s state politics correspondent, about his experience as the child of immigrants, and how that shaped his legal and political career.

Becerra joined KHN chief Washington correspondent Julie Rovner on her “What the Health?” podcast two years ago about his emphasis on health care as attorney general.

Last month, Becerra spoke with Samantha Young about his defense of the Affordable Care Act before the U.S. Supreme Court.

This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.


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Fear and Loathing as Colleges Face Another Season of Red Ink

When the University of California’s Board of Regents got a close look at the numbers in September, it was the visual equivalent of a thunderclap. The massive university system, with 10 campuses and more than 285,000 students, was hemorrhaging money — $2.2 billion in lost revenue and additional costs, mostly due to the pandemic.

While some of those losses came from medical centers that temporarily gave up high-paying elective procedures in order to treat COVID patients, the bigger picture was as vexing as it was simple: In the age of pandemic-induced remote learning, the campuses were largely deserted. And when students aren’t living on campus, schools stop making money. Fast.

“Colleges and universities get very high premiums on their housing. It’s a big revenue space for them,” said Dr. Jorge Nieva of the University of Southern California’s Keck School of Medicine. “But for many, many schools right now, they just can’t operate in person.”

When they try, the outcomes have often been dire. A New York Times rolling survey of roughly 1,900 colleges and universities has tracked more than 321,000 viral infections on campus among students, faculty and staff, with at least 80 deaths. Most of the fatalities occurred in the spring, and hundreds of schools have since opted for either 100% remote instruction or severe limits on how many students may be on campus.

Those decisions, driven by administrators’ understanding that it’s nearly impossible to contain the spread of COVID-19 in classrooms, dormitories and cafeterias, are prudent and comply with local and state health protocols. But as schools attempt to finalize plans for the winter quarter or spring semester beginning next month, a sense of dread has crept in. Absent student housing and dining money, budgets again will be blown.

The expected arrival of a coronavirus vaccine is welcome, but at many campuses, students are unlikely to pay for room and board again until the fall — and, even then, perhaps in reduced numbers. Larger schools and private universities with significant endowments will almost certainly get through it, but after that, the picture gets cloudier.

“We’re fully anticipating that some of the smaller schools will not make it,” said Patricia Gandara, a research professor of education at UCLA. “Some of the liberal arts schools, especially, are struggling to stay afloat. It’s a really terrible problem.”

Indeed, a recent model created by a Boston education company, Edmit, estimated that more than a third of the private four-year colleges it studied may need to merge or close in the next few years. New York University professor Scott Galloway, meanwhile, has identified more than 90 colleges that fall into the “low value, high vulnerability” quadrant of his analysis, meaning they’re already in trouble financially and may be pushed to the edge by the budgetary effects of the virus.

The national figures are mind-boggling. In a letter to Congress in October, the American Council on Education said it had estimated that the pandemic would cost colleges and universities at least $120 billion. In every category of university operation, the council wrote, “revenues are down and expenses are significantly increased.”

At many large school systems, those losses are compounded by state budget crises that also loop back to COVID-related economic downturns — and they follow a decade in which state funding was already significantly shaved. California reduced its general-fund contribution to the UC system for 2020-21 by $472 million, and federal relief is uncertain with a likely divided government, said education consultant Ben Kennedy.

Smaller schools are more vulnerable to an immediate threat. This summer, tiny Wells College, in New York’s Finger Lakes region, pondered closing its doors permanently. “If we don’t have room and board revenue, we won’t have enough revenue to operate the campus next year,” said President Jonathan Gibralter. The college ultimately decided to open this fall, with students living in the residence halls; it went into a “pause” in November, suspending in-person instruction and advising students to essentially stay in their dorm rooms, after positive cases of COVID began to rise at Wells. Students ultimately left the campus at Thanksgiving break and, as Wells had planned months earlier, will finish the semester remotely.

For Wells and other small schools, collecting even part of a semester’s worth of housing and dining fees is critical. According to research by the College Board, room and board costs rose faster than tuition and fees at public two- and four-year institutions over the past five years. In 2017, the Urban Institute found that room and board costs had more than doubled since 1980 in inflation-adjusted dollars.

Some of this has to do with the way the college pricing game is played. Schools often post sky-high tuition rates, then offer to knock them down — often by 50% or more — via grant or scholarship. The profit margins on housing and dining services make up the difference in the budget.

At UCLA, an in-state student in campus housing would pay $13,239 for tuition and $17,599 for room and board this school year, according to the school’s estimate. Out-of-state and foreign students pay an additional $29,754 in “supplemental tuition,” a premium that many schools raised aggressively over the past decade to recover funding deficits after the recession of 2007-09.

The University of Florida charges state residents $6,380 in tuition, but $10,590 in room and board. At Dartmouth College, students of families with incomes under $100,000 can expect a scholarship covering the $57,796 retail tuition, but room and board add $17,022.

Campus lockdowns have been devastating. From March to August, UCLA lost nearly $185 million in canceled housing and dining programs and “lost enrollments,” part of a system-worst $653 million overall revenue decline. Despite UCLA’s losses, overall the UC system’s enrollment levels remained flat.

Remote instruction will continue at least through March in the UC system, with on-campus housing again serving only those students with no other options. The residence halls at UCLA were about 10% occupied this fall.

Schools around the country generally operate within the health and safety guidelines of their cities or counties. As the nation plunges into its worst phase of the pandemic, that means few opportunities for a return to campus until a vaccine becomes available for college students, which may be well into the summer.

Still, there are some differences. While USC has followed Los Angeles County’s very cautious approach to reopening, New Jersey’s Princeton University went the other way, announcing that all enrolled undergraduates would be offered campus housing in the spring, even as classes remained mostly remote. (Room and board at Princeton for the spring semester comes to $8,910, according to the university’s statement of fees.)

With an endowment valued at more than $5.7 billion, USC can survive an extended time of reduced housing and dining revenue, as can the UC system, whose collective endowments total $15 billion.

But as the pandemic rolls on, the pressure on schools that are relatively underfunded — or were already leveraged — will only increase. When MacMurray College in Illinois announced its closure this spring after 174 years, its president noted that 2020 was MacMurray’s third consecutive year in deficit, part of a longer pattern of students gravitating toward larger schools and their amenities.

“If an institution wasn’t running a structural deficit with dwindling reserves pre-COVID, they should be OK now,” said Kennedy, the education consultant. “If they were already two to four years away from an existential crisis, then COVID has brought them, likely, to the point of no return.”

This KHN story first published on California Healthline, a service of the California Health Care Foundation.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.


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California Lawmakers to Newsom: Give All Immigrants Health Coverage

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SACRAMENTO — California Democratic lawmakers so far have failed to convince Gov. Gavin Newsom that the state can afford to spend an estimated $2.6 billion a year to expand its Medicaid program to all unauthorized immigrants.

Now, they’re trying a new strategy.

Rather than working independently, a fiercely liberal state senator from Los Angeles and a moderate Assembly member from the Central Valley are joining forces to pressure Newsom to make California the first state in the nation to cover every income-eligible resident regardless of immigration status. Unauthorized immigrants up to age 26 can already qualify for Medi-Cal, the state’s Medicaid program for low-income residents.

Emboldened by the win of Democratic President-elect Joe Biden and spurred by the urgency of the coronavirus pandemic, state Sen. María Elena Durazo (D-Los Angeles) and Assembly member Joaquin Arambula (D-Fresno) plan to introduce a two-bill package on Monday that would cover unauthorized senior immigrants first, and eventually the remainder of California’s undocumented immigrant population.

“It’s a national issue. Look at how all the national Democratic candidates raised their hands in front of the world to support covering undocumented immigrants in health insurance,” Durazo told California Healthline. “We want a clear commitment to finally do this, not just lip service.”

Newsom has long touted his goal of achieving universal health coverage in California and made campaign promises to work toward a single-payer health care system. But after nearly two years in office, Newsom’s ambitious health care agenda has been sidetracked by deadly wildfires and a widening homelessness crisis — as well as the COVID-19 pandemic — and he has not managed to dramatically expand coverage.

California currently covers about 200,000 unauthorized immigrant children and young adults, according to the state Department of Health Care Services. The state budgeted about $375 million to cover young adults ages 19 through 25 this fiscal year, but does not track spending for undocumented immigrant children, according to the state Department of Finance.

Opening the low-income health program to all eligible undocumented immigrants would expand coverage to at least 915,000 low-income residents and cost an additional $2.6 billion annually, according to a projection this year by the nonpartisan state Legislative Analyst’s Office. There are an estimated 1.5 million undocumented immigrant Californians who are uninsured, estimates show, but not all of them would qualify.

Public support for expanding coverage to unauthorized immigrants has risen over the past few years, according to the Public Policy Institute of California. But expending scarce taxpayer resources on such an effort is politically risky, said Doug Herman, a Los Angeles-based national Democratic strategist.

“Gavin’s got bigger priorities right now and he has been wounded, so he has to be very cautious about what he does,” Herman said. “Look at the French Laundry and [Employment Development Department] scandals. The homelessness crisis is raging and the prison outbreak happened on his watch. This doesn’t rise to that level.”

Newsom communications director Jesse Melgar said no one from his office was available for comment.

Since Newsom took office, Durazo and Arambula have authored separate bills to expand Medi-Cal to more undocumented immigrants. Durazo has gotten close after negotiating with Newsom — only for the first-term Democratic governor to back out, citing costs.

Such proposals have received widespread legislative support among Democratic lawmakers, who hold supermajority power in both houses of the state legislature.

A worsening economic outlook and long-term budget pressures could once again derail their efforts. Because the federal government prohibits states from using federal Medicaid dollars to cover undocumented immigrants — except for emergency services — California would have to pick up most of the price tag, which could top $3 billion annually to cover everyone, including children and adults, according to the Legislative Analyst’s Office.

Newsom will be forced to weigh an onslaught of budget demands while managing, and paying for, the ongoing COVID-19 emergency.

“That gives Newsom the ability to delay or oppose anything that doesn’t fit his agenda,” Herman said.

But some lawmakers, immigration rights activists and health care advocates argue the COVID pandemic has made their campaign more urgent as Latino and Black residents get sick and die at disproportionate rates.

Politicians cannot ignore that the pandemic has exposed a broken health care system that has left millions of taxpaying Californians without health coverage because their immigration status renders them ineligible, said Sarah Dar, director of health and public benefits for the California Immigrant Policy Center, which is already lobbying the governor to support the Medi-Cal expansion.

“Now we have a full picture of what this crisis is, and the blatant disparities faced by our essential workers, so there’s no excuse,” she said. “Immigrant communities and farmworkers in the food and agricultural sector, like meatpacking plants, have literally been hotbeds for the spread of disease.”

Dar acknowledged financial pressures ahead for the state, and said advocates will be pushing for ways to generate money to pay for the expansion, possibly including tax increases.

There could be some hope for a one-time cash infusion. Fiscal estimates show California could reap a $26 billion surplus next year, largely from personal income tax receipts from high-income earners who have not suffered devastating economic losses during the pandemic, according to state fiscal analysts. Durazo and Arambula are eyeing that revenue for the Medi-Cal expansion.

“He has routinely stated his vision, but we’d like Gov. Newsom to deliver on health care for all during his governorship,” Arambula said. “I’m not going to sit and wait.”

Durazo said she would introduce a bill Monday to expand Medi-Cal to unauthorized immigrant Californians age 65 and older. She put a similar bill on hold in 2019, in exchange for a commitment from Newsom to include the proposal in this year’s state budget.

Newsom included the proposal in the first version of his state budget in January, but then withdrew it, citing soaring unemployment, business closures and an economy decimated by the pandemic.

Durazo and other backers decided to craft a new approach: Alongside Durazo’s bill to cover older adults, Arambula plans to introduce companion legislation to cover all undocumented immigrant adults.

The lawmakers are using the two bills as a negotiating tactic. Arambula and advocates said they hope to win coverage for undocumented immigrants 65 and older next year, while developing a plan with Newsom to expand coverage to the entire population at some point during his governorship.

Durazo said both bills are equally important and are intentionally being used to pressure the governor into action next year.

“This is our way to finally have a real conversation about what it’ll take to get everyone covered, given we’ll have federal partners with the Biden-Harris administration,” said Orville Thomas, director of government affairs for the California Immigrant Policy Center.

This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.


This story can be republished for free (details).

As LA County Sets New Infection Record, State Leaders’ Behavior Sends Mixed Messages

California, like the rest of the nation, is seeing a dramatic rise in COVID infections and deaths — and Los Angeles County has some of the most dire statistics.

Health officials reported more than 7,500 new cases in the county on Tuesday, shattering the old record, set last week. Hospitalizations tripled in the past month, and on average 30 people are dying of COVID-19 in the county every day.

The most populous county in the country, Los Angeles leads all U.S. counties in raw numbers of both infections and deaths, according to statistics compiled by Johns Hopkins University.

On Monday, the county started a three-week stay-at-home order, and Gov. Gavin Newsom said a similar order for the whole state could prove necessary.

“If these trends continue, we’re going to have to take much more dramatic — arguably drastic — action,” Newsom said.

But even as the restrictions began in Los Angeles, leaders across California took heat for their do-as-I-say-not-as-I-do pandemic behavior.

Los Angeles County Supervisor Sheila Kuehl dined outdoors at a favorite restaurant shortly after she voted to ban outdoor dining, a local TV station reported.

San Jose Mayor Sam Liccardo apologized for spending Thanksgiving with eight people from five households in his extended family.

And the San Francisco Chronicle reported that San Francisco Mayor London Breed joined a party of seven to dine at the famed French Laundry restaurant the day after Newsom did, angering many.

The questionable behavior threatens to overshadow alarming news about pandemic trends. Tuesday, California reported 20,759 new cases, a few hundred less than the record number of the day before. The state is in its worst situation since the pandemic started. Yet despite the record case numbers, California is so populous that it’s far from the top of the list of states with the most new cases per capita. (That spot was held by Montana on Wednesday.)

Newsom said Monday that Southern California is forecast to run out of intensive care unit capacity by mid-December if trends continue. By Christmas Eve, ICU beds are forecast to be at 107% of capacity across the region. There’s no clear plan in place for what to do when hospital demand outstrips capacity.

All races and ethnicities are seeing increases in cases, but disparities are widening. In Los Angeles County, Hispanics’ infection rate is more than twice that of whites.

“Death rates among people in high rates of poverty are three times the death rate of people in more affluent areas,” county public health director Barbara Ferrer said Wednesday.

Health officials estimate that one in every 200 people in the county has the virus and is infectious.

The hope is that the new restrictions of the stay-at-home order in Los Angeles County will slow that spread.

The order is designed to keep people in their homes as much as possible. It prohibits gatherings with anyone outside of a household and reduces capacity at stores. K-12 schools will continue to operate but at 20% capacity. Outdoor areas like beaches, parks and trails will remain open, but people are not allowed to gather.

Officials say they are trying to find a sweet spot where they can keep people from gathering and spreading the virus, but still allow some stores to remain open. Thus far the rules are less stringent than those imposed in the spring, because businesses owners have pushed back hard against more restrictions. They are losing money and, unlike in the spring, have no federal aid to offset their losses.

This story is from a reporting partnership that includes KPCCNPR and KHN, an editorially an editorially independent program of KFF.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.


This story can be republished for free (details).

Where Does the Arsenic in Rice, Mushrooms, and Wine Come From?

What happens when our crops are grown in soil contaminated with arsenic-based pesticides and arsenic drug-laced chicken manure?

When arsenic-containing drugs are fed to chickens, not only does the arsenic grow out into their feathers, which are then fed back to them as a slaughterhouse byproduct, but the arsenic can also get into their tissues and then into our tissues when we eat eggs or meat, a cycle depicted at the start of my video Where Does the Arsenic in Rice, Mushrooms, and Wine Come From?. This explains why national studies have found that those who eat more poultry have tended to have more arsenic flowing through their bodies. Why would the industry do that? In modern poultry farms, often called CAFOs for concentrated animal feeding operations, there can be 200,000 birds under one roof and the floors of these buildings become covered with feces. While this so-called factory farming decreases costs, it also increases the risk of disease. That’s where arsenic-containing drugs and other antibiotic feed additives can come in: to try to cut down the spread of disease in such an unnatural environment. If you’re feeling a little smug because you don’t eat chicken, what do you think happens to the poop?

As depicted at 1:17 in my video, from chicken manure, the arsenic from the drugs in the animal feed can get into our crops, into the air, and into the groundwater, and find its way into our bodies whether we eat meat or not. Yes, but how much arsenic are we really talking about? Well, we raise billions of chickens a year, and, if, historically, the vast majority were fed arsenic, then, if you do the math, we’re talking about dumping a half million pounds of arsenic into the environment every year—much of it onto our crops or shoveled directly into the mouths of other farm animals.

Most of the arsenic in chicken waste is water soluble, so, there are certainly concerns about it seeping into the groundwater. But, if it’s used as a fertilizer, what about our food? Studies on the levels of arsenic in the U.S. food supply dating back to the 1970s identified two foods, fish aside, with the highest levels—chicken and rice—both of which can accumulate arsenic in the same way. Deliver an arsenic-containing drug like roxarsone to chickens, and it ends up in their manure, which ends up in the soil, which ends up in our pilaf. “Rice is [now] the primary source of As [arsenic] exposure in a non seafood diet.”

I was surprised to learn that mushrooms are in the top-five food sources of arsenic, but then it made sense after I found out that poultry litter is commonly used as a starting material to grow mushrooms in the United States. As you can see at 2:58 in my video, over the years, the arsenic content in mushrooms has rivaled arsenic concentration in rice, though people tend to eat more rice than mushrooms on a daily basis. Arsenic levels in mushrooms seemed to be dipping starting about a decade ago, which was confirmed in a 2016 paper that looked at a dozen different types of mushrooms: plain white button mushrooms, cremini, portobello, shiitake, trumpet, oyster, nameko, maitake, alba clamshell, brown clamshell, and chanterelle. Now, mushrooms are only averaging about half the arsenic content as rice, as you can see at 3:37 in my video.

Just like some mushrooms have less arsenic than others, some rice has less. Rice grown in California has 40 percent less arsenic than rice grown in Arkansas, Louisiana, Mississippi, Missouri, and Texas. Why? Well, arsenic-based pesticides had been used for more than a century on millions of acres of cotton fields, a practice noted to be “dangerous” back in 1927. Arsenic pesticides are now effectively banned, so it’s not simply a matter of buying organic versus conventional rice because millions of pounds of arsenic had been laid down in the soil well before the rice was even planted.

The rice industry is well aware of this. There’s an arsenic-toxicity disorder in rice called “straighthead,” where rice planted in soil too heavily contaminated with arsenic doesn’t grow right. So, instead of choosing cleaner cropland, they just developed arsenic-resistant strains of rice. Now, lots of arsenic can build up in rice without the plant getting hurt. Can the same be said, however, for the rice consumer?

It’s the same story with wine. Arsenic pesticides were used, decade after decade, and even though they’ve since been banned, arsenic can still be sucked up from the soil, leading to “the pervasive presence of arsenic in [American] wine [that] can pose a potential health risk.” Curiously, the researchers sum up their article by saying that “chronic arsenic exposure is known to lower IQ in children,” but if kids are drinking that much wine, arsenic toxicity is probably the least of their worries.

Hold on. Chickens are being fed arsenic-based drugs? See Where Does the Arsenic in Chicken Come From? to find out more.

 I expect the arsenic-in-rice issue brought up a lot of questions, and giving you answers is exactly why I’m here! Check out:

In health,

Michael Greger, M.D.

PS: If you haven’t yet, you can subscribe to my free videos here and watch my live presentations:

Where COVID Is on the Menu: Failed Contact Tracing Leaves Diners in the Dark

COVID-19 outbreaks have affected restaurants throughout Los Angeles County, from a Panda Express in Sun Valley to the University of California’s Bruin Cafe. If you live in Los Angeles, you can access health department reports about these outbreaks online.

But in most of the country, diners are left in the dark about which restaurants have been linked to outbreaks of the virus.

Restaurants appear to be among the most common places to get infected with the COVID-19 virus, but contact tracing in most areas has been so lackluster that few health departments have been able to link disease clusters to in-person dining.

When KHN contacted the health departments serving the 25 most populous counties in the U.S., only nine could confirm they were collecting and reporting data on potential links between restaurants and COVID cases.

As of Monday, 13 of the 25 counties hadn’t announced changes to their indoor restaurant dining policies, despite record-setting numbers of new COVID infections in the U.S.

While public health researchers are convinced indoor dining is a risky activity in areas where COVID-19 is spreading, getting solid data to justify restaurant restrictions has been difficult. It takes in-depth, resource-heavy disease investigations to determine where people were exposed to the coronavirus, and those contact-tracing efforts have never gotten off the ground in most of the country.

This has made it hard to develop more specific information about risky restaurants and bars, and may have contributed to an overall feeling of powerlessness in the face of the pandemic among people and officials.

It didn’t have to be this way, said Dr. Bill Miller, a senior associate dean of research at the Ohio State University College of Public Health.

“We’ve really missed an opportunity” to use contact tracing systematically to provide “useful information to give us ideas of where we might need to be intervening,” he said.

For contact tracing of other infectious diseases, such as HIV/AIDS, investigators usually ask patients to think through all the contacts with whom they might have shared a virus. They also dive further into the past to try to determine who might have infected the person in the first place.

But U.S. contact tracing for COVID-19 hasn’t taken this approach, in part because of a lack of resources and public trust. Contact-tracing departments are stretched thin, gathering minimum data and facing a suspicious and often uncooperative population.

Contact tracers in Maricopa County, Arizona, prioritize learning the names of individuals over the locations where the coronavirus may be spreading. With the exception of long-term care facilities and a few other locations, investigators don’t consider something an outbreak until they can trace 10 potential cases to a location, said Ron Coleman, a county spokesperson.

As winter looms and people increasingly gather indoors, many local governments are flying blind, lacking the data to create and adjust COVID restriction policies that could make a meaningful dent in rising case rates.

“Imagine there’s some major sporting event,” Miller said. “You might miss an entire cluster that came out of a social situation” if you didn’t check whether, for example, a COVID-positive person had gone to a crowded bar to watch it.

The COVID virus spreads mainly through respiratory droplets that an infected person can release by sneezing, coughing or talking, and a restaurant meal combines several high-risk activities in a single setting: going maskless to eat and drink, meeting up with people outside your household “bubble,” and chatting over a leisurely meal. If the meal takes place indoors, poor ventilation aggravates these risks because of the virus’s potential to linger in still air.

Published research on the role restaurants play in the pandemic is highly suggestive. Taken altogether, the studies paint a scary picture of how potent restaurants can be in spreading COVID-19.

A Centers for Disease Control and Prevention study across 10 states found that those who had tested positive for COVID-19 were more than twice as likely to say they had dined at a restaurant in the two weeks before their illness began, compared with those who tested negative. Dining at a restaurant was the only activity that differed significantly between those who tested positive and those who tested negative for the coronavirus.

For example, that study seemed to show no increased risk of infection linked to shopping, gathering with 10 or fewer people or spending time in an office, said Kiva Fisher, a CDC epidemiologist and lead author of the study.

Not surprisingly, restaurant restrictions appear effective at slowing viral spread in a community. Out of the many social distancing restrictions states chose to implement at the beginning of the pandemic, shutting down restaurants had the strongest correlation to reducing the spread of the disease, according to researchers at the University of Vermont.

A recent Stanford University-led study that used mobile phone data from different cities to create a simulation of viral spread suggests that restaurants operating at full capacity spread four times as many additional COVID-19 infections as the next-worst location, indoor gyms.

The model predicts that only about 10% of “points of interest” — public places where people gather — account for over 80% of infections that occurred in public places, said Jure Leskovec of Stanford University, lead author of the mobile phone data study.

“There are a small number of these superspreader sites that account for a large majority of infections,” he said. One characteristic of superspreader sites is that “people are packed and stay there a long time.”

Still, none of these studies can definitively prove that restaurant dining causes infections, the researchers said. Identifying any individual restaurant case or cluster requires the kind of shoe-leather investigation that few communities in the U.S. have been able to conduct.

“You’d have to follow the person and have a lot more detail and information to be able to make that claim,” said CDC epidemiologist Fisher.

Many countries have succeeded in following individual trails of virus. In China, for instance, contact tracing revealed how a restaurant’s air conditioning unit may have carried a positive patient’s viral droplets from one table to two others, infecting nine other people.

In Japan, investigators use contact tracing to identify clusters of disease where people live or congregate. Out of about 3,000 cases confirmed from January to April in that country, investigators could identify 61 clusters, 16% of which were in restaurants or bars.

The failure to achieve comprehensive contact tracing means that decisions about whether to close restaurants, or how many customers to allow at a time, have relied heavily on the local political climate. Because the data from contact tracing is sketchy, it’s not always easy to correlate a community’s restaurant restrictions with case rates.

In San Diego, where indoor dining had been permitted with restrictions since the debut of the state’s tiered reopening system in August, 9.2% of COVID-infected residents reported visiting a bar or restaurant up to two weeks before their symptoms appeared. All indoor dining ended in the county Nov. 14 because the county reached a threshold of case reports that led to state-required closings.

In Houston, meanwhile, 8.7% of COVID-positive people interviewed for contact tracing listed a restaurant, cafe or diner as a potential source of exposure since June 1. Restaurants there have been allowed to operate at 75% of indoor capacity since mid-September.

Other local governments have contact tracing completion rates so low that the data gleaned may not be meaningful.

For example, in Philadelphia, only about 2% of the COVID patients interviewed by contact tracers reported going to a restaurant, and the city allowed restaurants to reopen for indoor dining on Sept. 8. But it’s not clear how representative the city’s figures are. In one recent week, Philadelphia investigators were able to reach only 29% of the 2,110 positive cases they sought to contact. Despite this, indoor dining was stopped on Nov. 20 to combat a surge of cases.

In California, the state restricts the operation of establishments based on overall case and positivity rates in each county. But counties with more robust contact-tracing programs, like Los Angeles, have been able to glean striking insights from interviewing positive patients.

In Los Angeles, about 6% of COVID infections have occurred among restaurant customers, according to the public health department, though only outdoor dining has been allowed there since the state debuted its current tiered system in August.

That data suggests that even outdoor dining may spread the virus, said Shira Shafir, an associate professor of community health sciences and epidemiology at UCLA.

She gets takeout regularly to support the restaurants in her neighborhood but hasn’t eaten out since February, having concluded it isn’t worth the risk to herself and other patrons, or to the restaurant workers.

“I don’t want to ask someone else to take a risk that I’m unwilling to take,” she said.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.


This story can be republished for free (details).

Investors pour $91M into growing clinical-trial software firm

The Covid-19 pandemic is altering behavior and fueling demand for remote technologies in clinical trials with Medable, a company in the clinical trial software space, looking to capitalize.

OSHA Let Employers Decide Whether to Report Health Care Worker Deaths. Many Didn’t.

As Walter Veal cared for residents at the Ludeman Developmental Center in suburban Chicago, he saw the potential future of his grandson, who has autism.

This story also ran on The Guardian. It can be republished for free.

So he took it on himself not just to bathe and feed the residents, which was part of the job, but also to cut their hair, run to the store to buy their favorite body wash and barbecue for them on holidays.

“They were his second family,” said his wife, Carlene Veal.

Even after COVID-19 struck in mid-March and cases began spreading through the government-run facility, which serves nearly 350 adults with developmental disabilities, Walter was determined to go to work, Carlene said.

Staff members were struggling to acquire masks and other personal protective equipment at the time, many asking family members for donations and wearing rain ponchos sent by professional baseball teams.

All Walter had was a pair of gloves, Carlene said.

By mid-May, rumors of some sick residents and staffers had turned into 274 confirmed positive COVID tests, according to the Illinois Department of Human Services COVID tracking site. On May 16, Walter, 53, died of the virus. Three of his colleagues had already passed, according to interviews with Ludeman workers, the deceased employees’ families and union officials.

State and federal laws say facilities like Ludeman are required to alert Occupational Safety and Health Administration officials about work-related employee deaths within eight hours. But facility officials did not deem the first staff death on April 13 work-related, so they did not report it. They made the same decision about the second and third deaths. And Walter’s.

It’s a pattern that’s emerged across the nation, according to a KHN review of hundreds of worker deaths detailed by family members, colleagues and local, state and federal records.

Workplace safety regulators have taken a lenient stance toward employers during the pandemic, giving them broad discretion to decide internally whether to report worker deaths. As a result, scores of deaths were not reported to occupational safety officials from the earliest days of the pandemic through late October.

KHN examined more than 240 deaths of health care workers profiled for the Lost on the Frontline project and found that employers did not report more than one-third of them to a state or federal OSHA office, many based on internal decisions that the deaths were not work-related — conclusions that were not independently reviewed.

Work-safety advocates say OSHA investigations into staff deaths can help officials pinpoint problems before they endanger other employees as well as patients or residents. Yet, throughout the pandemic, health care staff deaths have steadily climbed. Thorough reviews could have also prompted the Department of Labor, which oversees OSHA, to urge the White House to address chronic protective gear shortages or sharpen guidance to help keep workers safe.

Since no public agency releases the names of health care workers who die of COVID-19, a team of reporters building the Lost on the Frontline database has scoured local news stories, GoFundMe campaigns, and obituary and social media sites to identify nearly 1,400 possible cases. More than 260 fatalities have been vetted with families, employers and public records.

For this investigation, journalists examined worker deaths at more than 100 health care facilities where OSHA records showed no fatality investigation was underway.

At Ludeman, the circumstances surrounding the April 13 worker death might have shed light on the hazards facing Veal. But no state work safety officials showed up to inspect — because the Department of Human Services, which operates Ludeman and employs the staff, said it did not report any of the four deaths there to Illinois OSHA.

The department said “it could not determine the employees contracted COVID-19 at the workplace” — despite its being the site of one of the largest U.S. outbreaks. Since Veal’s death in May, dozens more workers have tested positive for COVID-19, according to DHS’ COVID tracking site.

OSHA inspectors monitor local news media and sometimes will open investigations even without an employer’s fatality report. Through Nov. 5, federal OSHA offices issued 63 citations to facilities for failing to report a death. And when inspectors do show up, they often force improvements — requiring more protective equipment for workers and better training on how to use it, files reviewed by KHN show.

Still, many deaths receive little or no scrutiny from work-safety authorities. In California, public health officials have documented about 200 health care worker deaths. Yet the state’s OSHA office received only 75 fatality reports at health care facilities through Oct. 26, Cal/OSHA records show.

Nursing homes, which are under strict Medicare requirements, reported more than 1,000 staff deaths through mid-October, but only about 350 deaths of long-term care facility workers appear to have been reported to OSHA, agency records show.

Workers whose deaths went unreported include some who took painstaking precautions to avoid getting sick and passing the virus to family members: One California lab technician stayed in a hotel during the workweek. An Arizona nursing home worker wore a mask for family movie nights. A Nevada nurse told his brother he didn’t have adequate PPE. Nevada OSHA confirmed to KHN that his death was not reported to the agency and that officials would investigate.

KHN asked health care employers why they chose not to report fatalities. Some cited the lack of proof that a worker was exposed on-site, even in workplaces that reported a COVID outbreak. Others cited privacy concerns and gave no explanation. Still others ignored requests for comment or simply said they had followed government policies.

“It is so disrespectful of the agencies and the employers to shunt these cases aside and not do everything possible to investigate the exposures,” said Peg Seminario, a retired union health and safety director who co-authored a study on OSHA oversight with scholars from Harvard’s T.H. Chan School of Public Health.

A Department of Labor spokesperson said in a statement that an employer must report a fatality within eight hours of knowing the employee died and after determining the cause of death was a work-related case of COVID-19.

The department said employers also are bound to report a COVID death if it comes within 30 days of a workplace incident — meaning exposure to COVID-19.

Yet pinpointing exposure to an invisible virus can be difficult, with high rates of pre-symptomatic and asymptomatic transmission and spread of the virus just as prevalent inside a hospital COVID unit as out.

Those challenges, plus May guidance from OSHA, gave employers latitude to decide behind closed doors whether to report a case. So it’s no surprise that cases are going unreported, said Eric Frumin, who has testified to Congress on worker safety and is health and safety director for Change to Win, a partnership of seven unions.

“Why would an employer report unless they feel for some reason they’re socially responsible?” Frumin said. “Nobody’s holding them to account.”

Downside of Discretion

OSHA’s guidance to employers offered pointers on how to decide whether a COVID death is work-related. It would be if a cluster of infections arose at one site where employees work closely together “and there is no alternative explanation.” If a worker had close contact with someone outside of work infected with the virus, it might not have been work-related, the guidance says.

Ultimately, the memo says, if an employer can’t determine that a worker “more likely than not” got sick on the job, “the employer does not need to record that.”

In mid-March, the union that represented Paul Odighizuwa, a food service worker at Oregon Health & Science University, raised concerns with university management about the virus possibly spreading through the Food and Nutrition Services Department.

Workers there — those taking meal orders, preparing food, picking up trays for patient rooms and washing dishes — were unable to keep their distance from one another, said Michael Stewart, vice president of the American Federation of State, County and Municipal Employees Local 328, which represents about 7,000 workers at OHSU. Stewart said the union warned administrators they were endangering people’s lives.

Soon the virus tore through the department, Stewart said. At least 11 workers in food service got the virus, the union said. Odighizuwa, 61, a pillar of the local Nigerian community, died on May 12.

OHSU did not report the death to the state’s OSHA and defended the decision, saying it “was determined not to be work-related,” according to a statement from Tamara Hargens-Bradley, OHSU’s interim senior director of strategic communications.

She said the determination was made “[b]ased on the information gathered by OHSU’s Occupational Health team,” but she declined to provide details, citing privacy issues.

Stewart blasted OHSU’s response. When there’s an outbreak in a department, he said, it should be presumed that’s where a worker caught the virus.

“We have to do better going forward,” Stewart said. “We have to learn from this.” Without an investigation from an outside regulator like OSHA, he doubts that will happen.

Stacy Daugherty heard that Oasis Pavilion Nursing and Rehabilitation Center in Casa Grande, Arizona, was taking strict precautions as COVID-19 surged in the facility and in Pinal County, almost halfway between Phoenix and Tucson.

Her father, a certified nursing assistant there, was also extra cautious: He believed that if he got the virus, “he wouldn’t make it,” Daugherty said.

Mark Daugherty, a father of five, confided in his youngest son when he fell ill in May that he believed he contracted the coronavirus at work, his daughter said in a message to KHN.

Early in June, the facility filed its first public report on COVID cases to Medicare authorities: Twenty-three residents and eight staff members had fallen ill. It was one of the largest outbreaks in the state. (Medicare requires nursing homes to report staff deaths each week in a process unrelated to OSHA.)

By then, Daugherty, 60, was fighting for his life, his absence felt by the residents who enjoyed his banjo, accordion and piano performances. But the country’s occupational safety watchdog wasn’t called in to figure out whether Daugherty, who died June 19, was exposed to the virus at work. His employer did not report his death to OSHA.

“We don’t know where Mark might have contracted COVID 19 from, since the virus was widespread throughout the community at that time. Therefore there was no need to report to OSHA or any other regulatory agencies,” Oasis Pavilion’s administrator, Kenneth Opara, wrote in an email to KHN.

Since then, 15 additional staffers have tested positive and the facility suspects a dozen more have had the virus, according to Medicare records.

Gaps in the Law

If Oasis Pavilion needed another reason not to report Daugherty’s death, it might have had one. OSHA requires notice of a death only within 30 days of a work-related incident. Daugherty, like many others, clung to life for weeks before he died.

That is one loophole — among others — in work-safety laws that experts say could use a second look in the time of COVID-19.

In addition, federal OSHA rules don’t apply to about 8 million public employees. Only government workers in states with their own state OSHA agency are covered. In other words, in about half the country if a government employee dies on the job — such as a nurse at a public hospital in Florida, or a paramedic at a fire department in Texas — there’s no requirement to report it and no one to look into it.

So there was little chance anyone from OSHA would investigate the deaths of two health workers early this year at Central State Hospital in Georgia — a state-run psychiatric facility in a state without its own worker-safety agency.

On March 24, a manager at the facility had warned staff they “must not wear articles of clothing, including Personal Protective Equipment” that violate the dress code, according to an email KHN obtained through a public records request.

Three days later, what had started as a low-grade illness for Mark DeLong, a licensed practical nurse at the facility, got serious. His cough was so severe late on March 27 that he called 911 — and handed the phone to his wife, Jan, because he could barely speak, she said.

She went to visit him in the hospital the next day, fully expecting a pleasant visit with her karaoke partner. “By the time I got there it was too late,” she said. DeLong, 53 “had passed.”

She learned after his death that he’d had COVID-19.

Back at the hospital, workers had been frustrated with the early directive that employees should not wear their own PPE.

Bruce Davis had asked his supervisors if he could wear his own mask but was told no because it wasn’t part of the approved uniform, according to his wife, Gwendolyn Davis. “He told me ‘They don’t care,’” she said.

Two days after DeLong’s death, the directive was walked back and employees and contractors were informed they could “continue and are authorized to wear Personal Protective Gear,” according to a March 30 email from administrators. But Davis, a Pentecostal pastor and nursing assistant supervisor, was already sick. Davis worked at the hospital for 27 years and saw little distinction between the love he preached at the altar and his service to the patients he bathed, fed and cared for, his wife said.

Sick with the virus, Davis died April 11.

At the time, 24 of Central State’s staffers had tested positive, according to the Georgia Department of Behavioral Health and Developmental Disabilities, which runs the facility. To date, nearly 100 staffers and 33 patients at Central State have gotten the virus, according to figures from the state agency.

“I don’t think they knew what was going on either,” Jan DeLong said. “Somebody needs to check into it.”

In response to questions from KHN, a spokesperson for the department provided a prepared statement: “There was never a ban on commercially available personal protective equipment, even if the situation did not call for its use according to guidelines issued by the Centers for Disease Control and Prevention and the Georgia Department of Public Health at the time.”

KHN reviewed more than a dozen other health worker deaths at state or local government workplaces in states like Texas, Florida and Missouri that went unreported to OSHA for the same reason — the facilities were run by government agencies in a state without its own worker safety agency.

Inside Ludeman

In mid-March, staff members at the Ludeman Developmental Center were desperate for PPE. The facility was running low on everything from gloves and gowns to hand sanitizer, according to interviews with current and former workers, families of deceased workers, and union officials.

Due to a national shortage at the time, surgical masks went only to staffers working with known positive cases, said Anne Irving, regional director for AFSCME Council 31, the union that represents Ludeman employees.

Residents in the Village of Park Forest, Illinois, where the facility is located, tried to help by sewing masks or pivoting their businesses to produce face shields and hand sanitizer, said Mayor Jonathan Vanderbilt. But providing enough supplies for more than 900 Ludeman employees proved difficult.

Michelle Abernathy, 52, a newly appointed unit director, bought her own gloves at Costco. In late March, a resident on Abernathy’s unit showed symptoms, said Torrence Jones, her fiancé who also works at the facility. Then Abernathy developed a fever.

When she died on April 13 — the first known Ludeman staff member lost to the pandemic — the Illinois Department of Human Services, which runs Ludeman, made no report to safety regulators. After seeing media reports, Illinois OSHA sent the agency questions about Abernathy’s daily duties and working conditions. Based on DHS’ responses and subsequent phone calls, state OSHA officials determined Abernathy’s death was “not work-related.”

Barbara Abernathy, Michelle’s mom, doesn’t buy it. “Michelle was basically a hermit,” she said, going only from work to home. She couldn’t have gotten the virus anywhere else, she said. In response to OSHA’s inquiry for evidence that the exposure was not related to her workplace, her employer wrote “N/A,” according to documents reviewed by KHN.

Two weeks after Abernathy’s passing, two more employees died: Cephus Lee, 59, and Jose Veloz III, 52. Both worked in support services, boxing food and delivering it to the 40 buildings on campus. Their deaths were not reported to Illinois OSHA.

Veloz was meticulous at home, having groceries delivered and wiping down each item before bringing it inside, said his son, Joseph Ricketts.

But work was another story. Maintaining social distance in the food prep area was difficult, and there was little information on who had been infected or exposed to the virus, according to his son.

“No matter what my dad did, he was screwed,” Ricketts said. Adding, he thought Ludeman did not do what it should have done to protect his dad on the job.

A March 27 complaint to Illinois OSHA said it took a week for staff to be notified about multiple employees who tested positive, according to documents obtained by the Documenting COVID-19 project at the Brown Institute for Media Innovation and shared with KHN. An early April complaint was more frank: “Lives are endangered,” it said.

That’s how Rose Banks felt when managers insisted she go to work, even though she was sick and awaiting a test result, she said. Her husband, also a Ludeman employee, had already tested positive a week earlier.

Banks said she was angry about coming in sick, worried she might infect co-workers and residents. After spending a full day at the facility, she said, she came home to a phone call saying her test was positive. She’s currently on medical leave.

With some Ludeman staff assigned to different homes each shift, the virus quickly traveled across campus. By mid-May, 76 staff and 198 residents had tested positive, according to DHS’ COVID tracking site.

Carlene Veal said her husband, Walter, was tested at the facility in late April. But by the time he got the results weeks later, she said, he was already dying.

Carlene can still picture the last time she saw Walter, her high school sweetheart and a man she called her “superhero” for 35 years of marriage and raising four kids together. He was lying on a gurney in their driveway with an oxygen mask on his face, she said. He pulled the mask down to say “I love you” one last time before the ambulance pulled away.

The Illinois Department of Human Services said that, since the beginning of the pandemic, it has implemented many new protocols to mitigate the outbreak at Ludeman, working as quickly as possible based on what was known about the virus at the time. It has created an emergency staffing plan, identified negative-airflow spaces to isolate sick individuals and made “extensive efforts” to procure more PPE, and it is testing all staffers and residents regularly.

“We were deeply saddened to lose four colleagues who worked at Ludeman Developmental Center and succumbed to the virus,” the agency said in a statement. “We are committed to complying with and following all health and safety guidelines for COVID-19.”

The number of new cases at Ludeman has remained low for several months now, according to DHS’ COVID tracking site.

But that does little to console the families of those who have died.

When a Ludeman supervisor called Barbara Abernathy in June to express condolences and ask if there was anything they could do, Abernathy didn’t know how to respond.

“There was nothing they could do for me now,” she said. “They hadn’t done what they needed to do before.”

Shoshana Dubnow, Anna Sirianni, Melissa Bailey and Hannah Foote contributed to this report.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.


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Why Was Chicken the Primary Source of Arsenic Exposure in Children?

What was the National Chicken Council’s response to public health authorities calling for the industry to stop feeding arsenic-based drugs to poultry?

“Dietary practices influence our exposure to pesticides, toxic heavy metals, persistent organic pollutants, and industrial pollutants….A diet high in fish and other animal products, for example, results in greater exposure to persistent organic compounds and metals than does a plant-based diet because these compounds bioaccumulate up the food chain.” Researchers at UC Davis analyzed the diets of children and adults in California to see just how bad things have gotten.

Cancer benchmark levels were exceeded by all children—100 percent of children—for arsenic, the banned pesticides dieldrin and DDT, metabolite DDE, as well as dioxins, and not just by a little. As you can see at 0:51 in my video Where Does the Arsenic in Chicken Come From?, researchers found more than a hundred times the acceptable daily exposure for arsenic in preschoolers, school-aged children, parents, and older adults, about ten times the acceptable levels for various pesticides, and up to a thousand times the daily dose for dioxins. Where are all these toxins coming from?

The number-one source of dioxins in the diets of Californian preschoolers, kids, parents, and grandparents appears to be dairy for all age groups, followed by meat, and then white potatoes, refined grains, mushrooms, poultry, and fish.

These days, our DDT legacy is also mostly from dairy. Dieldrin was created as a safer alternative to DDT, but it was banned just two years later, in 1974, though it’s still found in our bodies, mostly thanks to dairy, meat, and, evidently, cucumbers.

Chlordane made it into the 1980s before being banned, though we’re still exposed through dairy (and cukes). Lead is — foodwise — also mostly from dairy, and mercury is not surprisingly mostly from tuna and other seafood. But the primary source of arsenic in children? Surprisingly, mostly from chicken. Why?

Let me tell you a tale of arsenic in chicken. Arsenic is “well known as a poison by anyone who reads mysteries or the history of the Borgias, and with its long and colourful history, arsenic is not something that people want in their food.” So, when a biostatistics student went to the USDA in 2000 in search of a project for his master’s degree, he decided to look into it. He found a startling difference: Arsenic levels in chicken were three times higher than in other meats. His veterinary colleagues weren’t at all surprised and explained that four different types of arsenic-containing antibiotic drugs are fed to poultry—and have been fed to them since 1944.

“While arsenic-based drugs had been fed to poultry since the 1940s, recognition of this source of exposure [for humans] only occurred after appropriate statistical analysis of the data”—that is, after this student churned through the data. It was published in 2004 and expanded upon in 2006. The National Chicken Council (NCC) was none too pleased, saying lots of foods are contaminated with arsenic. “By focusing specifically on chicken, IATP [the Institute for Agriculture and Trade Policy] makes it clear that it is producing a publicity-oriented document focused on the objective of forcing [chicken] producers to stop using these safe and effective products”—by which the NCC means these arsenic-containing drugs. In fact, the NCC admits to using them but says we don’t need to worry because chicken producers use organic arsenic, “not the inorganic form made infamous in ‘Arsenic and Old Lace.’” Okay, so we don’t need to worry—until, apparently, we cook it. When chicken is cooked, it appears that some of the arsenic drug in the meat turns into the ”Arsenic and Old Lace” variety. So, the Poison-Free Poultry Act of 2009 was introduced into Congress, flopped, and was followed by the subsequent introduction of the Poison-Free Poultry Act of 2011. Did the second attempt fare any better? No, legislators once again said pish posh to poison-poor poultry. So, in 2013, a coalition of nine organizations got together and sued the FDA, and by December 31, 2015, all arsenic-containing poultry drugs were withdrawn. As of 2016, arsenic is no longer to be fed to chickens. The bad news is that without giving birds the arsenic-containing drug roxarsone, chicken may lose some of its “appealing pink color.”

In the end, the poultry industry got away with exposing the American public to arsenic for 72 years. “It should be noted that the European Union has never approved drugs containing arsenic for animal consumption” in the first place, saying, Hmm, feed our animals arsenic? No thanks, nein danke, no grazie, non, merci.

Europe has also long since banned the “urgent threat to human health” posed by feeding farm animals millions of pounds of human antibiotics. As you can see at 5:30 in my video, feeding chickens en masse literally tons of drugs like tetracyclines and penicillins to fatten them faster is a problem that gets worse every year instead of better and dates back to 1951 when drug companies whipped out the ALL CAPS in advertisements,  promising “PROFITS…several times higher!”, a dangerous practice the poultry industry has gotten away with for 68 years…and counting.

If you don’t eat poultry and are feeling a little cocky, you may want to check out my 12-video series on arsenic in rice before you gloat too much:

Think feeding arsenic to chickens is weird? Check out Illegal Drugs in Chicken Feathers.

And for more on the critical public health threat posed by antibiotic overuse in animal agriculture, see:

In health,

Michael Greger, M.D.

PS: If you haven’t yet, you can subscribe to my free videos here and watch my live presentations:

Medicare Open Enrollment Is Complicated. Here’s How to Get Good Advice.

If you’ve been watching TV lately, you may have seen actor Danny Glover or Joe Namath, the 77-year-old NFL legend, urging you to call an 800 number to get fabulous extra benefits from Medicare.

There are plenty of other Medicare ads, too, many set against a red-white-and-blue background meant to suggest officialdom — though if you stand about a foot from the television screen, you might see the fine print saying they are not endorsed by any government agency.

Rather, they are health insurance agents aggressively vying for a piece of a lucrative market.

This is what Medicare’s annual enrollment period has come to. Beneficiaries — people who are 65 or older, or with long-term disabilities — have until Dec. 7 to join, switch or drop health or drug plans, which take effect Jan. 1. By switching plans, they can potentially save money or get benefits not ordinarily provided by the federal insurance program.

For all its complexity and nearly endless options, Medicare fundamentally boils down to two choices: traditional fee-for-service or the managed care approach of Medicare Advantage.

The right choice for you depends on your financial wherewithal and current health status, and on future health scenarios that are often difficult to foresee and unpleasant to contemplate.

Costs and benefits among the multitude of competing Medicare plans vary widely, and the maze of rules and other details can be overwhelming. Indeed, information overload is part of the reason a majority of the more than 60 million people on Medicare, including over 6 million in California, do not comparison-shop or switch to more suitable plans.

“I’ve been doing it for 33 years and my head still spins,” says Jill Selby, corporate vice president of strategic initiatives and product development at SCAN, a Long Beach nonprofit that is one of California’s largest purveyors of Medicare managed care, known as Medicare Advantage. “It’s definitely a college course.”

Which explains why airwaves and mailboxes are jammed with all that promotional material from people offering to help you pass the course.

Many are touting Medicare Advantage, which is administered by private health insurers. It might save you money, but not necessarily, and research suggests that, in some cases, it costs the government more than administering traditional Medicare.

But the hard marketing is not necessarily a sign of bad faith. Licensed insurance agents want the nice commission they get when they sign somebody up, but they can also provide valuable information on the bewildering nuances of Medicare.

Industry insiders and outside experts agree most people should not navigate Medicare alone. “It’s just too complicated for the average individual,” says Mark Diel, chief executive officer of California Coverage and Health Initiatives, a statewide association of local outreach and health care enrollment organizations.

However, if you decide to consult with an insurance agent, keep your antenna up. Ask people you trust to recommend agents, or try eHealth or another established online brokerage. Vet any agent you choose by asking questions on the phone.

“Be careful if you feel like the insurance agent is pushing you to make a decision,” says Andrew Shea, senior vice president of marketing at eHealth. And if in doubt, don’t hesitate to get a second opinion, Shea counsels.

You can also talk to a Medicare counselor through one of the State Health Insurance Assistance Programs, which are present in every state. Find your state’s SHIP at

Medicare & You, a comprehensive handbook, is worth reading. Download it at the official Medicare website,

The website offers a deep dive into all aspects of Medicare. If you type in your ZIP code, you can see and compare all the Medicare Advantage plans, supplemental insurance plans, known as Medigap, and stand-alone drug (Part D) plans.

The site also shows you quality ratings of the plans, on a five-star scale. And it will display your drug costs under each plan if you type in all your prescriptions. Explore the website before you talk to an insurance agent.

California Coverage and Health Initiatives can refer you to licensed insurance agents who will provide local advice and enrollment assistance. Call 833-720-2244. Its members specialize in helping people who are eligible for both Medicare and Medicaid, the health insurance program for low-income people.

These so-called dual eligibles — nearly 1.5 million in California and about 12 million nationwide — get additional benefits, and in some cases they don’t have to pay Medicare’s monthly medical (Part B) premium, which will be $148.50 in 2021 for most beneficiaries, but higher for people above certain income thresholds.

If you choose traditional Medicare, consider a Medigap supplement if you can afford it. Without it, you’re liable for 20% of your physician and outpatient costs and a hefty hospital deductible, with no cap on how much you pay out of your own pocket. If you need prescription drugs, you’ll probably want a Part D plan.

Medicare Advantage, by contrast, is a one-stop shop. It usually includes a drug benefit in addition to other Medicare benefits, with cost sharing for services and prescriptions that varies from plan to plan. Medicare Advantage plans typically have low to no premiums — aside from the Part B premium that most people pay in either version of Medicare. And they increasingly offer additional benefits, including vision, dental, transportation, meal deliveries and even coverage while traveling abroad.

Beware of the risks, however.

Yes, the traditional Medicare route is generally more expensive upfront if you want to be fully covered. That’s because you pay a monthly premium for a Medigap policy, which can cost $200 or more. Add to that the premium for Part D, estimated to average $41 a month in 2021, according to KFF. (KHN is an editorially independent program of KFF.)

However, Medigap policies will often protect you against large medical bills if you need lots of care.

In some cases, Medicare Advantage could end up being more expensive if you get seriously ill or injured, because copays can quickly add up. They are typically capped each year, but can still cost you thousands of dollars. Advantage plans also typically have more limited provider networks, and the extra benefits they offer can be subject to restrictions.

Over one-third of Medicare beneficiaries nationally are enrolled in Advantage plans. In California, about 40% are.

The main appeal of traditional Medicare is that it doesn’t have the rules and restrictions of managed care.

Dr. Mark Kalish, a retired psychiatrist in San Diego, says he opted for traditional fee-for-service with Medigap and Part D because he didn’t want a “mother may I” plan.

“I’m 69 years old, so heart attacks happen; cancer happens. I want to be able to pick my own doctor and go where I want,” Kalish says. “I’ve done well, so the money isn’t an issue for me.”

Be aware that if you don’t join a Medigap plan during a six-month open enrollment period that begins when you enroll in Medicare Part B, you could be denied coverage for a preexisting condition if you try to buy one later.

There are a few exceptions to that in federal law, and four states — New York, Massachusetts, Maine, Connecticut — require continuous or yearly access to Medigap coverage regardless of health status.

Make sure you understand the rules and exceptions that apply to you.

Indeed, that is an excellent rule of thumb for all Medicare beneficiaries. Read up and talk to insurance agents and Medicare counselors. Talk to friends, family members, your doctor, your health plan — and other health plans.

When it comes to Medicare, says Erin Trish, associate director of the University of Southern California’s Schaeffer Center for Health Policy and Economics, “it takes a village.”

This KHN story first published on California Healthline, a service of the California Health Care Foundation.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.


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California Law Banning Toxic Chemicals in Cosmetics Will Transform Industry

A toxic chemical ban signed into law in California will change the composition of cosmetics, shampoos, hair straighteners and other personal care products used by consumers across the country, industry officials and activists say.

The ban, signed by Gov. Gavin Newsom at the end of September, covers 24 chemicals, including mercury, formaldehyde and several types of per- and polyfluoroalkyl substances, known as PFAS. All the chemicals are carcinogenic or otherwise toxic — and advocates argue they have no place in beauty products.

When the law takes effect in 2025, it will mark the first major action to remove toxic substances from beauty products in almost a century. Federal regulation of cosmetics has not been updated meaningfully since 1938, and only 11 ingredients in personal care products are regulated by the Food and Drug Administration. By contrast, the European Union bans more than 1,600 cosmetic substances and ingredients from cosmetics.

The California law, passed by wide margins in both houses of the legislature, “is a milestone for cosmetic safety in the United States,” said Emily Rusch, executive director of the California Public Interest Research Group, which was heavily involved in shaping the bill.

The Personal Care Products Council, which represents big companies like Amway and Chanel, was hesitant but eventually supported the bill and worked directly with legislators on its final form. The industry’s buy-in will help give the California law national repercussions.

“If you’re doing business in the United States, you’re doing business in California,” said Mike Thompson, senior vice president for government affairs at the council. “I would assume that this would really, in many ways, set up a new standard.”

Breast Cancer Prevention Partners, another activist group, advocated strongly for the measure because many of the banned chemicals have been linked to breast cancer, said Janet Nudelman, the group’s director of program and policy.

For salon workers like Kristi Ramsburg, the bill could offer the peace of mind that comes from knowing her workplace is freer of toxics. Over the 20 years she’s worked as a hairdresser in Wilmington, North Carolina, Ramsburg has done hundreds of straightening jobs on her clients’ naturally frizzy hair. Performing the procedure known as a Brazilian Blowout three to four times a week exposed her to harsh and dangerous/toxic products including formaldehyde and phthalates.

She experienced “sore throats, dizziness. My vision changed, definitely,” she said. “You’d be almost crying at first.”

Studies dating to the early 1900s show that inhaling even small quantities of formaldehyde can lead to pneumonia or swelling of the liver. It’s been classified as a carcinogen, according to the FDA.

Ramsburg believes her exposure severely damaged her health. Over six years, she had surgeries to remove her gallbladder, ovaries and appendix. After her liver swelled dangerously, she suspected, based on medical consults and studies she read, that the formaldehyde she had been breathing for decades was to blame.

“I was just inundated with toxins constantly. I literally almost died,” she said.

Horror stories like Ramsburg’s are what motivated legislators, as well as the cosmetic industry, to support the California law.

Federal legislation that would have given the FDA more power to control or recall products containing the 11 federally regulated ingredients failed to gain traction in either chamber in recent sessions, despite the support of celebrities like Kourtney Kardashian.

Advocates say the inadequacies in federal regulation have been apparent for years. Current law does not require cosmetics to be reviewed and approved by the FDA before being sold to consumers. And the agency can take post-marketing action only if a cosmetic’s ingredients were found to be tampered with or its labeling is wrong or misleading.

The FDA couldn’t even intervene when asbestos was found in cosmetics sold at the youth-oriented Claire’s and Justice stores. In a 2019 letter, then-FDA Commissioner Scott Gottlieb wrote that his hands were tied because “there are currently no legal requirements for any cosmetic manufacturer marketing products to American consumers to test their products for safety.” No action was taken.

FDA scientists moved to ban formaldehyde from hair straighteners as early as 2016, according to internal agency emails, but weren’t successful. A 2019 study by government investigators found that using hair straighteners was linked with a higher risk of breast cancer, which rose with increased use. The study also found that using permanent hair dye was linked with an increased breast cancer risk.

After the federal legislation stalled, advocates changed their focus to California. The Golden State’s liberal leanings made it a likely place to pass a bill, while its status as the world’s fifth-largest economy meant any new law would have national impact. That has previously been the case, as when California set its own limits on car emissions or demanded nutrition labels for restaurant menus.

“It plays that pivotal role nationwide and has such a large economy, and so much of the cosmetic industry has a huge base here,” said Rusch, of the California Public Interest Research Group. “This type of landmark legislation has the effect essentially of setting a national standard. That was our intent.”

The Personal Care Products Council was open to the ban since the chemicals on the list — after some pruning during negotiations on the bill — include only those already prohibited in the European Union.

“You don’t want a patchwork of rules, either around the country or around the world. You want consistency,” Thompson said. “A lot of our companies may be already there, because they’re designing products for the European Union. … It’s just simpler for them to put out one product versus two.”

In recent years, growing consumer demand for transparency in beauty products has led to the development of a “clean cosmetics industry” whose products make up about 13% of high-end sales, double the percentage four years ago, according to the market research company NPD Group.

Drug and department stores have also increasingly moved toward “clean” products. CVS in 2019 removed parabens, phthalates and chemicals that contain or can give off formaldehyde from its store-brand products.

Advocates argue that the state law will force all companies to provide transparency and consistency about what, exactly, is in the products consumers put on their hair and faces.

“In order to ensure and give assurance to the public that the worst of the worst stuff is out of cosmetics, we felt we really needed to standardize and to put that into statute,” Rusch said.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.


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Surging LA

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On a Monday afternoon in March, four days after Gov. Gavin Newsom issued the nation’s first statewide stay-at-home order to slow the spread of the coronavirus, some of Southern California’s most famous landmarks were deserted and few cars traveled the region’s notoriously congested freeways.

Eight months later, businesses are open, traffic is back — and COVID-19 cases in the state are surging. 

“This is simply the fastest increase California has seen since the beginning of this pandemic,” Newsom said in a press conference Monday, when he announced a major rollback of the state’s reopening process, saying the state’s daily case numbers had doubled in the previous 10 days.

That same day, California Healthline’s Heidi de Marco returned to the landmarks she photographed in March. This time, it took her nearly two days — Monday and Tuesday — to document them because of traffic.

The biggest change was the greater number of vehicles on the road. Foot traffic had also stepped up, but most pedestrians and shoppers were wearing masks and not gathering in large numbers.

It turns out that activities such as strolling along the beach and window-shopping are not the primary way the disease is spreading in Los Angeles County. Public health officials there blame the surge on an increase in social gatherings, such as private dinners and sports-watching parties with people from multiple households, and the virus is spreading mostly among adults ages 18 to 29. In a bid to slow the virus, county public health director Barbara Ferrer announced additional restrictions on businesses, effective Friday. Among them, outdoor dining and drinking at restaurants and breweries will be limited to 50% of capacity, and outdoor gatherings can include only 15 people from no more than three households, including the host’s household.

KHN correspondent Anna Almendrala contributed to this report.

This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.


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KHN on the Air This Week

KHN Midwest correspondent Lauren Weber discussed COVID-19 surges in Wisconsin with Wisconsin Public Radio’s “Central Time” on Nov. 13.

California Healthline correspondent Angela Hart and editor Emily Bazar discussed how the Supreme Court case about the Affordable Care Act could affect California with the CalMatters and Capital Public Radio’s “California State of Mind” podcast.

KHN chief Washington correspondent Julie Rovner discussed open enrollment for ACA marketplace plans with Maine Public Radio’s “Maine Calling” on Monday.

KHN Midwest correspondent Cara Anthony discussed protections against race-based hair discrimination with KTVU Fox 2 on Tuesday.

KHN senior correspondent Liz Szabo discussed COVID vaccine candidates with Newsy on Tuesday.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.


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Push Is On in US to Figure Out South Asians’ High Heart Risks

For years, Sharad Acharya’s frequent hikes in the mountains outside Denver would leave him short of breath. But a real wake-up call came three years ago when he suddenly struggled to breathe while walking through an airport.

An electrocardiogram revealed that Acharya, a Nepali American from Broomfield, Colorado, had an irregular heartbeat on top of the high blood pressure he already knew about. He had to immediately undergo triple bypass surgery and get seven stents.

Acharya, now 54, thought of his late father and his many uncles who have had heart problems.

“It’s part of my genetics, for sure,” he said.

South Asian Americans — people with roots in Nepal, India, Pakistan, Sri Lanka, Bangladesh, Bhutan and the Maldives — have a disproportionately higher risk of heart disease and other cardiovascular ailments. Worldwide, South Asians account for 60% of all heart disease cases, even though — at 2 billion people — they make up only a quarter of the planet’s population.

In the United States, there’s increasing attention on these risks for Americans of South Asian descent, a growing population of about 5.4 million. Health care professionals attribute the problem to a mix of genetic, cultural and lifestyle influences — but researchers are advocating for more resources to fully understand it.

Rep. Pramila Jayapal (D-Wash.) is sponsoring legislation that would direct $5 million over the next five years toward research into heart disease among South Asian Americans and raising awareness of the issue. The bill passed the U.S. House in September and is up for consideration in the Senate.

The issue could gain more attention after Sen. Kamala Harris (D-Calif.) becomes the nation’s first vice president with South Asian lineage. Harris’ mother, Shyamala Gopalan, moved from India to the U.S. in 1958 to attend graduate school. Gopalan, a breast cancer researcher, died in 2009 of colon cancer.

A 2018 study for the American Heart Association found South Asian Americans are more likely to die of coronary heart disease than other Asian Americans and non-Hispanic white Americans. The study pointed to their high incidences of diabetes and prediabetes as risk factors, as well as high waist-to-hip ratios. People of South Asian descent have a higher tendency to gain visceral fat in the abdomen, which is associated with insulin resistance. They also were found to be less physically active than other ethnic groups in the U.S.

One of the nation’s largest undertakings to understand these risks is the Mediators of Atherosclerosis in South Asians Living in America study, which began in 2006. The MASALA researchers, from institutions such as Northwestern University and the University of California-San Francisco, have examined more than 1,100 South Asian American men and women ages 40-79 to better understand the prevalence and outcomes of cardiovascular disease. They stress that high blood pressure and diabetes are common in the community, even for people at normal weights.

That’s why, said Dr. Alka Kanaya, MASALA’s principal investigator and a professor at UCSF, South Asians cannot rely on traditional body mass index metrics, because BMI numbers considered normal could provide false reassurance to those who might still be at risk.

Kanaya recommends cardiac CT scans, which she said help identify high-risk patients, those who need to make more aggressive lifestyle changes and those who may need preventive medication.

Another risk factor, this one cultural, is diet. Some South Asian Americans are vegetarians, though it’s often a grain-heavy diet reliant on rice and flatbread. The AHA study found risks in such diets, which are high in refined carbohydrates and saturated fat.

“We have to understand the cultural nuances [with] an Indian vegetarian diet,” said Dr. Ronesh Sinha, author of “The South Asian Health Solution” and an internal medicine physician. “That means something totally different than … a Westerner who’s going to be consuming a lot of plant-based protein and tofu, eating lots of salads and things that typical South Asians don’t.”

But getting South Asians to change their eating habits can be challenging, because their culture expresses hospitality and love through food, according to Arnab Mukherjea, an associate professor of health sciences at California State University-East Bay. “One of the things South Asians tend to take a lot of pride in is transmitting cultural values and norms knowledge to the next generation,” Mukherjea said.

The intergenerational transmission goes both ways, according to MASALA researchers. Adult, second-generation South Asian Americans might be the key to helping those in the first generation who are resistant to change adopt healthier habits, according to Kanaya.

In the San Francisco Bay Area, El Camino Hospital’s South Asian Heart Center is one of the nation’s leading centers for educating the community. Its three locations are not far from Silicon Valley tech giants, which employ many South Asian Americans.

The center’s medical director, Dr. César Molina, said the center treats many relatively young patients of South Asian descent without typical risk factors for cardiovascular disease.

“It was like the typical 44-year-old engineer with a spouse and two kids showing up with a heart attack,” he said.

The South Asian Health Center helps patients make lifestyle changes through meditation, exercise, diet and sleep. The nearby Palo Alto Medical Foundation’s Prevention and Awareness for South Asians program and the Stanford South Asian Translational Heart Initiative provide medical support for the community. Even patients in the later stages of heart disease can be helped by lifestyle changes, Sinha said.

Dr. Kevin Shah, a University of Utah cardiologist who co-authored the AHA study, said people with diabetes, hypertension and obesity are also at higher risk of COVID-19 complications so should now especially work to improve their cardiovascular health and fitness.

In Colorado, Acharya’s health is still an issue. He said he had to get four more stents this year, and the surgeries have put pressure on his family. But he’s breathing well, watching what he eats — and once more exploring his beloved mountains.

“Nowadays, I feel very, very good,” he said. “I’m hiking a lot.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.


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As Broad Shutdowns Return, Weary Californians Ask ‘Is This the Best We Can Do?’

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SANTA CRUZ, Calif. — For Tom Davis, being told by the state this week that he must close his Pacific Edge Climbing Gym for the third time in six months is beyond frustrating. The first time the rock-climbing gym and fitness center shut down, co-owners Davis and Diane Russell took out a government loan to pay employees. The second time, they were forced to lay everyone off — themselves included. Now, as they face another surge of COVID cases across California, he fears he may lose the business for good.

California’s ping-ponging approach to managing the virus — twice reopening large portions of the service-sector economy only to shut them again — doesn’t seem just or reasonable, Davis said. As of Tuesday evening, he was planning to defy the order, keeping the gym open but with additional restrictions on capacity.

“The government is essentially saying, ‘We’re just picking you to personally go bankrupt and all the people who work with you,’” said Davis. “Nobody can afford to live in Santa Cruz on unemployment.”

It’s a grim time in the pandemic. California has surpassed 1 million cases of COVID-19 and 94% of Californians — more than 37.7 million people — live in a county considered to have “widespread” infection. Santa Cruz is one of 41 California counties now under the most restrictive orders in the state’s four-tiered COVID blueprint for determining which businesses can stay open amid the pandemic, and under what proscriptions.

Until Monday, Santa Cruz was in the red tier — the second-most restrictive — meaning Pacific Edge could be open at 10% capacity. Now, its owners are being told to close entirely.

For business owners and workers, a backward slide on the blueprint represents yet another financial setback in a bleak year, leaving some residents angry, exasperated and wondering if this is really the best the state can do.

It’s a question reverberating nationwide as every state experiences a deadly rise in COVID cases and a growing number of hospitals say they are simply out of beds. Among states, California is performing relatively well, ranking 39th in cases per capita and 32nd in deaths, according to a New York Times tracker.

But even here, the virus is too pervasive in its spread — and the public health infrastructure too enfeebled — to make the reopening of businesses and schools an easy proposition. Some experts say that during a pandemic, when the virus is everywhere, the push and pull California businesses are enduring may be what success looks like in much of the U.S. for months to come.

“The yo-yo nature of this is a feature of the pandemic,” said Dr. Ashish Jha, dean of the School of Public Health at Brown University. “And in fact, when I look at really successful countries like South Korea, Taiwan and New Zealand, they all have a yo-yo feeling to them.”

Experts say a crucial factor in being able to reopen safely is getting cases low enough that time-tested public health tools like quarantines and contact tracing can work. Most U.S. hot spots, including broad swaths of California, have never achieved those low levels.

In California, Gov. Gavin Newsom, like many other governors, is trying to thread the needle, to keep cases to a minimum while also allowing many businesses to remain open. It’s a sensitive equation, said Dr. Aimee Sisson, public health officer for Yolo County.

“It’s really hard to dial in the balances of getting our economy going again, which is important for public health, and maintaining our health, which is important for the economy.”

And while California is doing better than many other states, said Cameron Kaiser, the health officer for Riverside County, it’s certainly not cause for celebration. “At this point we’re clearly doing better, but our trends are not good either. When you’re talking about the relative impact of different tragedies, I’m not sure you’d call that a success.”

Even as it frustrates some residents, California’s tiered reopening system has won praise nationally. The system draws on three COVID metrics to guide restrictions: new cases per population; the share of people tested for the coronavirus who are positive; and, in larger counties, an equity measure to ensure cases are low across the county, including in high-risk communities. Under revised guidelines released this week, county tier assignments can change from week to week — and more than once a week if data indicates a county is losing ground.

“We think it’s a best practice nationally and globally,” said Dr. Tom Frieden, a former director of the Centers for Disease Control and Prevention. “This is not about closure — this is about adjusting what is open when.”

Still, the state blueprint isn’t perfect, health officers say. In its early stages, there were inconsistencies around which businesses could stay open. For example, nail salons were treated differently from hair salons, though the exposure conditions are fairly similar. The state has taken feedback, said Sisson, and tried to make improvements.

And perhaps the biggest weakness is how little data exists to determine which businesses present the greatest risks for exposure and transmission, said Sisson and other health officers. While restaurants and bars are broadly considered high-risk because people remove their masks while eating and drinking, not much is known about viral spread at places like gyms and movie theaters, where it’s possible to reduce occupancy and wear masks.

That’s part of what frustrates Davis in Santa Cruz. Pacific Edge has reduced occupancy to just 30 people in the sprawling old factory building and instituted a range of protective measures. “Compare that to Costco. I honestly believe we are just as safe if not safer than other businesses,” Davis said.

Measuring California’s success in navigating the pandemic depends on what your goal is, said Marm Kilpatrick, an infectious disease researcher at the University of California-Santa Cruz who has been advising local government and businesses, including Pacific Edge, on reopening. The state has prioritized both keeping businesses open and keeping cases down, which means neither can be done perfectly.

Still, he’s not sure the whiplash of openings and closings is the best the state can do. He worries the tiered system may inadvertently send the wrong signals: Again and again, public health officials have watched in dismay as residents whose counties move into less-restrictive tiers revert to socializing in large groups and shedding basic safety protocols like masks and social distancing — followed by a dangerous upsurge in infections and hospitalizations.

Dr. Mark Ghaly, the state’s Health and Human Services secretary, has acknowledged as much, stressing that cases are linked to both social gatherings and businesses. Ultimately, he said on Monday, the state is taking a “dual approach” that includes changes to business practices, and asking individuals to be disciplined in wearing masks outside the home, regularly sanitizing hands, staying 6 feet apart, and socializing outdoors and in small gatherings.

Meanwhile, the holiday season looms. The most recent spike in cases directly correlates to Halloween, several health officers said, just as previous spikes were linked to Memorial Day, the Fourth of July and Labor Day. With Thanksgiving, Christmas and New Year’s on the horizon, officials wonder whether they might have to recommend a farther-reaching stay-at-home order to keep cases under control.

“I’m very worried about Thanksgiving,” said Dr. Chris Farnitano, health officer for Contra Costa County. “The tradition of so many families is to get together with their extended families, and that means gatherings with groups of people, and that’s where the virus wants to spread.”

In addition, Farnitano said, given the realities of commerce and travel, what happens in other states affects California. “Having other states with the same restrictions would help California,” he said.

What’s really needed, several public health officials said, is a coordinated national message and strategy.

“I’m hoping we’re gonna have the new president come in and take the reins very firmly,” said Steffanie Strathdee, associate dean of global health at UC-San Diego. “He has the right people around him advising him. But, by then, winter will be half over and we’re going to be facing 400,000 deaths. Digging ourselves out of that mess is going to take awhile.”

This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.


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Lo que los doctores no aprenden: a detectar el racismo en la atención médica

Betial Asmerom, estudiante de medicina de cuarto año en la Universidad de California-San Diego (UCSD), nunca había demostrado interés en ser doctora.

En su adolescencia, ayudó a sus padres, inmigrantes de Eritrea que hablaban poco inglés, a navegar el sistema de atención de salud en Oakland. Veía a médicos que eran irrespetuosos con su familia y que no se preocupaban por el tratamiento de la cirrosis, la hipertensión y la diabetes de su madre.

“Todas esas experiencias hicieron que no me gustaran los médicos”, dijo Asmerom.

“En mi comunidad siempre se decía: ‘Sólo ve al médico si estás a punto de morir’”.

Pero eso cambió cuando tomó un curso en la universidad sobre disparidades en salud. Se dio cuenta que otras comunidades de color sufrían lo mismo que su familia y amigos eritreos. Asmerom pensó que, como médica, podía ayudar a cambiar las cosas.

Hace tiempo que profesores y activistas estudiantiles de todo el país les piden a las escuelas de medicina que aumenten el número de estudiantes e instructores de comunidades poco representadas, para mejorar el tratamiento y fomentar la inclusión.

Pero para identificar las raíces del racismo y sus efectos en el sistema de salud, dicen, se deben hacer cambios fundamentales en los planes de estudio.

Asmerom es una de las muchas voces que piden una sólida educación antirracista. Exigen que las escuelas eliminen el uso de la raza como herramienta de diagnóstico, que reconozcan cómo el racismo sistémico perjudica a los pacientes, y que tengan en cuenta parte de la historia racista de la medicina.

Este activismo no es algo nuevo. White Coats for Black Lives (WC4BL), una organización dirigida por estudiantes que lucha contra el racismo en la medicina surgió a raíz de las protestas de Black Lives Matter en 2014.

Pero después del asesinato de George Floyd en Minneapolis, en mayo, las escuelas de medicina y las organizaciones médicas están bajo más presión para tomar medidas concretas.

Dejar de usar la raza como herramienta de diagnóstico

Durante muchos años, se ha enseñado a los estudiantes de medicina que las diferencias genéticas entre las razas tenían un efecto en la salud. Pero en los últimos años, estudios han encontrado que la raza no refleja eso de manera confiable.

El Instituto Nacional de Investigación del Genoma Humano observa muy poca variación genética entre las razas, y más diferencias entre las personas dentro de cada raza. Por eso, más médicos aceptan que la raza no es una diferencia biológica intrínseca, sino una construcción social.

Pero la doctora Brooke Cunningham, médica y socióloga en la Escuela de Medicina de la Universidad de Minnesota, señaló que en una idea difícil de abandonar. Forma parte de la manera en que los médicos diagnostican y miden las enfermedades, explicó.

Algunos médicos afirman que es útil tener en cuenta la raza cuando se trata a los pacientes; otros sostienen que conduce a prejuicios y a una atención deficiente.

Esas opiniones han llevado a una variedad de creencias falsas, como que los negros tienen la piel más gruesa, que su sangre se coagula más rápido que la de los blancos o que sienten menos dolor.

Cuando la raza interviene en los cálculos médicos, puede conducir a tratamientos menos eficaces y perpetuar las desigualdades basadas en la raza.

Uno de estos cálculos estima la función renal (eGFR, o la tasa estimada de filtración glomerular). El eGFR puede limitar el acceso de los pacientes negros a la atención médica porque el número utilizado para denotar la raza negra en la fórmula proporciona un resultado que sugiere que los riñones funcionan mejor de lo que lo hacen, según informaron recientemente los investigadores en el New England Journal of Medicine.

Entre otra docena de ejemplos que citan está una fórmula que los obstetras usan para determinar la probabilidad de un parto vaginal exitoso después de una cesárea, lo cual pone en desventaja a las pacientes negras no hispanas e hispanas, y un ajuste para medir la capacidad pulmonar usando un espirómetro, lo cual puede causar estimaciones inexactas de la función pulmonar para pacientes con asma o enfermedad pulmonar obstructiva crónica.

A la luz de estas investigaciones, los estudiantes de medicina piden a las escuelas que se replanteen los planes de estudio que tratan la raza como un factor de riesgo de enfermedad.

Briana Christophers, estudiante de segundo año en el Weill Cornell Medical College de Nueva York, dijo que no tiene sentido que la raza haga a alguien más propenso a las enfermedades, aunque los factores económicos y sociales jueguen un papel importante.

Naomi Nkinsi, estudiante de tercer año de la Escuela de Medicina de la Universidad de Washington en Seattle (UW Medicine), recordó haber asistido a una conferencia —junto a otras cuatro estudiantes negras en la sala— y haber oído que los negros son más propensos a enfermedades.

“Lo sentí muy personal”, expresó Nkinsi. “Ese es mi cuerpo, esos son mis padres, esos son mis hermanos. Ahora, cada vez que vaya a un consultorio, sentiré que no sólo no me consideran una persona completa, sino que soy físicamente diferente a todos los demás pacientes sólo porque tengo más melanina en la piel”.

Nkinsi ayudó en una exitosa campaña para excluir la raza del cálculo del eGFR en la UW Medicine, uniéndose a un pequeño número de otros sistemas de salud. Ella dijo que el logro, anunciado oficialmente a finales de mayo, se debió en gran parte a los incansables esfuerzos de los estudiantes negros.

Reconocer los efectos adversos del racismo en la salud

El Liaison Committee on Medical Education (LCME), órgano oficial de acreditación de las facultades de medicina de los Estados Unidos y Canadá, dice que se debe enseñar a los estudiantes a reconocer los prejuicios “en ellos mismos, en los demás y en el proceso de prestación de servicios de atención de la salud”.

Pero el LCME no exige explícitamente a las instituciones acreditadas que enseñen sobre el racismo sistémico en la medicina.

Esto es lo que los estudiantes y algunos profesores quieren cambiar.

El doctor David Acosta, jefe de diversidad e inclusión de la Asociación Americana de Escuelas de Medicina (AAMC, en inglés), reportó que cerca del 80% de las facultades ofrecen un curso obligatorio o electivo sobre disparidades en salud. Pero explicó que hay pocos datos sobre cuántas escuelas enseñan a los estudiantes a reconocer y combatir el racismo.

Un plan de estudios antirracista debería explorar formas de mitigar o eliminar el daño del racismo, indicó Rachel Hardeman, profesora de políticas de salud de la Universidad de Minnesota.

“Hay que pensar en cómo penetra esto en el aprendizaje de la educación médica”, dijo. Los cursos que profundizan en el racismo sistémico deben ser obligatorios, añadió Hardeman.

Edwin Lindo, profesor en la Escuela de Medicina de la Universidad de Washington, dijo que se debería adoptar un modelo interdisciplinario, permitiendo a sociólogos o historiadores dar conferencias sobre cómo el racismo perjudica la salud.

Acosta dijo que la AAMC ha organizado un comité de expertos para desarrollar un plan de estudios contra el racismo para cada nivel de la educación médica. Esperan hacer público su trabajo este mes y hablar con el LCME sobre el desarrollo e implementación de estándares.

“Nuestra próxima tarea es cómo persuadir e influenciar al LCME para que piense en añadir cursos de capacitación antirracista”, dijo Acosta.

Reconocer el racismo en el pasado y el presente de la educación médica

Los activistas quieren que sus instituciones reconozcan sus propios pasos en falso, así como el racismo que ha acompañado a los logros médicos del pasado.

Dereck Paul, estudiante de medicina en la Universidad de California-San Francisco, dijo que quiere que en todas las facultades se incluyan conferencias sobre personas como Henrietta Lacks, la mujer negra que se estaba muriendo de cáncer cuando le extrajeron células sin su consentimiento, que se utilizaron para desarrollar líneas celulares que han sido fundamentales en la investigación médica.

Asmerom puntualizó que quiere que la facultad reconozca el pasado racista de la medicina en las clases. Citó un curso introductorio de anatomía en su escuela que no señaló que en el pasado, cuando los científicos trataban de estudiar el cuerpo humano, los negros y otros grupos habían sido maltratados. “Es como, OK, ¿pero no vas a contar que sacaron de sus tumbas cuerpos de negros para usarlos en el laboratorio de anatomía?” preguntó.

Aunque a Asmerom le alegra ver que su facultad escucha las reivindicaciones estudiantiles, siente que los administradores deben reconocer sus errores del pasado reciente.

“Alguien tiene que admitir cómo se perpetuó el racismo anti-negro en esta institución”, dijo Asmerom.

Asmerom, una de las líderes de la Coalición Antirracista de la UCSD, aseguró que la administración ha respondido favorablemente hasta ahora a las demandas de la coalición de invertir tiempo y dinero en iniciativas antirracistas. Y se siente cautelosamente esperanzada.

“No me atrevo a aguantar la respiración hasta que vea cambios reales”, concluyó.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.


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What Doctors Aren’t Always Taught: How to Spot Racism in Health Care

Betial Asmerom, a fourth-year medical student at the University of California-San Diego, didn’t have the slightest interest in becoming a doctor when she was growing up.

As an adolescent, she helped her parents — immigrants from Eritrea who spoke little English — navigate the health care system in Oakland, California. She saw physicians who were disrespectful to her family and uncaring about treatment for her mother’s cirrhosis, hypertension and diabetes.

“All of those experiences actually made me really dislike physicians,” Asmerom said. “Particularly in my community, the saying is, ‘You only go to the doctor if you’re about to die.’”

But that changed when she took a course in college about health disparities. It shocked her and made her realize that what her Eritrean family and friends saw was happening to other communities of color, too. Asmerom came to believe that as a doctor she could help turn things around.

Faculty members and student activists around the country have long called for medical schools to increase the number of students and instructors from underrepresented backgrounds to improve treatment and build inclusivity. But to identify racism’s roots and its effects in the health system, they say, fundamental changes must be made in medical school curriculums.

Asmerom is one of many crusaders seeking robust anti-racist education. They are demanding that the schools eliminate the use of race as a diagnostic tool, recognize how systemic racism harms patients and reckon with some of medicine’s racist history.

This activism has been ongoing — White Coats for Black Lives (WC4BL), a student-run organization fighting racism in medicine, grew out of the 2014 Black Lives Matter protests. But now, as with countless other U.S. institutions since the killing of George Floyd in Minneapolis in May, medical schools and national medical organizations are under even greater pressure to take concrete action.

Debunking Race as a Diagnostic Tool

For many years, medical students were taught that genetic differences among the races had an effect on health. But in recent years, studies have found race does not reliably reflect that. The National Human Genome Research Institute notes very little genetic variation among races, and more differences among people within each race. Because of this, more physicians are embracing the idea that race is not an intrinsic biological difference but instead a social construct.

Dr. Brooke Cunningham, a physician and sociologist at the University of Minnesota Medical School, said the medical community is conflicted about abandoning the idea of race as biological. It’s baked into the way doctors diagnose and measure illness, she said. Some physicians claim it is useful to take race into account when treating patients; others argue it leads to bias and poor care.

Those views have led to a variety of false beliefs, including that Black people have thicker skin, their blood coagulates more quickly than white people’s or they feel less pain.

When race is factored into medical calculations, it can lead to less effective treatments and perpetuate race-based inequities. One such calculation estimates kidney function (eGFR, or the estimated glomerular filtration rate). The eGFR can limit Black patients’ access to care because the number used to denote Black race in the formula provides a result suggesting kidneys are functioning better than they are, researchers recently reported in the New England Journal of Medicine. Among another dozen examples they cite is a formula that obstetricians use to determine the probability of a successful vaginal birth after a cesarean section, which disadvantages Black and Hispanic patients, and an adjustment for measuring lung capacity using a spirometer, which can cause inaccurate estimates of lung function for patients with asthma or chronic obstructive pulmonary disease.

In the face of this research, medical students are urging schools to rethink curricula that treat race as a risk factor for disease. Briana Christophers, a second-year student at Weill Cornell Medical College in New York, said it makes no sense that race would make someone more susceptible to disease, although economic and social factors play a significant role.

Naomi Nkinsi, a third-year student at the University of Washington School of Medicine in Seattle, recalled sitting in a lecture — one of five Black students in the room — and hearing that Black people are inherently more prone to disease.

“It was very personal,” Nkinsi said. “That’s my body, that’s my parents, that’s my siblings. Every time I go into a doctor’s office now, I’ll be reminded that they’re not just considering me as a whole person but as somehow physically different than all other patients just because I have more melanin in my skin.”

Nkinsi helped in a successful campaign to exclude race from the calculation of eGFR at UW Medicine, joining a small number of other health systems. She said the achievement — announced officially in late May — was largely due to Black students’ tireless efforts.

Acknowledging Racism’s Adverse Effects on Health

The Liaison Committee on Medical Education, the official accrediting body for medical schools in the U.S. and Canada, said faculty must teach students to recognize bias “in themselves, in others, and in the health care delivery process.” But the LCME does not explicitly require accredited institutions to teach about systemic racism in medicine.

This is what students and some faculty want to change. Dr. David Acosta, the chief diversity and inclusion officer of the American Association of Medical Colleges, said about 80% of medical schools offer either a mandatory or elective course on health disparities. But little data exists on how many schools teach students how to recognize and fight racism, he said.

An anti-racist curriculum should explore ways to mitigate or eliminate racism’s harm, said Rachel Hardeman, a health policy professor at the University of Minnesota.

“It’s thinking about how do you infuse this across all of the learning in medical education, so that it’s not this sort of drop in the bucket, like, one-time thing,” she said. Above all, the courses that delve into systemic racism need to be required, Hardeman said.

Edwin Lindo, a lecturer at the University of Washington School of Medicine, said medicine should embrace an interdisciplinary model, allowing sociologists or historians to lecture on how racism harms health.

Acosta said the AAMC has organized a committee of experts to develop an anti-racism curriculum for every step of medical education. They hope to share their work publicly this month and talk to the LCME about developing and implementing these standards.

“Our next work is how do we persuade and influence the LCME to think about adding anti-racist training in there,” Acosta said.

Recognizing Racism in Medical Education’s Past and Present

Activists especially want to see their institutions recognize their own missteps, as well as the racism that has accompanied past medical achievements. Dereck Paul, a student at the University of California-San Francisco School of Medicine, said he wants every medical school to include lectures on people like Henrietta Lacks, the Black woman who was dying of cancer when cells were taken without her consent and used to develop cell lines that have been instrumental in medical research.

Asmerom said she wants to see faculty acknowledge medicine’s racist past in lessons. She cited an introductory course on anatomy at her school that failed to note that in the past, as scientists sought to study the body, Blacks and other minorities were mistreated. “It’s like, OK, but you’re not going to talk about the fact that Black bodies were taken out of graves in order to have bodies to use for anatomy lab?” she said.

While Asmerom is glad to see her medical school actively listening to students, she feels administrators need to own up to their mistakes in the recent past. “There needs to be an admission of how you perpetuated anti-Black racism at this institution,” Asmerom said.

Asmerom, who is one of the leaders of the UCSD Anti-Racism Coalition, said the administration has responded favorably so far to the coalition’s demands to pour time and money into anti-racist initiatives. She’s cautiously hopeful.

“But I’m not going to hold my breath until I see actual changes,” she said.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.


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Stanford vs. Harvard: Two Famous Biz Schools’ Opposing Tactics on COVID

At the Stanford Graduate School of Business in Northern California, the stories got weird almost immediately upon students’ return for the fall semester. Some said they were being followed around campus by people wearing green vests telling them where they could and could not be, go, stop, chat or conduct even a socially distanced gathering. Others said they were threatened with the loss of their campus housing if they didn’t follow the rules.

“They were breaking up picnics. They were breaking up yoga groups,” said one graduate student, who asked not to be identified so as to avoid social media blowback. “Sometimes they’d ask you whether you actually lived in the dorm you were about to go into.”

Across the country in Boston, students at the Harvard Business School gathered for the new semester after being gently advised by the school’s top administrators, via email, that they were part of “a delicate experiment.” The students were given the ground rules for the term, then received updates every few days about how things were going. And that, basically, was that.

In the time of COVID-19, it’s fair to say that no two institutions have come to quite the same conclusions about how to proceed safely. But as Harvard’s and Stanford’s elite MBA-granting programs have proved, those paths can diverge radically, even as they may eventually lead toward the same place.

For months, college and university administrators nationwide have huddled with their own medical experts and with local and county health authorities, trying to determine how best to operate in the midst of the novel coronavirus. Could classes be offered in person? Would students be allowed to live on campus — and, if so, how many? Could they hang out together?

“The complexity of the task and the enormity of the task really can’t be overstated,” said Dr. Sarah Van Orman, head of student health services at the University of Southern California and a past president of the American College Health Association. “Our first concern is making sure our campuses are safe and that we can maintain the health of our students, and each institution goes through that analysis to determine what it can deliver.”

With a campus spread over more than 8,000 acres on the San Francisco Peninsula, Stanford might have seemed like a great candidate to host large numbers of students in the fall. But after sounding hopeful tones earlier in the summer, university officials reversed course as the pandemic worsened, discussing several possibilities before finally deciding to limit on-campus residential status to graduate students and certain undergrads with special circumstances.

The Graduate School of Business sits in the middle of that vast and now mostly deserted campus, so the thought was that Stanford’s MBA hopefuls would have all the physical distance they needed to stay safe. Almost from the students’ arrival in late August, though, Stanford’s approach was wracked by missteps, policy reversals and general confusion over what the COVID rules were and how they were to be applied.

Stanford’s business grad students were asked to sign a campus compact that specified strict safety measures for residents. Students at Harvard Business School signed a similar agreement. In both cases, state and local regulations weighed heavily, especially in limiting the size of gatherings. But Harvard’s compact emerged fully formed and relied largely on the trustworthiness of its students. The process at Stanford was unexpectedly torturous, with serial adjustments and enforcers who sometimes went above and beyond the stated restrictions.

Graduate students there, mobilized by their frustration over not being consulted when the policy was conceived, urged colleagues not to sign the compact even though they wouldn’t be allowed to enroll in classes, receive pay for teaching or live in campus housing until they did. Among their objections: Stanford’s original policy had no clear appeals process, and it did not guarantee amnesty from COVID violation punishments to those who reported a sexual assault “at a party/gathering of multiple individuals” if the gathering broke COVID protocols.

Under heavy pressure, university administrators ultimately altered course, solicited input from the grad student population and produced a revised compact addressing the students’ concerns in early September, including the amnesty they sought for reporting sexual assault. But the Stanford business students were already unsettled by the manners of enforcement, including the specter of vest-wearing staffers roaming campus.

According to the Stanford Daily, nine graduate students were approached in late August by armed campus police officers who said they’d received a call about the group’s outdoor picnic and who — according to the students — threatened eviction from campus housing as an ultimate penalty for flouting safety rules. “For international students, [losing] housing is really threatening,” one of the students told the newspaper.

The people in the vests were Event Services staff working as “Safety Ambassadors,” Stanford spokesperson E.J. Miranda wrote in an email. The staffers were not on campus to enforce the compact, but rather were “emphasizing educational and restorative interventions,” he said. Still, when the university announced the division of its campus into five zones in September, it told students in a health alert email that the program “will be enforced by civilian Stanford representatives” — the safety ambassadors.

The Harvard Business School’s approach was certainly different in style. In July, an email from top administrators reaffirmed the school’s commitment to students living on campus and taking business classes in person in a hybrid learning model. As for COVID protocols, the officials adopted “a parental tone,” as the graduate business education site Poets & Quants put it. “All eyes are on us,” the administrators wrote in an August email.

But the guts of the school’s instructions were similar to those at Stanford. Both Harvard and Stanford severely restricted who could be on campus at any given time, limiting access to students, staff members and preapproved visitors. Both required that anyone living on campus report their health daily through an online portal, checking for any symptoms that could be caused by COVID-19. Both required face coverings when outside on campus — even, a Harvard missive said, in situations “when physical distancing from others can be maintained.”

So far, both Harvard and Stanford have posted low positive test rates overall, and the business schools are part of those reporting totals, with no significant outbreaks reported. Despite their distinct delivery methods, the schools ultimately relied on science to guide their COVID-related decisions.

“I feel like we’ve been treated as adults who know how to stay safe,” said a Harvard second-year MBA candidate who requested anonymity. “It’s worked — at least here.”

But as the experiences at the two campuses show, policies are being written and enforced on the fly, in the midst of a pandemic that has brought challenge after challenge. While the gentler approach at Harvard Business School largely worked, it did so within a larger framework of the health regulations put forth by local and county officials. As skyrocketing COVID-19 rates across the nation suggest, merely writing recommendations does little to slow the spread of disease.

Universities have struggled to strike a balance between the desire to deliver a meaningful college experience and the discipline needed to keep the campus caseload low in hopes of further reopening in 2021. In Stanford’s case, that struggle led to overreach and grad-student blowback that Harvard was able to avoid.

The fall term has seen colleges across the country cycling through a series of fits and stops. Some schools welcomed students for in-person classes but quickly reverted to distance learning only. And large campuses, with little ability to maintain the kind of control of a grad school, have been hit tremendously hard. Major outbreaks have been recorded at Clemson, Arizona State, Wisconsin, Penn State, Texas Tech — locations all over the map that opened their doors with more students and less stringent guidelines.

In May, as campuses mostly shut down to consider their future plans, USC’s Van Orman expressed hope that universities’ past experiences with international students and global outbreaks, such as SARS, would put them in a position to better plan for COVID-19. “In many ways, we’re one of the best-prepared sectors for this test,” she said.

Six months later, colleges are still being tested.

This KHN story first published on California Healthline, a service of the California Health Care Foundation.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.


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Fiscal general de California: los jueces deben ver que ACA es “indispensable”

Sacramento.- Cuando la Corte Suprema de los Estados Unidos esté escuchando el martes 10 un caso que podría decidir el destino de la Ley de Cuidado de Salud a Bajo Precio (ACA), California liderará la defensa de la ley federal que impacta en casi todos los aspectos del sistema de salud del país.

Por lo general, es tarea del gobierno federal defender una ley federal, pero la Administración Trump quiere que ACA, también conocida como Obamacare, se revoque.

Por eso, el fiscal general de California, Xavier Becerra, respaldado por más de 20 estados, defiende la ley contra el desafío presentado hace dos años por una coalición de funcionarios estatales republicanos.

Becerra ha sido uno de los adversarios más formidables de Trump: ha llevado a la administración a los tribunales decenas de veces por sus políticas, que van desde la inmigración y el control de la natalidad hasta el cambio climático. Se le considera uno de los principales contendientes para llenar la vacante del Senado que se abrirá ahora que la senadora por California Kamala Harris ha sido elegida vicepresidenta.

“Tan enérgicamente como un presidente y su administración están luchando para destruir la Ley de Cuidado de Salud a Bajo Precio, nosotros estamos luchando para salvarla para todos los estadounidenses”, dijo Becerra a los periodistas en una conferencia de prensa el lunes 9.

Si el tribunal anula toda la ley, el impacto se sentiría ampliamente. La ley proporciona seguro médico a más de 23 millones de estadounidenses. Permite a las personas que califican comprar seguros a través de los mercados estatales y el federal, y recibir subsidios.

También ha recomendado  a los estados expandir sus programas de Medicaid a más personas; previene que las compañías de seguros nieguen cobertura a personas con afecciones médicas preexistentes; prohíbe los límites de por vida en la cobertura; agrega beneficios a Medicare; y permite que los hijos permanezcan en los planes de sus padres hasta los 26 años.

El tema central en California vs. Texas es la multa fiscal federal por no tener seguro médico, como exige la ley. En 2017, el Congreso liderado por los republicanos redujo esta multa a cero, pero mantuvo intacta al resto de la ley, una medida que, según Becerra y otros expertos en leyes, muestra la intención del Congreso de apoyarla.

Sin embargo, funcionarios estatales republicanos dicen que la pérdida de la penalidad invalida el mandato de tener un seguro, así como toda la ley.

Becerra dijo que es posible que el tribunal determine que los impugnadores no tienen legitimidad para demandar al gobierno porque nadie ha sido perjudicado por una multa que cuesta cero.

Aunque la corte ha ratificado dos veces esta ley, la composición de la corte ha cambiado desde su último fallo sobre ACA en 2015. Desde entonces, Trump ha nombrado a tres jueces conservadores. Dos reemplazaron a otros conservadores, pero Amy Coney Barrett, quien fue confirmada a fines de octubre, ocupa el asiento de un ícono liberal, la jueza Ruth Bader Ginsburg.

Abbe Gluck, directora del Centro Salomón de Derecho y Políticas de Salud de la Escuela de Derecho de Yale, dijo que si el tribunal cree que el requisito del seguro médico es inconstitucional sin la penalidad, debería simplemente declarar inválida esa sección de la ley, pero no anularla por completo.

Pero “he aprendido que nunca se puede predecir lo que sucede en la corte cuando se trata de la Ley de Cuidado de Salud a Bajo Precio”, dijo Gluck. “Por eso hay más preocupación, porque el estatuto se ha vuelto tan fundamentalmente importante para una quinta parte de nuestra economía y para la atención médica de prácticamente todos los estadounidenses”.

Becerra habló con Samantha Young de California Healthline sobre su defensa del Obamacare y el enorme alcance de la influencia de la ley. La entrevista ha sido editada por extension, y para mayor claridad.

¿Cuáles son las posibilidades de que la Corte Suprema derogue la Ley de Cuidado de Salud a Bajo Precio?

Confiamos en que no solo verán la lógica legal detrás de esto, sino también la sabiduría y el éxito práctico de la Ley de Cuidado de Salud a Bajo Precio, lo cual pesa mucho a favor de que los jueces reconozcan no solo que es legal, sino indispensable. Cuando los jueces examinen los fundamentos de la Ley de Cuidado de Salud a Bajo Precio, encontrarán que es constitucional.

La composición de la Corte Suprema de los Estados Unidos ha cambiado desde la última vez que se pronunció sobre ACA. ¿Por qué cree que estos jueces decidirán de la misma manera?

Eso no debería cambiar el hecho de que los fundamentos de la ley siguen siendo los mismos. Los fundamentos de ACA son sólidos y funcionan. Espero que nueve jueces que revisan la misma ley observen ese precedente.

¿A qué debe prestar atención el público durante los argumentos orales?

Algo interesante de observar es cómo la corte interpreta las acciones tomadas por el Congreso en 2017, cuando aprobaron el proyecto de ley de exención de impuestos y redujeron a cero la tarifa o multa por el mandato individual. Ahora, estamos ante un presidente y al menos una cámara en el Congreso que está preparada para defender la Ley de Cuidado de Salud a Bajo Precio. ¿Cómo podría considerar el tribunal el hecho de que otro Congreso podría restablecer parte de ese mandato?

¿Cómo se relaciona esto con el argumento legal de que haber reducido a cero el mandato de alguna manera provocó la inconstitucionalidad de toda la ley? Creo que es una cuestión que el tribunal tendrá que examinar.

¿Qué pasará si la Corte Suprema de los Estados Unidos declara inconstitucional la Ley de Cuidado de Salud a Bajo Precio?

Volverán las preocupaciones. La atención preventiva de Medicare desaparecería. Los días en que los estadounidenses no tenían que preocuparse por la bancarrota por haber pisado un hospital prácticamente se esfumarían.

Tengo tres hijas. Hubo un tiempo que, como adultas, las tres estaban en nuestra cobertura de atención médica. Eso desaparecería porque la disposición que permite que los hijos adultos menores de 26 años permanezcan en la cobertura de los padres desaparecería. Y podría seguir y seguir.

¿Podrían los estados, incluido California, darse el lujo de intervenir por su cuenta?

No sé si hay algún estado que tenga la capacidad de reemplazar lo que hace la Ley de Cuidado de Salud a Bajo Precio. Es casi imposible. Parte de eso se debe a que no podemos replicar algunas de las cosas que puede hacer el gobierno federal. No tenemos esa jurisdicción federal, no tenemos esa amplitud y profundidad de alcance.

Si el tribunal anula ACA, ¿el Congreso no puede aprobar protecciones parciales que cuenten con el apoyo de los republicanos, como la cobertura de afecciones preexistentes?

Hemos escuchado a los republicanos decir “revocar y reemplazar” durante más de 10 años, y ha sido una retórica vacía desde el principio. Para los padres que tienen hijos con afecciones médicas preexistentes, no es reconfortante que alguien les prometa que reemplazarán un derecho que saben que ahora tienen para que sus hijo vayan al hospital. Y, ¿por qué desecharías eso por una promesa vacía que ya lleva 10 años?

La mayoría de los estadounidenses dirían: sigue construyendo sobre la base de la Ley de Cuidado de Salud a Bajo Precio. Mejorémosla, pero no descartemos lo que ha funcionado.

¿Cómo sabe que la Ley de Cuidado de Salud a Bajo Precio está funcionando?

Mi antiguo distrito congresional en Los Ángeles se encontraba entre los distritos congresionales con más cantidad de personas sin seguro de salud de la nación. En cuestión de años, una vez que entró en vigor la Ley de Cuidado de Salud a Bajo Precio, la tasa de personas sin seguro en ese distrito se redujo en un 50%. Fue simplemente astronómico.

La Ley de Cuidado de Salud a Bajo Precio hizo posible que las familias trabajadoras pudieran obtener cobertura y eso es enorme. Ese es el tipo de carga que se quita del alma.

¿Cree que tener a Joe Biden como presidente y a Kamala Harris como vicepresidenta en la Casa Blanca llevará a una mejora en la Ley de Cuidado de Salud a Bajo Precio?

Como candidato a presidente, Joe Biden dijo que se basaría en el éxito de la presidencia de Obama-Biden y se aseguraría que sigamos aumentando el número de estadounidenses con acceso a una atención médica asequible. Lo bueno es que finalmente tienes a alguien en la parte superior del tótem que dice que lo vamos a mejorar. Por eso esta elección fue tan importante.

Esta historia de KHN fue publicada primero en California Healthline, un servicio de la California Health Care Foundation.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.


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Orange County Struggles With Health Equity — And Battles State Restrictions

California’s most popular amusement park has become the focal point of a struggle over how best to contain COVID-19 while keeping the economy afloat.

California’s Democratic leaders have tied the fate of Disneyland — “the Happiest Place on Earth” — to the health of the people who live around it, who have been hit hard by the virus. But conservative Orange County officials want to ease restrictions to allow for the reopening of the lucrative tourist attraction, saying the economic health of all residents depends on it.

State rules say large theme parks can’t open, even in a limited capacity, until there’s less than one new case per day per 100,000 county residents. The state also requires counties to lower infection rates in their poorest communities to near the average level of the county overall. In Orange County, as in the rest of the state, Latinos have borne the brunt of COVID cases and deaths.

Under these requirements, Disneyland and Knott’s Berry Farm, another big county amusement park, will likely remain shut down until next summer or later, said Dr. Clayton Chau, director of the Orange County Health Care Agency.

Orange County supervisors argue that it’s infeasible to quickly address the socioeconomic factors — including poverty and crowded housing — that cause some communities to have higher COVID positivity rates, and that the whole county shouldn’t be punished because of it.

“If we have disadvantaged communities that are, because … of living conditions and other circumstances, damaged significantly by the virus, why must we thus visit the pain of the lockdown and shutdown on the children in other communities?” asked Supervisor Donald Wagner — who represents prosperous Anaheim Hills, Irvine and Orange, which have low positivity rates — at a meeting last month.

While the county has invested additional resources to fight COVID-19 in Santa Ana and Anaheim, which are majority Latino, the best way to help them is to return “some semblance of a normal life” to the entire county, to generate the revenue it needs to help the disadvantaged, Wagner said.

But public health experts say that the key to a strong economy is a healthy population and that the county, Southern California’s most densely populated, isn’t ready for the park to reopen.

“I’m the biggest Disney fan in the whole wide world, and for mental health, I’d love to open up,” said Bernadette Boden-Albala, director of the public health program at the University of California-Irvine. “But we’re going into flu season, and we have not got a hold of this virus.”

“How can you be a strong county when your low-income neighborhoods are devastated by this pandemic, and are super vulnerable to being victims of another pandemic or another wave?” said Dr. America Bracho, CEO of Latino Health Access, a nonprofit group that has been tapped by the county to lead a health equity initiative targeting Latinos.

In part, the battle over what the state calls its “health equity metric” reflects the changing politics of Orange County, which encompasses poor, Latino and heavily immigrant communities such as Anaheim — home to Disneyland — as well as tony Newport Beach. Four of the five members of the board of supervisors are Republican. The county as a whole, however, is trending Democratic. It voted for a Democratic president for the first time in 80 years in 2016, and initial results gave Vice President Joe Biden 54% of this year’s vote. The most Democratic areas of the county tend to be those hit hardest by COVID-19.

The Walt Disney Co. is the biggest employer in the county, responsible for 3.6% of all jobs, according to an analysis in 2019 by the Woods Center for Economic Analysis and Forecasting at California State University-Fullerton. Disney had about 30,000 of its own employees, and almost 27,000 other jobs in Southern California relied on the resort, according to the report. On Nov. 1, an estimated 10,000 Disneyland resort workers received layoff notices.

There’s a consensus among local politicians, management, unions and many workers that Disneyland should reopen as soon as possible.

Union reps say Disneyland workers have health concerns but want to return to work, noting that the federal CARES Act’s weekly $600 unemployment benefit expired in July.

Disney says it knows how to reopen its parks safely. Since Walt Disney World began gradually reopening in Florida in July, no COVID outbreaks have been linked to it, said Orange County, Florida, health department spokesperson Kent Donahue.

Disneyland proposes reopening with a host of safety measures, including mandatory face covers for staff and guests, more hand-washing stations, physical barriers, temperature screenings and reduced capacity.

Chau, the Orange County public health leader, wants the state to allow the theme park to open once the county hits the orange tier, the second-best status among the state’s four-tiered, color-coded system that tracks counties by case and infection positivity rates. The orange tier allows for an official case rate of up to 3.9 cases per 100,000 people. The county is currently in the red tier, the second-worst, with a rate of six per 100,000 overall and a test positivity rate of 3.6%. In its poorest neighborhoods, the positivity rate is 5.7%, while it is as low as 0.9% in a Laguna Woods ZIP code.

Under the tiered system, which followed a surge in cases and deaths throughout the state in June and July, the state requires counties to achieve lower case and test positivity rates and then maintain them for at least two weeks before progressing to the less restrictive tier, which allows businesses greater flexibility to reopen.

Other counties, including Riverside and 12 northern rural counties, also are challenging the stringent tiered system, which has helped tamp down infections but has fatigued residents and stoked fears of widespread business closures.

While Orange County supervisors have claimed the system is unscientific, the state health department points to studies it says underscore the importance of a gradual relaxing of COVID lockdowns. States like New York and Massachusetts also have tiered reopening schedules.

“We’re in the middle of an unprecedented pandemic that we haven’t seen since 1918,” said Dr. George Rutherford, a University of California-San Francisco professor who has advised the state on its approach. “You’ve got to give the state a little latitude to try to figure out how to best go about this.”

Viral hot spots ripple far beyond their initial boundaries, he said, so a failure to commit to health equity for the poor imperils everyone.

“All of a sudden you’re going to be dealing with a mini-Wisconsin in downtown Santa Ana, and it’s going to seed the rest of the county, and the rest of Southern California, and the rest of the state.”

Throughout the pandemic, a vocal minority of Orange County residents have protested angrily against mask mandates and business closures. Death threats have been so intense they prompted the county’s top public health official to resign in June.

Yet county health officials have worked hard to help hard-hit areas, said Bracho, of Latino Health Access.

She successfully advocated for the county’s COVID rates to be broken out by ZIP code in May, and her group was contracted to work with the Latino populations most affected by the virus through testing, education, contact tracing and other services.

Positivity rates in Santa Ana and Anaheim, which were approaching 30% in early July, have declined to less than 10% since late August. It’s dramatic progress but not enough to meet the county’s health equity metric.

The case numbers are slowly rising again in Orange County and throughout Southern California, in what public health experts fear could be the start of a third wave of infections.

Chau, who thinks Disneyland can reopen safely, has shown a commitment to health equity, which included the creation of a new director position for population health and equity efforts, Bracho said.

Yet the lack of solidarity among those representing the old and new Orange County has been disheartening, said Dr. José Mayorga, executive director of UCI Family Health Center, which treats primarily low-income Latinos in Santa Ana and Anaheim.

At work, Mayorga delivers COVID diagnoses to patients, who cry at the news and fear they’ve already exposed loved ones to the virus. When he visits mostly white towns like Newport Beach or San Clemente, where he lives and his daughter is in school, many of those he encounters are maskless.

It breaks his heart, Mayorga said. “People act like there’s nothing happening.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.


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Justices Bound to See ACA as ‘Indispensable,’ Says Californian Leading Defense

SACRAMENTO — When the U.S. Supreme Court hears a case Tuesday that could decide the fate of the Affordable Care Act, California will be leading the defense to uphold the federal law that touches nearly every aspect of the country’s health care system.

It’s usually the federal government’s job to defend a federal law, but President Donald Trump’s administration wants this law, also known as Obamacare, to be overturned.

So California Attorney General Xavier Becerra, backed by more than 20 other states, is defending the law against the challenge brought by a coalition of Republican state officials two years ago.

Becerra has been one of Trump’s most formidable adversaries, taking the administration to court scores of times over its policies, ranging from immigration and birth control to climate change. He is considered one of the leading contenders to fill the Senate vacancy that will open now that Sen. Kamala Harris of California has been elected vice president.

“Just as vigorously as a president and his administration are fighting to destroy the Affordable Care Act, we are fighting to save it for every American,” Becerra told reporters in a press conference Monday.

Should the court overturn the entire law, the impact would be felt widely. The law provides health insurance to more than 23 million Americans. It allows qualified people to buy subsidized insurance through federal or state insurance exchanges; permits states to expand their Medicaid programs to more people; prevents insurance companies from denying coverage to people with preexisting medical conditions; bans lifetime limits on coverage; adds benefits to Medicare; and allows children to stay on their parents’ plans up to age 26.

At issue in California v. Texas is the federal tax penalty for not having health insurance, as the law requires. The Republican-led Congress in 2017 zeroed out the penalty but kept the rest of the health law intact, a move Becerra and some other legal experts say shows congressional intent to support the law. The Republican state officials, however, say the loss of the tax invalidates the mandate to have insurance — as well as the entire law.

Becerra said it’s possible the court may determine that the challengers don’t have standing to sue the government because no one has been harmed by a zero-tax penalty.

Although the court has twice upheld the federal health care law, the composition of the court has changed since its last ACA ruling in 2015. Trump has appointed three conservative judges since then. Two replaced other conservatives, but Amy Coney Barrett, who was confirmed in late October, took the seat of a liberal icon, Justice Ruth Bader Ginsburg.

Abbe Gluck, faculty director of the Solomon Center for Health Law and Policy at Yale Law School, said that if the court believes the health insurance requirement is unconstitutional without the penalty, it should just hold that section of the law invalid but not overturn the entire law.

But “I have learned that you can never predict what happens in court when it comes to the Affordable Care Act,” Gluck said. “And that is why there is this heightened sense of concern, because the statute has become so fundamentally important to one-fifth of our economy and the health care of virtually all Americans.”

Becerra talked to California Healthline’s Samantha Young about his defense of Obamacare and the far-reaching influence of the law. The interview has been edited for length and clarity.

Q: What are the chances the Supreme Court could overturn the Affordable Care Act?

We’re confident they will see not just the legal logic behind it, but the wisdom and the practical success of the Affordable Care Act — all of which weigh heavily in favor of the justices recognizing that it’s not only legal but indispensable. When the justices look to the fundamentals of the Affordable Care Act, they’re going to find that it is constitutional.

Q: The makeup of the U.S. Supreme Court has changed since it last ruled on the ACA. Why do you think these justices will rule the same way?

That shouldn’t change the fact that the fundamentals of the law have remained the same. The fundamentals of the ACA are grounded, they’re solid, and they work. I would hope that nine justices reviewing the same law would look at that precedent.

Q: What should the public pay attention to during the oral arguments?

One thing interesting to watch is how the court interprets the actions taken by Congress in 2017 when they passed the tax break bill and zeroed out the individual mandate fee or penalty. Now, we’re looking at a president and at least one house in Congress that’s prepared to defend the Affordable Care Act. How might the court look at the fact that another Congress could reinstitute part of that mandate?

What does that do to the legal argument that having zeroed out the mandate somehow triggered the unconstitutionality of the entire law? I think that’s a question the court will have to examine.

Q: What happens if the U.S. Supreme Court declares the Affordable Care Act unconstitutional?

The worries return. Preventative care under Medicare would be gone. The days when Americans don’t have to worry about going personally bankrupt for having visited a hospital would pretty much be gone.

I’ve got three daughters. There was a time when all three of them as adults were on our health care coverage. That would be gone because the provision that allows adult children under the age of 26 to remain on a parent’s coverage would disappear. I could go on and on.

Q: Could states, including California, afford to step in on their own?

I don’t know if there’s any state who has the capacity to replace what the Affordable Care Act does. It’d be almost insurmountable. Part of that is because we can’t replicate some of the things that the federal government can do. We don’t have that federal jurisdiction, we don’t have that breadth and depth of reach.

Q: If the court overturns the ACA, can’t Congress pass piecemeal protections that have Republican support, such as coverage for preexisting conditions?

We have heard Republicans say “repeal and replace” for more than 10 years, and it’s been empty rhetoric from the beginning. I’ve gotta tell you that for parents who have children with preexisting medical conditions, it is no comfort to have someone promise you that they will replace a right that you know you now have for your child to visit a hospital. And, why would you throw that away for an empty promise that’s 10 years old?

Most Americans would say, Keep building on the Affordable Care Act. Let’s make it better, but don’t scrap what’s worked.

Q: How do you know the Affordable Care Act is working?

My former congressional district in Los Angeles ranked among the most uninsured congressional districts in the nation. In a matter of years, once the Affordable Care Act took place, the uninsured rate in that congressional district had gone down by 50%. It was just astronomical.

The Affordable Care Act made it possible for working families to secure coverage and that’s huge. That’s the kind of burden that’s lifted off your soul.

Q: Do you think having a President Joe Biden and a Vice President Kamala Harris in the White House will lead to an improved Affordable Care Act?

As a candidate for president, Joe Biden said that he would build on the success of the Obama-Biden presidency and make sure that we continue to increase the number of Americans who have access to affordable health care. The good thing is you finally have someone at the top of the totem pole who says we’re going to make it better. And that’s why this election was so important.

This KHN story first published on California Healthline, a service of the California Health Care Foundation.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.


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Search for a Snakebite Drug Might Lead to a COVID Treatment, Too

Dr. Matthew Lewin, founder of the Center for Exploration and Travel Health at the California Academy of Sciences, was researching snakebite treatments in rural locations in preparation for an expedition to the Philippines in 2011.

The story of a renowned herpetologist from the academy, Joseph Slowinski, who was bitten by a highly venomous krait in Myanmar and couldn’t get to a hospital in time to save his life a decade earlier, weighed on the emergency room doctor.

“I concluded that I needed something small and compact and that doesn’t care what kind of snake,” Lewin said.

It didn’t exist. That set Lewin in pursuit of a modern snakebite drug, a journey that finds his Corte Madera, California, company, Ophirex, nearing a promising oral treatment that fits in a pocket; is stable, easy to use and affordable; and treats the venom from many species. “That’s the holy grail of snakebite treatment,” he said.

His work has gotten a boost with multimillion-dollar grants from a British charity and the U.S. Army. If it works — and it has been shown to work extremely well in mice and pigs — it could save tens of thousands of lives a year.

Lewin and Ophirex are not alone in their quest. Snakebites kill nearly 140,000 people a year, overwhelmingly in impoverished rural areas of Asia and Africa without adequate medical infrastructure and knowledge to administer anti-venom. Though just a few people die each year in the U.S. from snakebites, the problem has risen to the top of the list of global health concerns in recent years. Funding has soared, and other research groups have also done promising work on new treatments. Herpetologists say deforestation and climate change are increasing human-snake encounters by forcing snakes to move to new habitats.

Lewin’s research is centered on a drug called varespladib. The enzyme inhibitor has proven itself in in-vitro lab studies and has effectively saved mice and pigs dosed with venom.

Along the way, Lewin and his team have come across another potential use for the drug. Varespladib has a positive effect on acute respiratory distress syndrome, associated with COVID-19. Next year, Ophirex will conduct human trials for the possible treatment of the condition funded with $9.9 million from the Army.

The link to a snakebite? The inflammation of the lungs caused by the coronavirus produces the sPLA2 enzyme. A more deadly version of the same enzyme is produced by snake venom.

The other companies that have come up with promising approaches to snakebite aren’t as far along as Ophirex. At the University of California-Irvine, chemist Ken Shea and his team created a nanogel — a kind of polymer used in medical applications — that blocks key proteins in the venom that cause cell destruction. At the Technical University of Denmark, Andreas Laustsen is looking at engineering bacteria to manufacture anti-venom in fermentation tanks.

The days of incising a snakebite and sucking out the poison are long over, but the current treatment for venomous snakebites remains archaic.

Since the early 1900s, anti-venom has been made by injecting horses or other animals with venom milked from snakes and diluted. The animals’ immune systems generate antibodies over several months, and blood plasma is taken from the animals and antibodies extracted from it.

It’s extremely expensive. Hospitals in the U.S. can charge as much as $15,000 a vial — and a single snakebite might require anywhere from four to 50 vials. Moreover, anti-venom exists for little more than half the world’s species of venomous snakes.

A major problem is the roughly two hours it takes on average for a snakebite victim to reach a hospital and begin treatment. The chemical weapon that is venom starts immediately to destroy cells as it digests its next meal, making fast treatment essential to saving lives and preventing tissue loss.

“The two-hour window between fang and needle is where the most damage occurs,” said Leslie Boyer, director of the University of Arizona’s Venom Immunochemistry, Pharmacology and Emergency Response — VIPER — Institute. “We have a saying, ‘Time is tissue.’”

That’s why the search for a new snakebite drug has focused on an inexpensive treatment that can be taken into the field. Lewin’s drug wouldn’t replace anti-venom. Instead, he thinks of it as the first line of defense until the victim can reach a hospital for anti-venom treatment.

Lewin said he expects the drug to be inexpensive, so people in regions where snakebites are common can afford it.

Venom is extremely complicated chemically, and Lewin began his search by sussing out which of its myriad components to block. He zeroed in on the sPLA2 enzyme.

Surveying the literature about drugs that had been clinically tested for other conditions, he came across varespladib. It had been developed jointly by Eli Lilly and Shionogi, a Japanese pharmaceutical company, as a possible treatment for sepsis. They had never taken it to market.

If it worked, Lewin could license the right to produce the drug, which had already been thoroughly studied and was shown to be safe.

He placed venom in an array of test tubes. Varespladib and other drugs were added to the venom. He then added a reagent. If the venom was still active, the solution would turn yellow; if it was neutralized, it would remain clear.

The vials with varespladib “came up completely blank,” he said. “It was so stunning I said, ‘I must have made a mistake.’”

With a small grant, he sent the drug to the Yale Center for Molecular Discovery and found that varespladib effectively neutralized the venom of snakes found on six continents. The results were published in the journal Toxins and sent ripples through the small community of snakebite researchers.

Lewin then conducted tests on mice and pigs. Both were successful.

Human clinical trials are next, but they have been delayed by the pandemic. They are scheduled to get underway next spring.

Along the way, Lewin was fortunate enough to make some good connections that led to funding. In 2012, he attended a party at the Mill Valley, California, home of Jerry Harrison, the former guitarist and keyboardist for Talking Heads. Harrison had long been interested in business and startups — he said he was the most careful reader of the ’80s band’s contracts — and at the party he asked “if anyone had any ideas lying fallow,” Harrison said.

“And Matt pipes up and says, ‘I have this idea how to prevent people from dying from snakebites,’” Harrison said.

The musician said he was a bit taken aback by such an unusual and dire problem, but “I thought if it can save lives we have to do it,” he said. He became an investor and co-founder of Ophirex with Lewin.

Lewin met Lt. Col. Rebecca Carter, a biochemist who was assigned to lead the Medical Modernization Division of Air Force Special Operations Command, in 2016 when she attended a Venom Week conference in Greenville, North Carolina. He was presenting the results of his mouse studies. She told him about her first mission: to find a universal anti-venom for medics on special operations teams in Africa. She persuaded the Special Operations Command Biomedical Research Advisory Group, which specializes in getting critical projects to production, to grant Ophirex $148,000 in 2017. She later retired from the Air Force and now works for Ophirex as vice president.

More multimillion-dollar grants followed, including the Army’s COVID grant. Clinical trials are scheduled to begin this winter.

Despite the progress and the sudden cash flow, Lewin tamps down talk of a universal snakebite cure. “There’s enough evidence to say the drug deserves to have its day in clinical trials,” he said.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.


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KHN on the Air This Week

Columnist and California Healthline senior correspondent Bernard J. Wolfson discussed the start of open enrollment for health care plans in California with KPCC’s “Take Two” on Monday.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.


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String of FDA approvals gives momentum to liquid biopsies

Following years of research and investment, liquid biopsies are steadily accumulating FDA approvals. The tests are being used in molecular profiling of solid tumors and as companion diagnostics for targeted cancer therapies.

Sin presidente todavía, el futuro de la salud también sigue siendo incierto

Sin un ganador y sin saber todavía qué partido controlará el Senado, el futuro del sistema de salud de la nación también sigue siendo incierto.

Lo que está en juego es si el gobierno federal desempeñará un papel más importante en el financiamiento y el establecimiento de las reglas básicas para la cobertura de atención médica o cederá más autoridad a los estados y al sector privado.

Si el presidente Donald Trump gana y los republicanos retienen el control del Senado, es posible que Trump aún no pueda hacer cambios radicales mientras la Cámara siga bajo control demócrata.

Pero, gracias a las reglas establecidas por los republicanos del Senado, se podrían seguir apilando demandas en los tribunales federales con juristas conservadores que probablemente defiendan el uso expansivo del poder ejecutivo por parte de Trump para tomar decisiones de salud.

El presidente también se ha comprometido a continuar sus esfuerzos para deshacerse de la Ley de Cuidado de Salud a Bajo Precio (ACA). Si la Corte Suprema anula la ley general como parte de un desafío que escuchará la próxima semana, se pondrá a prueba la promesa de los republicanos de proteger a las personas con condiciones médicas preexistentes.

En un segundo mandato, la administración probablemente también continuará sus esfuerzos para modificar Medicaid instituyendo requisitos laborales para los adultos inscritos y brindando más flexibilidad a los estados para cambiar el diseño del programa.

Si Joe Biden gana y los demócratas obtienen la mayoría en el Senado, sería la primera vez que el partido controla la Casa Blanca y ambas cámaras del Congreso desde 2010, el año en que se aprobó ACA.

Una de las principales prioridades será lidiar con la pandemia de COVID-19 y sus consecuencias económicas. Biden hizo de este tema una piedra angular de su campaña, prometiendo implementar políticas basadas en el asesoramiento médico y científico, y proporcionar más directrices y ayuda a los estados.

Pero también ocupa un lugar destacado en su agenda abordar partes de ACA que no han funcionado tan bien como esperaban sus autores. Se comprometió a agregar una “opción pública” administrada por el gobierno, que sería una alternativa a los planes de seguros privados en los mercados, y a reducir la edad de elegibilidad para Medicare a 60 años.

Si bien los demócratas continuarán controlando la Cámara, aún no se ha determinado la composición final del Senado. E incluso si los demócratas ganan el Senado, no se espera que obtengan una mayoría que les permita aprobar leyes sin el apoyo de algunos senadores republicanos, a menos que cambien las reglas del Senado.

Pero quién controle Washington es solo una parte del impacto de las elecciones en las políticas de salud. Varios problemas de salud clave están en manos de los estados. Algunos de ellos:


En Colorado, una medida que habría prohibido los abortos después de las 22 semanas de embarazo, excepto para salvar la vida de la embarazada, fracasó, según The Associated Press. Colorado es uno de los siete estados que no prohíben los abortos en algún momento del embarazo.

También alberga una de las pocas clínicas del país que realizan abortos en el tercer trimestre del embarazo, a menudo por complicaciones médicas graves. La clínica atrae pacientes de todo el país, por lo que los residentes de otros estados se habrían visto afectados si se aprobara la enmienda de Colorado.

En Louisiana, sin embargo, los votantes aprobaron fácilmente una enmienda a la constitución estatal para indicar que nada en el documento proteja el derecho al aborto o a financiarlo. Esto facilitaría que el estado prohíba el aborto si la Corte Suprema anula Roe v. Wade, que hace que las prohibiciones estatales del aborto sean inconstitucionales.


El destino del programa de salud para las personas de bajos ingresos no está en la boleta electoral directamente en ninguna parte de esta elección. (Los votantes aprobaron expansiones del programa en Missouri y Oklahoma a principios de este año).

Pero el programa se verá afectado no solo por quién controle la presidencia y el Congreso, sino también por quién controle las legislaturas en los estados que no han expandido Medicaid en el marco de ACA. Carolina del Norte es un estado clave donde un cambio en la mayoría de la legislatura podría modificar el rumbo de la expansión.

Marihuana y alucinógenos

En seis estados, los votantes están decidiendo la legalidad de la marihuana de una forma u otra. Montana, Arizona y Nueva Jersey estaban decidiendo si unirse a los 11 estados que permiten su uso recreativo.

Los votantes de Mississippi y Nebraska estaban eligiendo si legalizarían la marihuana medicinal, y Dakota del Sur se convirtió en el primer estado en votar sobre la legalización de la marihuana medicinal y recreativa en la misma elección.

Las setas alucinógenas (hongos) están en dos papeletas. Se aprobó una medida en Oregon para permitir el uso de hongos productores de psilocibina con fines medicinales, y una propuesta del Distrito de Columbia para despenalizar los hongos alucinógenos estaba ganando adeptos.

También se aprobó una pregunta en la boleta electoral en Oregon para despenalizar la posesión de pequeñas cantidades de drogas duras, incluida la heroína, cocaína y metanfetamina, y ordenar el establecimiento de centros de recuperación de adicciones, utilizando parte de los ingresos fiscales de las ventas de marihuana para establecer esos centros.


Como de costumbre, los votantes de California se enfrentaron a una larga lista de medidas electorales relacionadas con la salud.

Por segunda vez en dos años, la rentable industria de diálisis renal del estado fue cuestionada en las urnas. Una iniciativa patrocinada por un sindicato habría requerido que las empresas de diálisis contrataran a un médico en cada clínica y presentaran informes sobre casos de infecciones al estado. Pero la industria gastó $105 millones en contra de la medida. La medida falló, según AP.

También se les pidió a los votantes que decidieran, nuevamente, si financiarían la investigación con células madre del Instituto de Medicina Regenerativa de California a través de la Proposición 14. Los votantes aprobaron por primera vez el financiamiento para la agencia en 2004 y, desde entonces, se han gastado miles de millones con pocos resultados que derivaran en curas. La medida estaba ganando en los primeros resultados.

California ha estado a la vanguardia de la lucha por la llamada economía de los gig, y la votación de este año incluyó una propuesta impulsada por empresas de transporte como Uber y Lyft que les permitiría seguir tratando a los conductores como contratistas independientes en lugar de empleados.

Según la Proposición 22, las empresas no tendrían que proporcionar beneficios de salud directos a los conductores, pero tendrían que darles a los que califiquen un estipendio que podrían utilizar para pagar las primas de seguro médico comprado en el mercado del estado, Covered California. La medida fue aprobada.

Finalmente, se preguntó a los votantes si imponer impuestos a la propiedad más altos a los dueños de propiedades comerciales con terrenos y tenencias de propiedades valoradas en $3 millones o más, lo que podría ayudar a proporcionar nuevos ingresos destinados a ciudades y condados con problemas económicos afectados por el COVID-19, así como escuelas K-12 y colegios comunitarios.

Las clínicas comunitarias, las enfermeras de California y Planned Parenthood se lanzaron a la espinosa batalla política por la Propuesta 15, enfrentándose a poderosos grupos empresariales, con la mira puesta en los ingresos para ayudar a reconstruir el empobrecido sistema de salud pública de California.

Los demócratas en California, que controlan todos los cargos electos en todo el estado y tienen una supermayoría en la legislatura, se han estado posicionando para una victoria de Biden, y algunos ya estaban redactando una ambiciosa legislación de atención médica para el próximo año.

Si gana Biden, dijeron que planean tomar medidas enérgicas contra la consolidación de hospitales y terminar con las facturas sorpresa de las salas de emergencias, y algunos estaban discutiendo en silencio iniciativas liberales como buscar un sistema de atención médica de pagador único y expandir Medicaid para cubrir a más inmigrantes sin papeles.

JoNel Aleccia, Rachel Bluth, Angela Hart, Matt Volz y Samantha Young colaboraron con esta historia.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.


This story can be republished for free (details).

It’s Open Enrollment. Here’s What You Need to Know

California’s annual health insurance enrollment season for individuals and families kicks off this week against a dramatic backdrop: the hotly contested presidential election; a pandemic raging out of control in much of the U.S.; and, on Nov. 10, a Supreme Court hearing of a case that could end the Affordable Care Act and strand millions without coverage.

The massive unemployment caused by the pandemic has already stripped employer-based health insurance from millions nationwide and induced severe financial anxiety as families struggle to pay rent and buy food.

One question hovering over enrollment for 2021 health plans is whether the large-scale loss of medical coverage will generate a surge of sign-ups, or if more pressing financial worries for many people will push insurance lower down their priority list.

“People have so many things to deal with: They’ve lost jobs, they’ve lost a lot of income, and in California they’re also facing fires. I don’t think health insurance has been top of mind for people,” says Cheryl Fish-Parcham, director of access initiatives at Families USA, a consumer health care advocacy organization.

But Peter Lee, executive director of Covered California, the state’s ACA marketplace, is confident it will match the 40% increase in new sign-ups it had for 2020 coverage.

“It is clear that COVID is on Californians’ minds,” he says. “You cannot have COVID on your mind without also having coverage on your mind.”

A Supreme Court decision on the future of the ACA probably won’t come until well into next year, and it is unlikely to affect your 2021 coverage. “So people should feel confident in looking for a health plan,” says Sara Collins, vice president for health care coverage and access at the Commonwealth Fund.

If you are 65 or older, you probably qualify for Medicare, the federal program for seniors, which is entirely separate from the ACA exchanges and broader individual market. Open enrollment for the private Medicare Advantage plans and Part D drug plans is also underway and ends Dec. 7. Insurance agents can usually help you with Medicare, and you can get advice by calling 1-800-434-0222.

If you are under 65, live in the Golden State and want to buy insurance for you and your family, start with Covered California. It’s the only place you can get federal and state assistance to cover some or all of your premiums.

The enrollment period for Covered California, and for the individual market outside the exchange, started Nov. 1 and runs through Jan. 31. In states whose exchanges are operated by the federal government, the enrollment window shuts Dec. 15.

If you lost coverage and need it for the month of December this year, you can still get it through Covered California if you sign up by Nov. 30. For regular annual coverage that starts Jan. 1, you must sign up by Dec. 15. If you miss that deadline, you can still get coverage starting Feb. 1 if you enroll by the final Jan. 31 deadline.

Many people leave money on the table because they aren’t aware of the financial assistance or think they earn too much to qualify. But you don’t need to be poor to get aid.

The federal subsidies, which are tax credits typically provided in the form of reduced monthly premiums, are available to individuals with annual income up to about $51,000 and a family of four with income up to nearly $105,000.

California has supplemented the federal aid with state-funded assistance that extends further into the middle class: up to around $76,500 for an individual and $157,000 for a family of four.

If you log on to Covered California’s website,, you can check how much financial help you qualify for and compare health plans. Or, an insurance agent or certified enroller can do the legwork work for you — at no charge. You can find one on the website. You can also call Covered California directly at 800-300-1506.

If your income is below 138% of the federal poverty level, you will probably qualify for Medi-Cal, the government insurance program for people of limited means. The Covered California website — or an enroller — will let you know if you do and walk you through signing up. You can also contact your county’s Medi-Cal office. If you don’t qualify for Medi-Cal, your children might, because the income threshold is higher for them.

If you are looking for exchange-sponsored coverage, click the “shop and compare” tab on the Covered California website, which takes you to a screen that asks your age, income, ZIP code and family size and shows the health plans available, their premiums and your aid amount.

The website also provides quality ratings of the participating health plans. And you can check for plans that have your doctors in their networks — though, as the website warns, that information is not always up to date.

Comparison shopping on the website is straightforward, because at each of the four levels of coverage — bronze, silver, gold and platinum — benefits are uniform from insurer to insurer. So once you’ve decided which metal tier is best for you, you only need to think about the price and whether your providers are in the network.

If you have a Covered California health plan already, shop around rather than automatically renew the one you’re in. “The best deal last year is not necessarily the best deal this year,” says Anthony Wright, executive director of Health Access California.

Covered California announced a 0.5% average statewide premium increase last month, but actual rate changes vary across the state and among carriers.

Anthem Blue Cross, for example, will hike rates by a statewide average of 6%, and the Oscar Health Plan of California by 7.6%, while Blue Shield of California will cut rates by an average of 2.4% and the L.A. Care Health Plan by 4.6%.

If you switch to the lowest-cost plan in your current metal tier, you could reduce your premium by as much as 7.4%, according to Covered California.

Keep in mind that the lowest premium, a bronze plan, is not necessarily the wisest — or cheapest — choice.

Tom Freker, a Huntington Beach insurance agent, counsels people not to buy bronze, because its higher deductibles and coinsurance rates could cost more than a higher-premium plan if you fall ill or have a serious accident.

Freker recommends you enroll in Covered California rather than the off-exchange market, even if you don’t initially qualify for aid. That’s because if your income drops and you report it to the exchange, you might then qualify and get a break on premiums for the rest of the year or a tax credit the following April, he says.

If your income rises during the year you also should report it, so your monthly premium subsidy is reduced, helping you avoid a potentially hefty tax bill come April.

Your initial aid amount, if you qualify, will be based on your projected 2021 income. In this period of pandemic-driven furloughs, slashed hours and job loss, that might be difficult to predict.

Maria Weston, a massage therapist in Long Beach, said her income has fluctuated week to week since the pandemic started and is down about 50% overall.

Her priority for 2021 was to find a less expensive option, so she switched to a cheaper silver plan last month (current enrollees were allowed to make their health plan choices starting Oct. 1).

Weston’s new health plan will save her nearly $1,700 a year on premiums. “I could put that in my retirement account — or eat,” she says. “One of the two.”

This KHN story first published on California Healthline, a service of the California Health Care Foundation.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.


This story can be republished for free (details).

No Winner for President Yet and Health Care Hangs in the Balance

With the winner of the presidency and party control of the Senate still unclear the morning after Election Day, the future of the nation’s health system remains uncertain. At stake is whether the federal government will play a stronger role in financing and setting the ground rules for health care coverage or cede more authority to states and the private sector.

Should President Donald Trump win and Republicans retain control of the Senate, Trump still may not be able to make sweeping changes through legislation as long as the House is still controlled by Democrats. But — thanks to rules set up by the Senate GOP — the ability to continue to stack the federal courts with conservative jurists who are likely to uphold Trump’s expansive use of executive power could effectively remake the government’s relationship with the health care system even without signed legislation.

The president has also pledged to continue his efforts to get rid of the Affordable Care Act, and if the Supreme Court overturns the sweeping law as part of a challenge it will hear next week, the Republicans’ promise to protect people with preexisting medical conditions will be put to the test. In a second term, the administration would also likely push to continue to revamp Medicaid with its efforts to institute work requirements for adult enrollees and provide more flexibility for states to change the contours of the program.

If former Vice President Joe Biden wins and Democrats gain a Senate majority, it would represent the first time the party has controlled the White House and both houses of Congress since 2010 — the year the ACA was passed. A top priority will be dealing with the COVID-19 pandemic and the economic fallout. Biden made that a keystone of his campaign, promising to implement policies based on advice from medical and scientific advisers and provide more directives and aid to the states.

But also high on his agenda will be addressing parts of the ACA that haven’t worked as well as its authors hoped. He pledged to add a government-run “public option,” which would be an alternative to private insurance plans on the marketplaces, and to lower the eligibility age for Medicare to 60.

While Democrats will continue to control the House, the final makeup of the Senate is still to be determined. And even if the Democrats win the Senate, they are not expected to come away with a majority that would allow them to pass legislation without support from at least some GOP senators, unless they change the Senate’s rules. That could lower expectations of what the Democrats can accomplish — and may lead to some tensions among members.

But who controls Washington, D.C., is only part of the election’s impact on health policy. Several key health issues are on the ballot both directly and indirectly in many states. Here are a few:


In Colorado, a measure that would have banned abortions after 22 weeks of pregnancy — except to save the life of the pregnant person — failed, according to The Associated Press. Colorado is one of seven states that don’t prohibit abortions at some point in pregnancy. It is also home to one of the few clinics in the nation that perform abortions in the third trimester, often for severe medical complications. The clinic draws patients from around the nation, so residents of other states would have been affected if the Colorado amendment passed.

In Louisiana, however, voters easily approved an amendment to the state constitution to say that nothing in the document protects the right to, or requires the funding of, abortion. That would make it easier for the state to outlaw abortion if the Supreme Court overturns Roe v. Wade, which makes state abortion bans unconstitutional.


The fate of the Medicaid program for people with low incomes is not on the ballot directly anywhere this election. (Voters approved expansions of the program in Missouri and Oklahoma earlier this year.) But the program will be affected not only by who controls the presidency and Congress, but also by who controls the legislatures in states that have not expanded the program under the Affordable Care Act. North Carolina is a key swing state where a change in majority in the legislature could turn the expansion tide.

Drug Policy

In six states, voters are deciding the legality of marijuana in one form or another. Montana, Arizona and New Jersey were deciding whether to join the 11 states that allow recreational use of the drug. Mississippi and Nebraska voters were choosing whether to legalize medical marijuana, and South Dakota became the first state to vote on legalizing both recreational and medical pot in the same election.

Magic mushrooms are on two ballots. A measure in Oregon to allow the use of psilocybin-producing mushrooms for medicinal purposes was leading, as was a District of Columbia proposal to decriminalize the hallucinogenic fungi.

Also apparently heading for approval was a separate ballot question in Oregon to decriminalize possession of small amounts of hard drugs, including heroin, cocaine and methamphetamine, and mandate establishing addiction recovery centers, using some tax proceeds from marijuana sales to establish those centers.


As usual, voters in California faced a lengthy list of health-related ballot measures.

For the second time in two years, the state’s profitable kidney dialysis industry was challenged at the ballot box. A union-sponsored initiative would have required dialysis companies to employ a doctor at every clinic and submit infection reports to the state. But the industry spent $105 million against the measure. The measure failed, according to AP.

Voters were also asked to decide, again, whether to fund stem cell research through the California Institute for Regenerative Medicine via Proposition 14. Voters first approved funding for the agency in 2004, and since then, billions have been spent with few cures to show for it. The measure was winning in early returns.

California has been at the forefront of the fight over the so-called gig economy, and this year’s ballot included a proposal pushed by ride-hailing companies like Uber and Lyft that would let them continue to treat drivers as independent contractors instead of employees. Under Proposition 22, the companies would not have to provide direct health benefits to drivers but would have to give those who qualify a stipend they could use toward a premium for health insurance purchased through the state’s individual marketplace, Covered California. The measure also appeared to be headed for approval.

Finally, voters in the Golden State were asked whether to impose higher property taxes on commercial property owners with land and property holdings valued at $3 million or more, which could help provide new revenue earmarked for economically struggling cities and counties hit hard by COVID-19, as well as K-12 schools and community colleges. Community clinics, California nurses and Planned Parenthood jumped into the thorny political battle over Proposition 15 — taking on powerful business groups — eyeing revenue to help rebuild California’s underfunded public health system. The measure was too close to call in early returns.

Democrats in California, who control all statewide elected offices and hold a supermajority in the legislature, have been positioning for a Biden win, and some were already penning ambitious health care legislation for next year. Should Biden win, they said they plan to crack down on hospital consolidation and end surprise emergency room bills, and some were quietly discussing liberal initiatives such as pursuing a single-payer health care system and expanding Medicaid to cover more unauthorized immigrants.

JoNel Aleccia, Rachel Bluth, Angela Hart, Matt Volz and Samantha Young contributed to this story.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.


This story can be republished for free (details).

¿Estás internado? Todavía puedes votar en gran parte del país

Johnathon Talamantes se rompió la cadera en un accidente de auto el 22 de octubre y se sometió a una cirugía cinco días después en un hospital público cerca del centro de Los Angeles.

Talamantes tendrá que estar en el hospital del condado de LA USC Medical Center hasta pasadas las elecciones, algo que le preocupaba antes de la cirugía.

“Una de las primeras cosas que le pregunté a mi enfermera esa mañana fue: ‘Oh, ¿cómo voy a votar?’”, contó Talamantes, de 30 años, el día antes de la operación.

Primero le pidió a su mamá que buscara la boleta electoral que había recibido tiempo antes, como todos los votantes registrados de California para esta elección.

Pero el personal de LAC + USC le dio otra opción: podían ayudarlo a obtener una boleta de emergencia y emitir su voto sin tener que levantarse de la cama. Entonces Talamantes le dijo a su mamá que no se molestara.

“No quiero que ella venga aquí, por las restricciones de COVID”, dijo.

La ley de California protege los derechos de los votantes que se encuentran en el hospital u otras instalaciones de atención, o confinados en sus hogares. Les permite obtener ayuda de cualquier persona que elijan, que no sea un empleador o un representante sindical, y emitir un voto de emergencia.

Al menos otros 37 estados permiten la votación de emergencia por razones médicas, según la Conferencia Nacional de Legislaturas Estatales. Pero las prácticas varían.

En algunos, solo los miembros de la familia pueden ayudar a los pacientes hospitalizados a votar desde el hospital.

En California, Nueva York y varios otros estados, los empleados y voluntarios del hospital pueden ayudar a un paciente a completar una solicitud de boleta de emergencia. Pueden recoger la boleta del paciente y enviarla a la oficina electoral o depositarla en un buzón oficial.

Por el contrario, en Carolina del Norte, que un trabajador de salud ayude a un paciente a votar es un delito.

En 18 estados, la ley permite que las juntas electorales locales envíen representantes directamente a las cabeceras de los pacientes, aunque seis de esos estados cancelaron ese servicio este otoño debido a la pandemia de COVID-19, dijo el doctor Kelly Wong, fundadora de Patient Voting, un organización no partidista dedicada a aumentar la participación entre los votantes registrados hospitalizados inesperadamente durante la época de las elecciones.

El sitio web del grupo tiene un mapa interactivo de los Estados Unidos con información estado por estado sobre la votación en el hospital. También permite a los pacientes verificar si están registrados para votar.

Wong, residente de la sala de emergencias del Hospital de Rhode Island en Providence, recordó que cuando era estudiante de medicina y trabajaba en una sala de emergencias, los pacientes que estaban a punto de ser ingresados ​​en el hospital le decían: “No puedo estar internado, tengo que cuidar a mi perro o atender a mi abuela”. Luego, durante las elecciones de 2016, escuchó: “No puedo quedarme. Tengo que ir a votar”.

“Eso realmente me llamó la atención”, dijo Wong. Investigó y descubrió que los pacientes podían votar en el hospital mediante una boleta de emergencia, algo que ninguno de sus compañeros de trabajo sabía. “Nuestros pacientes no saben esto. Debería ser nuestro trabajo decírselo”, dijo.

Algunos hospitales han estado ayudando a los pacientes a votar en las elecciones principales durante dos décadas o más, como parte de una tendencia en la industria de la atención médica hacia el compromiso cívico.

Las clínicas comunitarias registran a los votantes en sus salas de espera o en campañas de registro público. En un número cada vez mayor de salas de emergencia, los pacientes y sus familias tienen la oportunidad de registrarse. Muchos hospitales, incluido LAC + USC, tendrán unidades de votación móviles este año, abiertas a los miembros del personal, a los pacientes que están lo suficientemente bien para caminar y a sus familias.

Estos esfuerzos tienen como telón de fondo el papel protagónico de la atención médica en el acalorado drama político de la nación: COVID-19 se ha convertido en un tema principal de la campaña presidencial, mientras que la Corte Suprema de los Estados Unidos, más conservadora desde esta semana, se prepara para escuchar un caso, una semana después de las elecciones, que podría ser la sentencia de muerte para la Ley del Cuidado de Salud a Bajo Precio (ACA).

La pandemia ha hecho que la votación para los pacientes internados sea un desafío debido a las estrictas restricciones en los hospitales y a los muchos empleados que han sido despedidos, cesanteados o que trabajan desde la casa. Y un aumento significativo en la votación adelatanda y el uso de boletas por correo en muchos estados puede reducir la cantidad de pacientes que necesitan ayuda.

“La mayoría de nuestros pacientes, espero, ya habrán votado, porque eso aliviará el estrés; para ellos, es una cosa menos de qué preocuparse”, dijo Camille Camello, directora asociada de servicios de voluntariado en las casi 900 camas del Cedars-Sinai Medical Center en Los Angeles, que tiene un programa para ayudar a los pacientes hospitalizados a votar. Dijo que, en elecciones pasadas, más de 200 pacientes solicitaron boletas.

En LAC + USC, los administradores han intentado asegurarse de que los pacientes sepan que pueden obtener ayuda para votar. Hay carteles en los espacios comunes y el personal está repartiendo volantes con información sobre las votaciones a cada paciente que ingresa, dijo Gabriela Hernández, directora de servicios voluntarios del hospital.

Hernández dijo que ella y unos 25 voluntarios han estado visitando las distintas unidades durante el último mes, preguntando a los pacientes si quieren ayuda para votar.

Los pacientes que dicen que sí reciben solicitudes de boleta de emergencia, que el hospital ha estado enviando al área de registro de votos condado del condado de Los Ángeles para verificación. Las solicitudes de boleta seguirán estando disponibles para los pacientes hasta la mañana del día de las elecciones.

Hernández y su equipo recogerán las boletas y las distribuirán a los pacientes, luego las devolverán al registro antes de las 8 pm, fecha límite el día de las elecciones.

Otros hospitales tienen una agenda más apretada.

En St. Jude Medical Center en Fullerton, California, el personal del hospital está preguntando a los pacientes el lunes 2 de noviembre si quieren asistencia para votar y les traerán boletas el día de las elecciones, dijo Gian Santos, gerente de servicios voluntarios en el hospital. En las elecciones de 2016, solo unos siete u ocho pacientes votaron de esa manera, agregó Santos.

El Hospital St. Joseph en Orange, California, planea hacer todo -solicitudes y boletas- el mismo día de las elecciones.

Para los grandes hospitales, la votación de pacientes hospitalizados puede ser una tarea enorme. Las personas a menudo necesitan asistencia en varios idiomas y los hospitales suelen contratar servicios de traducción.

Muchos hospitales reciben pacientes de numerosos condados y de otros estados.

El Hospital Lenox Hill en Manhattan planea ayudar hasta a 200 pacientes de nueve condados en el estado de Nueva York y tres en Nueva Jersey, dijo Erin Smith, enfermera especializada en obstetricia que, junto con su colega Lisa Schavrien, está liderando el esfuerzo.

El hospital asignará uno o dos “corredores” a cada una de las 12 juntas electorales del condado, dijo Smith. Para ella, hacer que los pacientes vulnerables puedan ejercer su derecho al voto merece el esfuerzo.

“Si no los ayudamos, ¿cuántas miles de personas no van a votar en las elecciones porque sufrieron un accidente automovilístico, tuvieron apendicitis, o una cirugía cerebral inesperada?”, se preguntó Smith.

“Si no lo hacemos en el hospital, es como negarles el voto a los votantes”.

Esta historia de KHN fue publicada primero en California Healthline, un servicio de la California Health Care Foundation.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.


This story can be republished for free (details).

They Work in Several Nursing Homes to Eke Out a Living, Possibly Spreading the Virus

To make ends meet, Martha Tapia works 64 hours a week at two Orange County, California, nursing homes. She is one of thousands of certified nursing assistants who perform the intimate and physical work of bathing, dressing and feeding the nation’s fragile elderly.

“We do everything for them. Everything you do for yourself, you have to do for the residents,” Tapia said.

And she’s one of many in that low-paid field, predominantly women of color, who work at more than one facility.

In March, when the coronavirus began racing through nursing homes, the federal government banned visitors. (That guidance has since been updated.) But even with the ban, infections kept spreading. A team of researchers from UCLA and Yale University decided to examine the people who continued to enter nursing homes during that time: the employees.

Keith Chen, a behavioral economist and UCLA professor, said the key question is this: “The people who, we can infer, work in this nursing home — what other nursing homes do they work at?”

Using location data from 30 million smartphones when the visitor ban was in place helped the scientists “see” the movements of people going into and out of nursing homes. The data showed a lot of nursing home workers are — like Tapia — working at more than one facility. Chen said the findings suggest that staffers who work in multiple nursing homes are one source of the spread of infections.

“When you learn that over 20 of your workers are also spending time in other nursing homes, that should be a real red flag,” Chen said.

The Toll on Patients and Beyond

More than 84,000 residents and staff members of nursing homes and other long-term care facilities have died of COVID-19 across the U.S., representing 40% of all coronavirus fatalities in the country, according to KFF’s most recent analysis. (KHN is an editorially independent program of KFF.)

In California, the analogous toll is more than 5,700 deaths, making up 35% of all coronavirus fatalities in the state.

The UCLA team created maps of movement and found that on average each nursing home is connected to seven others through staff movement. Limiting nursing home employees to one facility could mean fewer COVID-19 infections — but that would hurt the workforce of people who say they work multiple jobs because of low wages.

After each of her shifts, Tapia worries she’ll bring the coronavirus home to her granddaughter. She tries to take precautions, including buying N95 masks from nurses. She knows it’s not just patients who are at risk. Nursing home workers such as Tapia are also contracting COVID-19 — in California alone, 153 of them have died since the pandemic began.

At the nursing home where she works in the morning, Tapia gets an N95 mask that she must only use — and reuse — in that facility. At her other nursing home job, in the afternoons, she gets a blue surgical mask to wear.

“They say they cannot give us N95 [masks],” she said, because she works in the “general area” where residents haven’t tested positive for the coronavirus.

She doesn’t want to work at multiple nursing homes, but her rent in Orange County is $2,200 a month, and her low pay and limited hours at each nursing home make multiple jobs a necessity.

“I don’t want to get sick. But we need to work. We need to eat, we need to pay rent. That’s just how it is,” Tapia said.

Staff Connections Equal Infections

The UCLA study also found that some areas of the country have a much higher overlap in nursing home staffing than others.

“There are some facilities in Florida, in New Jersey, where they’re sharing upwards of 50 to 100 workers,” said UCLA associate professor Elisa Long, who, along with her colleagues, examined data during the federal visitor ban from March to May. “This is over an 11-week time period, but that’s a huge number of individuals that are moving between these facilities; all of these are potential sources of COVID transmission.”

They also found the more shared workers a nursing home has, the more COVID-19 infections among the residents.

“Not only does it matter how connected your nursing home is, but what really matters is how connected your connections are,” Long said.

The researchers say they’ve informally dubbed these highly connected nursing homes as each state’s “Kevin Bacon of nursing homes,” after the Six Degrees of Kevin Bacon parlor game.

“We found that if you’re going to see a nursing home outbreak anywhere, it’s likely to spread to the Kevin Bacon of nursing homes in each state,” Chen said.

The team hopes that local health departments could use similar cellphone data methods as an early warning system. Using the test results from the “Kevin Bacon of nursing homes” as an indicator would be the first step.

“As soon as you detect an outbreak in one nursing home, you can immediately prioritize those other nursing homes that you know are at increased risk,” Chen said.

Prioritize Masks and Hand-Washing

The California Association of Health Facilities represents most nursing homes in the Golden State. In response to the study, the group said its members can’t prevent workers such as Tapia from taking jobs elsewhere, and they can’t pay them more, because California doesn’t pay them enough through Medicaid reimbursements.

Mike Dark, an attorney with the California Advocates for Nursing Home Reform, doesn’t buy that argument. He said the state already tried paying nursing homes more in 2006 — and that made them more profitable but not more safe and efficient. He said he’s skeptical that extra funding to pay staff would reach those workers.

“We know from past experience that money tends to go into the pockets of the executives and administrators who run these places,” Dark said.

He agreed that health workers such as Tapia should be paid more but cautioned against one idea being floated in some policy circles: limiting workers to one nursing home.

“Then you can wind up depriving some of the crucial health caregivers that we have in these facilities of their livelihoods, which can’t be a good solution,” he said.

Instead, he said, regulators need to focus on the basics, especially in the 100 California nursing homes with ongoing outbreaks, since it’s been shown that infection control measures work.

“Right now there’s poor access to [personal protective equipment]. There’s still erratic compliance with things like hand-washing requirements,” he said. “If we spent more time addressing those key issues, there would be much less concern about spread between facilities.”

Jackie Fortiér is health reporter for KPCC and This story is part of a partnership that includes KPCC, NPR and Kaiser Health News.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.


This story can be republished for free (details).

California’s Progressive — and Expensive — Health Care Ambitions Rely on Biden Win

SACRAMENTO — For deep blue California, where first-in-the-nation health care proposals regularly flood the Democratic agenda, there could not be more at stake in the presidential race.

If Republican President Donald Trump prevails, Democratic state lawmakers worry, they’ll be forced to scale back their ambitious plans and play defense the next four years, battling Republican attempts to curtail federal Medicaid spending and further unravel the Affordable Care Act.

Should Democratic presidential nominee Joe Biden win, California Democrats — who control all statewide elected offices and hold a supermajority in the legislature — are poised to go big on health care, pushing aggressively for a health care system that covers all Californians, regardless of their immigration status or ability to pay.

“This election will determine whether California has a willing federal partner who can move us forward in the ways we want to see health care expanded,” said Assembly member David Chiu (D-San Francisco).

“It is incredibly unlikely that another four years of Trump will allow us to make significant strides toward universal health care, whereas a Biden-Harris administration would allow us to make real progress toward not just health care for all, but so much more.”

California Dems Counting on Biden Win

Behind the scenes, Democrats in California are positioning for a White House led by Biden and vice presidential nominee Kamala Harris — which they presume would be more supportive of California’s agenda — and some are already planning legislation for next year. Not only are they plotting ways to crack down on hospital consolidation and end surprise emergency room bills, but they are also quietly discussing a trio of liberal initiatives that could again push California to the forefront of health care policy. They include:

  • A new single-payer health care bill that would nix private insurance and create a taxpayer-funded health care system for all Californians. “Just expanding the Affordable Care Act is not nearly enough. We need to be willing to stand up to the drivers of health care costs rather than give Americans an insurance card that they can’t afford to use,” said Assembly member Ash Kalra (D-San Jose), who is considering introducing the measure. A legislative analysis in 2017 estimated that single-payer could cost California $400 billion a year.
  • A wealth tax that could generate $7.5 billion a year to help finance potential coverage expansions. Assembly member Rob Bonta (D-Alameda) said wealthier people should pay more to help finance health care, education and other services, especially for Californians hit hard by the pandemic. “Some people have been offended and think that punishes the doers and innovators, but our intent is to help the most vulnerable,” he said.
  • Expanding its Medicaid program for low-income residents, called Medi-Cal, to more unauthorized immigrants. California currently offers full Medi-Cal benefits to all qualified residents, regardless of immigration status, up to age 26. “To see Latinos in this state testing positive at disproportionate rates of COVID-19, it makes it clear that people are dying and suffering from lack of health coverage,” said state Sen. Maria Elena Durazo (D-Los Angeles), who plans to spearhead the proposal.

Democratic Gov. Gavin Newsom has argued that the future of health care, and California’s ability to combat COVID-19, is at stake this election.

Although Newsom has sought to play nice with Trump — partly because California relies on federal cooperation and federal money to respond to COVID-19 — the first-term governor strongly backs Biden.

“We can quite literally go backward with an administration that actively wants to get rid of health care for tens of millions of people with preexisting conditions,” Newsom said in September. But Biden, he said, will allow California to “accelerate our health care reforms and have a real partner that can advance those reforms to lower costs and improve quality, as well as expand access.”

The governor’s health care agenda includes far-reaching measures to expand access to care and set government-imposed limits on health care spending, possibly penalizing hospitals and doctors for failing to meet cost reduction targets. Though Newsom withdrew his biggest proposals earlier this year, citing a projected $54 billion state budget deficit, Health and Human Services Secretary Dr. Mark Ghaly said the administration is considering reintroducing proposals that died this year, including a new Office of Health Care Affordability.

But these plans could be jettisoned no matter who wins the election, warned Rose Kapolczynski, a California-based Democratic strategist. The state’s pandemic-crippled economy is likely to lead to more budget cuts, making it difficult to adopt new, expensive programs, she said.

“Everyone is going to be fighting for money, and it’s going to be hard to pass big-ticket expensive items like single-payer if California faces massive layoffs of state workers and cuts to health care programs that already exist,” she said.

A Trump Win Could Spur Health Care Innovation

While Democrats fear a rollback of health care funding and benefits should Trump win, his reelection could offer greater opportunity for Medicaid innovation in states, said Lanhee Chen, former adviser to 2012 Republican presidential nominee Mitt Romney and research fellow at Stanford University’s right-leaning Hoover Institution.

“States can be laboratories of innovation,” Chen said at an October presidential election forum at the UCLA Fielding School of Public Health.

In what is known as the waiver process, states can ask the federal government for permission to use federal dollars to offer services or pursue new approaches to health care that go beyond what Medicaid and Obamacare traditionally allow.

If reelected, Trump could help both red and blue states by giving them greater “freedom and flexibility” to undertake new programs, Chen said. The Trump administration has begun to embrace such experiments, including in Minnesota, where it approved a bipartisan effort to establish a reinsurance program that compensates insurers for taking on certain high-cost patients.

In Georgia, Republican Gov. Brian Kemp received permission from the administration to impose work requirements for Medicaid enrollees and require some to pay monthly premiums.

This process “is a way of both satisfying a conservative desire to enhance private marketplaces as well as a progressive desire to expand coverage,” Chen said.

Mark Peterson, a professor of public policy, political science and law at UCLA, is skeptical, saying the process has favored Republicans under Trump.

“The Trump administration has been trying to use Medicaid waivers to go in a more conservative direction, doing things such as allowing Medicaid work requirements,” he said.

The Newsom administration is seeking permission from the Trump administration to dramatically transform Medi-Cal to focus more on preventing enrollees from getting sick, and to invest in getting homeless people into housing and treatment. A COVID-spurred budget crisis forced Newsom to pause the $3.5 billion Medi-Cal overhaul earlier this year.

Newsom is also relying on federal cooperation to respond to COVID-19. The federal government, for example, allows California hospitals in hard-hit communities to relax minimum nursing staff levels.

To go as far as California wants on health care, “we do need the support and cooperation of the federal government — there’s no doubt,” Ghaly said in an interview with California Healthline.

But state Sen. Richard Pan (D-Sacramento) dismissed the idea that the Trump administration’s idea of innovation would help California Democrats, who are pursuing health policies Trump has attacked. “We’ve been hamstrung,” said Pan, who chairs the Senate Health Committee. “Trump has been president for four years and we haven’t seen it.”

The Affordable Care Act

One major issue doesn’t hinge on the presidential election but could nonetheless cast major doubt on Democrats’ big health care plans: the fate of the Affordable Care Act.

The U.S. Supreme Court will hear a case on Nov. 10 brought by Republican states, and backed by the Trump administration, that could invalidate Obamacare. California is leading the defense, and the state “stands to lose much of the historic gains it made,” said Melanie Fontes Rainer, a health care adviser to Attorney General Xavier Becerra.

Should the law be struck down, nearly 5 million Californians could lose health coverage, health insurance premiums could rise, and the state would likely have to make dramatic cuts to health and social safety net programs. Last year alone, the state received $25 billion to help fund its Affordable Care Act programs, according to Ben Johnson, a health care analyst at the nonpartisan Legislative Analyst’s Office.

California has also gone well beyond the requirements of Obamacare. It has expanded Medi-Cal to more people; imposed its own requirement to have insurance or pay a tax penalty after Congress eliminated the federal tax penalty; and offers state-financed premium subsidies for low- and middle-income Californians.

Yet state leaders have not identified a backup plan if Obamacare is struck down, and as they plot a far more aggressive agenda, they fear they would be forced to backtrack and struggle to protect what California has already done.

“We’ll be crippled and our gains would collapse,” Pan said. “We’d have to retrench entirely.”

This KHN story first published on California Healthline, a service of the California Health Care Foundation.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.


This story can be republished for free (details).

Hospitalized? You Can Still Vote in Most Parts of the Country

Johnathon Talamantes, of South-Central Los Angeles, broke his hip in a car accident on Oct. 22 and underwent surgery five days later at a public hospital near downtown.

His post-op recovery will keep him in the hospital, L.A. County+USC Medical Center, beyond Election Day, and as he prepared himself for the surgery, he wondered what that would mean.

“One of the first things I asked my nurse this morning was, ‘Oh, how am I going to vote?’” Talamantes, 30, said from his hospital bed the day before the operation.

He initially thought of asking his mom to rummage through a pile of papers at the home he shares with her and bring him the mail-in ballot that he, like all registered California voters, received for this election.

But then staffers at LAC+USC told him about another option: They could help him get an emergency ballot and cast his vote without having to get out of bed. So Talamantes told his mom not to bother.

“I don’t want her coming down here, because of the COVID restrictions,” he said.

California law protects the rights of voters who are in the hospital or other care facilities, or confined at home. It allows them to get help from anyone they choose — other than an employer or a union representative — and to cast an emergency ballot.

At least 37 other states allow emergency voting for medical reasons, according to the National Conference of State Legislatures. But practices vary.

In some states, only family members can assist hospitalized patients with voting from the hospital.

In California, New York and several other states, hospital employees and volunteers can help a patient complete an emergency ballot application. They can pick up the ballot for the patient and deliver the finished ballot back to the election office or deposit it in an official drop box.

In North Carolina, by contrast, it is a felony for a health care worker to assist a patient with voting.

In 18 states, the law allows local election boards to send representatives directly to patients’ bedsides, though six of those states have canceled that service this fall because of the COVID-19 pandemic, said Dr. Kelly Wong, founder of Patient Voting, a nonpartisan organization dedicated to increasing turnout among registered voters unexpectedly hospitalized around election time.

The group’s website features an interactive map of the United States with state-by-state information on voting while in the hospital. It also allows patients to check whether they are registered to vote.

Wong, an emergency room resident at Rhode Island Hospital in Providence, recalled that when she was a medical student working in an ER, patients who were about to be admitted to the hospital would tell her, “‘I can’t be admitted; I have let the dogs out, or I’m the sole caretaker of my grandmother.’” Then during the election of 2016, she heard, “‘I can’t stay. I have to go vote.’”

“That really caught my attention,” Wong said. She did research and learned patients could vote in the hospital using an emergency ballot — something none of her co-workers knew. “Our patients don’t know this, she said. “It should be our job to tell them.”

Some U.S. hospitals have been assisting patients with voting in major elections for two decades or more, part of a broader tendency in the health care industry toward civic engagement.

Community clinics register voters in their waiting rooms or at public registration drives. In an increasing number of ERs, patients and their families are offered the chance to register. Many hospitals, including LAC+USC, this year will have mobile voting units on-site, open to staff members, patients who are well enough to walk, and their families.

These efforts come against the backdrop of health care’s starring role in the nation’s heated political drama: COVID-19 has become a top presidential campaign issue, while the U.S. Supreme Court, its conservative majority fortified this week, prepares to hear a case — one week after the election — that could be the death knell for the Affordable Care Act.

The pandemic has made inpatient voting a challenge because of tight restrictions at hospitals and the many employees furloughed, laid off or working at home. And a significant increase in early voting and the use of mail-in ballots in many states may reduce the number of patients who need help.

“The majority of our patients, I am hoping, will have voted already, because that will alleviate the stress — for them, it’s one less thing to worry about,” said Camille Camello, associate director of volunteer services at the nearly 900-bed Cedars-Sinai Medical Center in Los Angeles, which has a program to help inpatients vote. In past elections, she said, over 200 patients have requested ballots.

At LAC+USC, administrators have been trying to ensure patients know they can get help voting. Posters line the walls of common spaces and staffers are handing out flyers with voting information to every patient who is admitted, said Gabriela Hernandez, the hospital’s director of volunteer services.

Hernandez said she and about 25 volunteers have been walking the halls in the inpatient units of the hospital for the past month, asking patients if they want help voting.

Patients who say yes get emergency ballot applications, which the hospital has been sending to the L.A. County Registrar-Recorder for verification. The ballot applications will continue to be made available to patients up to the morning of Election Day.

Hernandez and her team will collect the ballots and distribute them to patients, then return them to the registrar before the 8 p.m. deadline on Election Day.

Other hospitals have a more collapsed timeline.

At St. Jude Medical Center in Fullerton, California, hospital staffers will start asking patients Monday if they want voting assistance and bring them ballots on Election Day, said Gian Santos, manager of volunteer services at the hospital. In the 2016 election, only about seven or eight patients voted that way, Santos said.

St. Joseph Hospital in Orange, California, plans to do everything — applications and ballots — on Election Day.

For big hospitals, inpatient voting can be a massive undertaking. People often require assistance in multiple languages, and the hospitals frequently contract with translation services to accommodate them.

Many hospitals receive patients from numerous counties — and across state lines.

Lenox Hill Hospital in Manhattan plans to assist as many as 200 patients from nine counties in New York state and three in New Jersey, said Erin Smith, an obstetrical nurse navigator who, along with fellow OB nurse navigator Lisa Schavrien, is leading the effort.

The hospital will assign one or two “runners” to each of the 12 county election boards, Smith said. For her, enabling vulnerable patients to exercise their right to vote is worth the effort.

“If we’re not helping them do it, how many thousands of people are not voting in elections because they were in a car accident, because they had appendicitis, because they had unexpected brain surgery?” Smith asked.

“If we’re not making it happen in the hospital, it kind of feels to me like voter suppression.”

This KHN story first published on California Healthline, a service of the California Health Care Foundation.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.


This story can be republished for free (details).

KHN on the Air This Week

KHN chief Washington correspondent Julie Rovner discussed the current surge in COVID-19 cases, health policy in the election and the Affordable Care Act case before the Supreme Court with NPR’s “All Things Considered” on Sunday and WBUR’s “On Point.”

Columnist and California Healthline senior correspondent Bernard Wolfson discussed the possible impact of Judge Amy Coney Barrett and the Supreme Court on the ACA with KPCC’s “Take Two” on Tuesday.

KHN senior Colorado correspondent Markian Hawryluk discussed how health care may shape the U.S. Senate race in Colorado with Colorado Public Radio’s “Colorado Matters” on Thursday.

KHN senior correspondent Sarah Jane Tribble discussed KHN’s “Where It Hurts” podcast and COVID-19 in rural America with NPR’s “Weekend Edition” on Oct. 17. 

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.


This story can be republished for free (details).

Democrats Link GOP Challengers to Trump’s COVID Record, Efforts to Undo Obamacare

In a tweet to his 78,000 followers Sunday, U.S. Rep. Harley Rouda, a Democrat from Orange County, California, described his Republican opponent Michelle Steel’s attendance at an indoor fundraiser without a mask as “sickening.”

Democratic U.S. Rep. Gil Cisneros also blasted his Republican opponent, Young Kim, on Twitter for attending the “superspreader fundraiser,” calling it a “slap in the face to frontline workers” and his constituents in southern Los Angeles County and northern Orange County.

After President Trump’s superspreader event in Orange County last week, @YoungKimCA decided to host her own. The superspreader fundraiser—a crowded, indoor event with no social distancing/no masks—goes against CDC guidelines. It’s a slap in the face to frontline workers & #CA39.

— Gil Cisneros (@GilCisnerosCA) October 26, 2020

Earlier in the month, another Democrat, U.S. Rep. TJ Cox of Bakersfield, told a television debate audience that his GOP challenger, David Valadao, “is in lockstep with Donald Trump” and that Valadao aims to undo federal health protections.

These charges by incumbent lawmakers — who represent vast areas of California, from its inland farmlands to its coastal mansions and urban working-class neighborhoods — reflect a disciplined and widely used strategy Democratic congressional hopefuls are deploying across California and the nation: By associating their Republican opponents with the out-of-control coronavirus pandemic and threats to the Affordable Care Act, they hope to convince voters the Democratic Party is the one that can better protect Americans’ health.

In doing so, they are linking their challengers to President Donald Trump, who is deeply unpopular in the Golden State, with just 32% of likely voters approving of the way he is handling his job, according to a recent Public Policy Institute of California survey.

“Democrats have been able to tie the national conversation around the coronavirus pandemic with health care and with the economy and social unrest,” said David McCuan, a political science professor at California State University-Sonoma. “That allows Democrats to turn or hold individual districts.”

But the strategy isn’t a slam-dunk for Democrats, especially in the districts they flipped in 2018 — including seven in California. Despite the changing demographics in the once Republican strongholds of Orange County and the Central Valley, McCuan and other political analysts said Republican victories are possible if even a small number of residents who voted Democratic in 2018 swung back to the GOP.

Republicans have already taken back one of those seats. U.S. Rep. Mike Garcia (R-Santa Clarita) beat Christy Smith in a May special election — 55% to 45% — to fill the vacancy left after Katie Hill resigned from Congress amid allegations of inappropriate relationships with staff members. Voters in the district that includes Santa Clarita and Simi Valley will pick between the same two candidates in Tuesday’s election.

In these competitive districts, political analysts say the winner will come down to voter turnout and Trump’s approval ratings, which is now inextricably tied to his handling of the public health crisis. Nationwide, 26 congressional seats are ranked as toss-ups, according to the Cook Political Report, which tracks races.

“A lot of it’s about the president,” said Wesley Hussey, a political science professor at California State University-Sacramento. “And part of the component of the presidential election is health care, and that does trickle down to congressional races.”

Calls to the state Republican Party and the National Republican Congressional Committee were not returned. And none of the Republican challengers to the Democrats interviewed for this story responded to repeated interview requests.

In California’s southern Central Valley congressional district currently held by Cox, political analysts predict another nail-biter. Cox ousted Valadao from Congress in the last election by just 862 votes, in part by tying the three-term incumbent to Trump and criticizing Valadao’s votes to overturn the Affordable Care Act.

Now, Cox has added Trump’s handling of the pandemic as a reason for voters to reject Valadao again.

“He is in lockstep with Donald Trump,” Cox charged in a televised debate Oct. 20. “And I don’t know how you can stand behind a guy that’s saying, ‘Hey, we did a fantastic job and 200,000 Americans have died so far.’”

In the recent poll by the Public Policy Institute of California, California voters rated COVID-19 as the state’s top concern.

The tweets that Cisneros and Rouda penned Sunday, which included photos of their opponents at a fundraiser without masks, capitalize on that concern. Rouda, for example, reminded voters that his opponent, as the head of the Orange County Board of Supervisors, publicly questioned the local public health officer’s springtime recommendation that residents wear masks.

“Michelle Steel is Orange County’s top official and she violated public health orders to attend an indoor, maskless fundraiser just to receive a check,” Rouda told California Healthline on Monday. “The example she is setting shows that she lacks the leadership needed for her current position and the position she’s running for.”

Steel spokesperson Lance Trover accused Rouda of politicizing the pandemic, saying Steel has helped secure personal protective equipment for front-line workers, and food assistance and testing for the county’s most vulnerable residents.

Steel has publicly criticized Democratic Gov. Gavin Newsom for opening California’s economy too slowly, and her campaign has shared photos of Rouda socializing on a beach and in a restaurant without a mask. (Rouda said the only other people in the beach photo were close family members, and that the restaurant photo was taken before the pandemic.)

“Harley Rouda is a hypocrite who has spent the entire summer seeking to politicize the work of Orange County in battling the coronavirus,” Trover said.

While wearing a mask may resonate in California’s swing districts, there remain solidly red areas of California where defying a government mandate can score a candidate political points. U.S. Rep. Tom McClintock, a Republican who represents a sprawling conservative district spanning multiple northern and central counties, has called masks useless, balked at wearing one at a congressional hearing and asserted that state lockdowns have led to increased deaths.

So in addition to focusing on McClintock’s COVID response, his opponent, Brynne Kennedy, a first-time candidate and small-business owner, is targeting another health issue: his opposition to the ACA.

In her travels throughout the mostly rural district, Kennedy is highlighting his votes — 66 by her count — to weaken or overturn the Affordable Care Act.

“This is radically out of step with where our district is,” said Kennedy, whom political analysts describe as a long-shot candidate. “Talking about that to people, that’s very concerning to them, and it’s absolutely on the ballot this year.”

Kennedy’s focus on protecting the federal health care law, particularly preserving access to insurance for people with preexisting medical conditions, mirrors the messaging of her fellow Democrats.

And it’s putting a lot of Republicans on the defense, especially with Trump on the campaign trail advocating for the repeal of the Affordable Care Act, said GOP political consultant Rob Stutzman.

“Republicans are making a point of telling voters that they will support protecting preexisting conditions,” Stutzman said. “It’s clearly a vulnerability.”

U.S. Rep. Josh Harder (D-Modesto) has been talking about preexisting conditions since he first campaigned for his seat two years ago, referencing his brother’s health issues as a young child. He believes health care is once again the single-biggest issue in his race.

But Harder has recrafted his pitch from 2018, when he talked about backing “Medicare for All,” a position now seen as a vulnerability in swing districts where Republicans have labeled their opponents as liberal or socialist.

Now, Harder and other Democrats are talking about shoring up the ACA and creating a “public option” that would allow every American to enroll in a government-sponsored plan.

Harder said he is asking voters to reelect him to ensure Congress has the votes to protect the federal health care law if the Supreme Court invalidates it.

“We need to make sure that people understand that the stakes couldn’t be higher,” he said. “The only way that we get a legislative solution that prioritizes people with asthma, cancer and other preexisting conditions is if we elect Democrats to the House, to the Senate and the presidency.”

This KHN story first published on California Healthline, a service of the California Health Care Foundation.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.


This story can be republished for free (details).

App-Based Companies Pushing Prop. 22 Say Drivers Will Get Health Benefits. Will They?

App-based driving services such as Uber, Lyft, DoorDash and Instacart are bankrolling California’s Proposition 22, which would keep their drivers classified as independent contractors, not employees.

Leading into the Nov. 3 election, the ballot measure — which has become the most expensive in state history — is mired in controversy and the subject of a lawsuit from Uber drivers alleging that the company inappropriately pressured them to vote for the initiative.

But what’s occasionally lost in the debate over Proposition 22 are the claims about what it will mean for app-based drivers.

Detractors, like unions and driver advocacy groups, say Proposition 22 would strip drivers of the protections of AB-5, a 2019 California law delayed by legal challenges. The law requires drivers to be classified as employees, which would afford them the associated benefits like paid sick leave, workers’ compensation and access to unemployment insurance.

Supporters, such as ride-sharing companies and the California Chamber of Commerce, say Proposition 22 would give drivers benefits, like a guarantee of minimum earnings and compensation when they are hurt on the job, while allowing them to maintain the flexible schedule of independent contractors.

In an online ad paid for by Lyft, the company says “Prop. 22 will give them … health care benefits.”

That sounds like drivers with Uber, Lyft and other app-based companies will automatically get health insurance if Proposition 22 passes. The truth is a little more complicated.

What Does ‘Health Care Benefits’ Mean?

We reached out to Lyft to back up its claim, and the company directed us to the “Yes on 22” campaign. This is how the campaign explained “health care benefits”:

Under Proposition 22, drivers who qualify — more on that in a minute — would get a stipend they could use to buy an insurance plan from Covered California, the state’s health insurance marketplace.

That stipend would be calculated like this: App-based companies would look at the statewide average monthly premium of bronze-level plans sold on the Covered California exchange.

The companies would then give qualified drivers a stipend of 82% of the average premium, said Geoff Vetter, a spokesperson for the Yes on 22 campaign. (On average, U.S. employers covered 82% of premiums costs for single coverage in 2019.)

So hypothetically, if bronze plans cost an average of $100 per month, Uber, Lyft or a similar company would provide qualifying drivers with $82 per month.

Drivers would be eligible for the full stipend — all $82 in the hypothetical case — if they average 25 hours per week of “engaged” time, which is time spent driving while there’s a passenger in the car. Time spent driving between passengers would not count.

“Most drivers work part time” and spend about one-third of their time waiting for rides and deliveries, according to the nonpartisan state Legislative Analyst’s Office. Using that equation, drivers would need to work an average of 37.5 hours per week for a single company in order to receive the full stipend.

A driver who averages at least 15 but less than 25 hours of engaged time each week would be eligible for 50% of the stipend — or $41 per month.

The stipend would be similar to employer-sponsored insurance because both employers and employees would contribute to the cost of insurance, Vetter said.

“For the people who do work closer to full time, it does give them that ability to receive health care coverage by getting a typical employer contribution for that coverage,” Vetter said.

Does a Stipend Equal Coverage?

But this stipend bears little resemblance to traditional employer-based insurance, which is what drivers would get if they were considered employees instead of gig workers, said Ken Jacobs, chair of the University of California-Berkeley Center for Labor Research and Education.

“It has very, very little relationship to what anyone would think of as job-based coverage,” Jacobs said. “It’s really wrong to think of this as health insurance.”

For instance, under Proposition 22, the stipends would be calculated and distributed quarterly, based on drivers’ hours. That could force drivers to periodically reassess what kind of coverage they would qualify for and could afford.

With traditional employer-sponsored insurance, a driver would enroll in a plan once per year and the premium wouldn’t change.

A vacation or illness could mean that drivers can’t maintain the hours required by the measure, costing them their stipend — and perhaps their insurance — for the quarter, and stripping them of the stability usually associated with job-based coverage, Jacobs said.

And getting money to buy an individual plan isn’t the same as participating in a large group plan offered by an employer, said Jen Flory, a policy advocate at the Western Center on Law & Poverty, a nonprofit organization that advocates for low-income Californians and opposes Proposition 22.

Covered California plans are typically less generous than the policies employees usually get through work, she said. And bronze-level plans, which have the lowest monthly premiums, also have the highest out-of-pocket costs for medical services.

Consider the deductible, which is how much a person needs to pay out-of-pocket before insurance starts paying for care.

In 2018, fewer than half of Californians who had work-based insurance had a deductible, and on average, that deductible was $1,402 for a single person, according to research from the California Health Care Foundation. (California Healthline is an editorially independent service of the California Health Care Foundation.)

The deductible on a Covered California bronze plan for an individual in 2021 will be $6,300 for medical services plus $500 for prescription drugs. Proposition 22 ties the stipend “to the highest deductible, highest out-of-pocket plans on the market,” Flory said. “And it’s for workers who aren’t making a whole lot of money.”

Drivers could use the stipend to buy a more generous plan, but the monthly premium would be higher and the stipend would cover less of it.

Depending on their incomes and other factors, drivers may also be eligible for tax credits and state and federal subsidies to help them afford plans on the individual market. But Flory said this amounts to the government subsidizing health insurance that employers should be paying for themselves.

It’s also problematic to base the stipends on a statewide average of bronze premiums because that doesn’t take into account the huge regional differences in the cost of care, said Gerald Kominski, a senior fellow at the UCLA Center for Health Policy Research.

“In the Bay Area, that contribution is going to buy a lot less than it would in Southern California,” Kominski said. “We’re a big state and have a lot of variation of health care costs.”

Our Ruling

The stipend offered under Proposition 22 is a “health care benefit,” but the wording is misleading and ignores critical information.

While neither Lyft nor the Yes on 22 campaign says the proposition will give drivers health insurance, saying that it will offer them “health care benefits” gives the impression that the stipend is similar to traditional job-based coverage. It’s not.

Drivers who value the ability to make their own schedules would have to figure out how to work an average of nearly 40 hours a week — essentially full time — to receive the full stipend. The stipend would cover a fraction of the premiums for health insurance that’s typically less generous than what they’d get as employees.

Moreover, because drivers’ stipends could change quarterly based on their driving time — which could be affected by vacation or illness — any coverage purchased with the stipend could carry a cloud of uncertainty.

We rate this claim as Half True.

This KHN story first published on California Healthline, a service of the California Health Care Foundation.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.


This story can be republished for free (details).

As Anxieties Rise, Californians Buy Hundreds of Thousands More Guns

Handgun sales in California have risen to unprecedented levels during the COVID-19 pandemic, and experts say first-time buyers are driving the trend.

The FBI conducted 462,000 background checks related to handgun purchases in California from March through September, an increase of 209,000, or 83%, from the same period last year. That’s more than in any other seven-month period on record.

People who study gun ownership think the increase means more people are buying guns for the first time. Handguns, as opposed to rifles and shotguns, are often the first firearm purchase made by someone looking for protection.

Background checks related to long gun or other gun sales also rose statewide, by 110,000, or 54%, from March through September compared with the same period in 2019. While that increase is steep, it does not match the rise in long gun sales seen in California during periods, often following mass shootings, when state leaders have considered legislation to sharply rein in access to military-style assault rifles.

In California, background checks for handguns and long guns correlate with gun sales, federal and state data show. Other states have purchasing systems that can result in a disconnect between background checks and sales.

Even so, the national numbers are startling: The FBI conducted about 7.7 million background checks related to handgun sales from March through September, an increase of 3.9 million, or 104%, from the same period in 2019.

Gun rights activists, gun control supporters and public health experts largely agree that the increase in gun sales is driven by fear, uncertainty and longing for a greater sense of protection.

Some Californians worry about dark fallout from pervasive unemployment and a faltering economy. Others are disconcerted by the angry and sometimes destructive protests over police shootings and pandemic lockdowns. The upcoming election has added to the unease.

“Every dealer I know has a very low inventory of guns. They’re backlogged for months in filling orders because of this run on guns,” said Sam Paredes, executive director of Gun Owners of California, which advocates for fewer restrictions on gun purchases. “Every one of them, the first thing they say is, ‘Sam, you will not believe how many new gun buyers we have.’”

With about 3,000 firearm-related deaths occurring each year in California and 40,000 nationwide, gun ownership is increasingly viewed through the lens of public health. Several studies have drawn a connection between gun ownership and gun-related deaths.

Researchers at UC-Davis’ Violence Prevention Research Program said they are particularly concerned about the latest surge in sales, since many buyers appear to be introducing a gun into their home for the first time.

“There are obvious and well-documented risks associated with [going from] having no access to a firearm to having access to a firearm,” said Julia Schleimer, a data analyst with the UC-Davis program. “That extends to all household members, not just the person who owns the gun. And that’s for suicide, homicide, unintentional injury — basically for everyone, children included.”

Schleimer and her colleagues recently published a study examining the effects of the rise in gun sales during the pandemic. Using national data from the Gun Violence Archive, the study estimated that additional gun sales accounted for nearly 800 excess firearm injuries and deaths during assaults from March through May.

Recent FBI statistics show a rise in homicides and aggravated assaults, crimes often committed with guns, in large California cities and across the nation in the first half of 2020.

Dr. Garen Wintemute, director of the UC-Davis violence prevention program, is among the experts concerned about the connection between gun sales and a rise in domestic violence incidents as families have been forced to shelter together amid pandemic-related quarantines and shutdowns.

“If a firearm is involved, risk that intimate partner violence will have a fatal outcome goes up by a factor of five,” Wintemute said.

U.S. firearm suicide rates rose for several years leading up to 2020. Public health advocates fear that the mental strain of the pandemic combined with access to more guns will only exacerbate that trend.

“People have been cooped up and under tension with anxiety and depression,” said Dr. Bill Durston, president of Americans Against Gun Violence. “Adding a gun to that is like adding gasoline to a fire.”

For now, preliminary data does not show an increase in suicides in California during the pandemic. There were 1,621 suicides in California from March through July, down from 1,930 the year before, according to the California Department of Public Health.

It may be years before the full effects of the increase in gun sales during the pandemic are clear. In California, six of the top 10 months for background checks related to handgun sales have occurred during the pandemic. More than 60,000 handgun background checks were sold in September alone, double the number from September 2019.

Paredes said some dealers tell him more than 70% of their buyers are new customers. People “find themselves in a position where they’re thinking, ‘What might be the next step with the pandemic?’ That they might have to protect themselves in their own homes,” he said.

Even when the pandemic begins to taper off, Paredes expects the impact on gun sales to linger as first-time buyers become second- and third-time buyers.

“We will continue to see an increase,” he said, “because you’re going to have millions of people out there who are now going to experience guns.”

Phillip Reese is a data reporting specialist and an assistant professor of journalism at California State University-Sacramento.

This KHN story first published on California Healthline, a service of the California Health Care Foundation.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.


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Savvy Patient Fought for the Price She Was Quoted − And Didn’t Give Up

When Tiffany Qiu heard how much her surgery was going to cost her, she was sure the hospital’s financial department had made a mistake. Qiu, who already knew from a breast cancer scare earlier that year that her plan required a 30% coinsurance payment on operations, pressed the person on the phone several times to make sure she had heard correctly: Her coinsurance payment would be only 20% if she had the procedure at Palomar Medical Center in Poway, California, about 38 miles south of where Qiu lives.

“I was kind of in doubt, so I called them a second time,” said Qiu. “They gave me the exact same amount.”

Qiu had been diagnosed with uterine polyps, a benign condition that was making her periods heavier and more unpredictable. Her OB-GYN proposed removing them but said it was safe to wait. Qiu said that she asked about the possibility of doing it in the doctor’s office under local anesthesia to make the procedure cheaper, but that her doctor rebuffed her suggestion because of her preference for general anesthesia.

Because Qiu thought she was getting a deal on her usual 30% share of the bill, she decided to go ahead with the polyp removal on Nov. 5, 2019. As she sat in the waiting room filling out forms, staffers let her know she needed to pay in full before the surgery.

Unease set in. The hospital asked for the 20% coinsurance — $1,656.10 — that she had been quoted over the phone, but Qiu hadn’t been told she needed to pay on the day of the procedure. As she handed over her credit card, she confirmed one more time that this would be her total patient responsibility, barring complications.

The surgery was over in less than 30 minutes, and she walked out of the hospital with her husband, feeling perfectly fine.

Then the bill came.

Patient: Tiffany Qiu is a 49-year-old real estate agent and mother of two who lives in Temecula, California. Her family of four is covered by a Blue Shield of California policy that she and her husband purchased on the marketplace. Last year, they paid a $1,455 monthly premium, with an individual annual $1,850 deductible and an individual out-of-pocket maximum of $7,550.

Total Bill: Palomar Health billed Blue Shield $22,219.64 for the polyp removal, which the insurer negotiated down to $8,576.79. Blue Shield paid $5,769.72 and stated in an explanation of benefits document that Qiu was responsible for a $334.32 deductible and $2,472.75 coinsurance.

Because Qiu had already paid $1,873.20 on the day of surgery, the hospital billed her an additional $933.87, which meant Qiu was on the hook for the remainder of her 30% coinsurance.

These figures don’t include the fees Qiu paid for anesthesia or her doctor’s services.

Service Provider: Palomar Medical Center in Poway is one of three hospitals in the Palomar Health system. Palomar Health is a San Diego County public health care district, which means the health care facilities are nonprofit and receive property taxes as a portion of their revenue stream. The system is governed by a board of directors elected from within the district’s boundaries.

What Gives: Hospitals and surgery centers sometimes offer discounts if patients are uninsured and able to pay with cash or a credit card. Physicians may even offer discounts on a patient’s share of the costs if they know the patient is unemployed or has fallen on hard times. But regularly offering discounts to attract patients is not common, and could even be fraudulent if the patients are insured through Medicare, said Paul Ginsburg, director of the USC-Brookings Schaeffer Initiative for Health Policy.

In Qiu’s case, the hospital seemed to be offering a discount on the insurer’s normally required coinsurance.

“The hospital would be in breach of their contract with the insurance if they did not bill her for that amount,” said Martine Brousse, a California-based patient advocate and medical billing consultant for AdvimedPRO. “She owes what the insurance has calculated, and the facility has every right to demand payment.”

Copayments and coinsurance exist, in theory, so patients have “skin in the game.” They have to pay a clearly defined portion of the cost of their care, according to their policy, so they will shop around and use medical care judiciously (though many health experts say coinsurance amounts have gotten so high that many cannot afford them).

Resolution: If she hadn’t been quoted 20%, Qiu said, she would have shopped for a better deal. She flies to China often to visit her mother and was open to getting the surgery done there.

Qiu called the hospital to ask why she was being billed a second time, despite the lack of complications during the surgery. She remembers the back-and-forth over the remaining bill was exhausting, especially because it happened over the holidays.

“I got tired and said, ‘I don’t want to play this game anymore,’” Qiu recalled. “‘If you want to send it to collections, you can do it, but I’m not going to pay for it.’”

The bill landed at a collection agency called IC System. In a May 23 phone call, Qiu said, a representative offered to slash the remaining bill by 25% if she would just pay that day.

But Qiu refused, though she could easily afford to pay. She’s undaunted by the risk the unpaid bill poses to her credit score, preferring instead to fight the hospital on behalf of other patients who may not have the time or luxury to persist.

The experience left her feeling as if the hospital offered her a fake discount to reel in her business.

“I double-checked and tripled-checked with them,” Qiu said. “They have financial departments that should be verifying this with my insurance company.”

Another thing to note is how much the hospital billed Qiu for a simple outpatient procedure: $22,219.64. That amount is “totally laughable,” said Dr. Merrit Quarum, founder of WellRithms, a company that works with self-funded employers and other clients to make sense of complex medical claims.

Not only is the charge far out of line with what that procedure typically costs in that region (around $5,500), but Qiu is now stuck paying a larger amount as her share under the terms of her insurance. This is how those “sticker prices” that few people pay still drive up costs for individuals.

After a reporter’s call, Palomar Health looked back at phone records, confirmed Qiu’s version of events and said a hospital staffer had made a mistake by quoting her a 20% cost-sharing obligation. That percentage then got automatically put into her patient notes and was on the bill of estimated costs she signed and paid on the day of surgery, even though it was incorrect.

They apologized for giving the mistaken impression that Qiu was getting a discount. Staff members are not authorized to offer discounts when providing estimates, said Derryl Acosta, a spokesman for Palomar Health.

Acosta also pointed out other communication breakdowns, like dropping the complaint Qiu phoned in after she received the second bill in late November. Her issue did not get put into the standard customer complaint process, which would have elevated the problem and triggered an investigation into the phone records. That’s why Qiu’s bill was sent to the collection agency.

“We definitely admit that the call should have been handled differently,” Acosta said. “We now have a new call center that we believe will handle this type of call better.”

Because Palomar Health was able to see in their phone records that a staffer had confirmed the erroneous 20% coinsurance amount to Qiu, the health system will change her bill to reflect what she was promised. Qiu will get a statement in the mail saying she has a zero balance, Acosta said.

The Takeaway: Multiple medical billing advocates who reviewed Qiu’s case praised her for her tenacity in calling the hospital financial department twice before the procedure. But as she herself acknowledged, most people don’t have the time or spine to fight.

To avoid such situations, experts advised, patients should check in with their insurer about the discounts offered, as hospital staffers may be poorly trained or ill informed.

If a patient hears conflicting information about charges before a procedure, they need to approach their insurer to confirm the details of their own policy, said Brousse, the patient advocate.

The simple fact that a hospital staffer misinformed a patient isn’t a legal reason to force a hospital to lower a bill, Brousse said.

Also, get promises in writing — before the day of surgery. Make sure the offer is explicit about which services are included and what might count as a complication. Ask whether you’ll have to pay upfront.

Initial estimated bills can be full of asterisks and “weasel words,” said Akshay Gupta, co-founder of CoPatient, a medical bill review and patient advocacy company.

“Even though she tried to be diligent, obviously she still didn’t know that she would need to get something that was legally enforceable,” said Gupta.

Dan Weissmann, host of the podcast “An Arm and a Leg,” reported the radio interview of this story. Joe Neel of NPR produced the interview with KHN Editor-in-Chief Elisabeth Rosenthal on “Morning Edition.”

Bill of the Month is a crowdsourced investigation by KHN and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.


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Telemedicine or In-Person Visit? Pros and Cons

As COVID-19 took hold in March, U.S. doctors limited in-person appointments — and many patients avoided them — for fear of infection. The result was a huge increase in the volume of remote medical and behavioral health visits.

Doctors, hospitals and mental health providers across the country reported a 50- to 175-fold rise in the number of virtual visits, according to a report released in May by the consulting firm McKinsey & Co.

The COVID-fueled surge has tapered off as patients venture back to doctors’ offices. But medical professionals and health experts predict that when the pandemic is over, telehealth will still play a much larger role than before.

Studies show patient satisfaction with telehealth is high. And for physicians who previously were skeptical of remote care, necessity has been the mother of invention.

“There are still a few doubting Thomases, but now that we’ve run our practices this way for three months, people have learned that it’s pretty useful,” says Dr. Joseph Kvedar, president of the American Telemedicine Association and a practicing dermatologist who teaches at Harvard Medical School in Boston.

For patients, the advantages of telemedicine are clear: You typically can get an appointment sooner, in the safety of your own home or workplace, saving time and money on gas and parking — in some cases, even avoiding a loss in wages for missing work.

James Wolfrom, a 69-year-old retired postal executive in San Francisco, has had mostly virtual health care appointments since the pandemic started. He particularly appreciates the video visits.

“It’s just like I’m in the room with the doctor, with all of the benefits and none of the disadvantages of having to haul my body over to the facility,” says Wolfrom, who has Type 2 diabetes. “Even after the pandemic, I’m going to prefer doing the video conferencing over having to go there.”

Telemedicine also provides care for people in rural areas who live far from medical facilities.

The growth of virtual care has been facilitated by Medicare rule changes for the COVID-19 emergency, including one that reimburses doctors for telemedicine at the same rate as in-person care for an expanded list of services. State regulators and commercial health plans also loosened their telehealth policies.

In California, the Department of Managed Health Care, which regulates health plans covering the vast majority of the state’s insured residents, requires commercial plans and most Medi-Cal managed care plans during the pandemic to pay providers for telehealth at parity with regular appointments and limit cost sharing by patients to no more than what they would pay for in-person visits. Starting Jan. 1, a state law — AB-744 — will make that permanent for commercial plans.

Five other states — Delaware, Georgia, Hawaii, Minnesota and New Mexico — have pay-parity laws already in effect, according to Mei Wa Kwong, executive director of the Center for Connected Health Policy. Washington state has one that also will begin Jan. 1.

If you are planning a telehealth appointment, be sure to ask your health plan if it is covered and how much the copay or coinsurance will be. The appointment may be through your in-network provider or a telehealth company your insurer contracts with, such as Teladoc, Doctor On Demand or MD Live.

You can also contact one of those companies directly for a medical consultation if you don’t have insurance, and pay between $75 and $82 for a regular doctor visit.

If you are one of the 13 million Californians enrolled in Medi-Cal, the state’s Medicaid program, you can get telehealth services at little to no cost.

Large medical offices and health systems usually have their own telemedicine platforms. In other cases, your provider may use a publicly available platform such as FaceTime, Skype or Zoom. Either way, you will need access to a laptop, tablet or smartphone — though, for a phone conversation, a landline or simple cellphone will suffice.

Smartphones with good cameras can be particularly useful in telemedicine because high-resolution photos can help doctors see certain medical problems more clearly. For example, a photo from a good smartphone camera usually provides enough detail for a dermatologist to determine whether a mole requires further attention, Kvedar said.

Relatively inexpensive apps and at-home tools enable you to measure your own blood pressure, pulse rate, oxygen saturation level and blood sugar. It’s a good idea to monitor your vitals and have the numbers ready before you start a virtual visit.

Be aware that a remote visit is not right for every situation. In the case of serious injury, severe chest pain or a drug overdose, for example, you should call 911 or get to the ER as quickly as possible.

Virtual visits also are not recommended in other cases for which the doctor needs to lay hands on you.

Wolfrom has had only a few in-person health visits this year, one of them with a podiatrist who checks his feet every six to 12 months for diabetes-related neuropathy. “That can only be done when you are in the room and the podiatrist is touching and feeling your feet,” Wolfrom says.

Face-to-face visits are generally better for young children. Kids often require vaccinations, and it’s easier for doctors to monitor their growth and development in person, says Dr. Dan Vostrejs, a pediatrician at Santa Clara Valley Medical Center in San Jose.

In general, telemedicine is effective in cases that would typically send you to an urgent care clinic, such as minor injuries or flu-like symptoms, including fever, cough and sore throat.

It is also increasingly used for post-surgical follow-ups. Telemedicine can be a godsend for geriatric or disabled patients with reduced mobility. And it’s a no-brainer for mental health care, which is mostly talking anyway.

Among the top telehealth adopters are medical specialists who treat chronic illnesses such as diabetes, hypertension, cardiovascular disease and asthma, says Dr. Peter Alperin, a San Francisco internist and vice president of product at Doximity, a kind of LinkedIn for medical professionals.

Providers can monitor patients’ vitals remotely and discuss lab results, diet, medications and any symptoms in a video chat or a phone conversation. “If you happen to see something that’s awry, you can bring them into your office,” Alperin says, adding it’s “a better form of triage.”

But telemedicine has some serious disadvantages. For one thing, the less formal setting can allow some routine medical practices to slip through the cracks.

In the second quarter of this year, blood pressure was recorded in 70% of doctor office visits compared with about 10% of telemedicine visits, according to a study published early this month.

Elsa Pearson, a resident of Dedham, Massachusetts, had a medical appointment scheduled in March, which was switched to a telephone call because of the pandemic-induced lockdown.

“It was honestly the most efficient appointment I’ve had in my life,” says Pearson, 30. But, “I must admit, without the push of having the labs right there when you leave the appointment, I’ve yet to get them done.”

Perhaps the biggest pitfall in telehealth is the loss of a more intimate and valuable doctor-patient relationship.

In a recent essay, Dr. Paul Hyman, a Maine physician, reflected on the times when an unexpected discovery during an in-person examination had possibly saved a patient’s life: “A discovery of an irregular mole, a soft tissue mass, or a new murmur — I do not forget these cases, and I do not think the patients do either.”

This KHN story first published on California Healthline, a service of the California Health Care Foundation.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.


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Verily’s COVID Testing Program Halted in San Francisco and Oakland

OAKLAND, Calif. — Amid fanfare in March, California officials celebrated the launch of a multimillion-dollar contract with Verily — Google’s health-focused sister company — that they said would vastly expand COVID testing among the state’s impoverished and underserved communities.

But seven months later, San Francisco and Alameda counties — two of the state’s most populous — have severed ties with the company’s testing sites amid concerns about patients’ data privacy and complaints that funding intended to boost testing in low-income Black and Latino neighborhoods instead was benefiting higher-income residents in other communities.

San Francisco and Alameda are among at least 28 counties, including Los Angeles, where California has paid Verily to boost testing capacity through contracts collectively worth $55 million, according to a spokesperson for the California Governor’s Office of Emergency Services. About half of them have received COVID tests through six mobile units that travel among rural areas.

Gov. Gavin Newsom has heralded the investment as a game changer in addressing persistent inequities in access to COVID testing across the state that tend to fall along lines of ethnicity and income. The goal, he said in April, touting six new Verily testing sites, was to “make sure we’re truly testing California broadly defined, not just parts of California and those that somehow have the privilege of getting ahead of the line.”

Yet the roadblocks for getting underrepresented populations to use the program soon became apparent to Alameda County officials. In a June letter to California Secretary of Health Mark Ghaly, Oakland Mayor Libby Schaaf and other members of the county’s COVID-19 Racial Disparities Task Force raised numerous concerns about the Verily protocols.

Among their complaints: People signing up for a test through Verily had to do so online, using an existing or newly created Gmail account; the sign-ups were offered only in English or Spanish; and participants were asked to provide sensitive personal information, including their home address and whether they were managing chronic health conditions such as diabetes, obesity or congestive heart failure, which could expose their data to third-party use.

“It is critical in this crisis that we continue to build trust between government and healthcare providers and vulnerable communities,” the task force members wrote.

Verily had two sites in Alameda County, and one was shuttered by May. The second, located at an Oakland church, closed in August and is set to reopen using a different testing vendor. Alameda County testing director Dr. Jocelyn Freeman Garrick said that while the Verily sites helped the county reach testing goals in terms of raw numbers, they were phased out because of long wait times of a week or more for results, and because the tests were not reaching the residents in greatest need.

Verily does not manufacture the COVID tests used at its California sites. It contracts with major corporations such as Quest Diagnostics and Thermo Fisher Scientific to provide the test kits and perform the lab work. What Verily provides is a digital platform where people are screened for symptoms, schedule testing appointments at participating sites and check back for test results.

Dr. Noha Aboelata is CEO of Roots Community Health Center, an East Oakland clinic that serves mostly African Americans and is one of the original Verily sites in Oakland. Her experience with Verily is best described as a tale of two lines.

In May, Aboelata worked with Verily to establish a walk-up site at her clinic, rather than the drive-thru model the company typically uses. There would be two lines: one for people who scheduled their appointments through Verily’s online portal; and a second for people who had not preregistered with Verily. Roots would staff both lines, and Verily would supply test kits and personal protective equipment including masks, which were “like gold” at the time, Aboelata said.

Problems emerged almost immediately, she said. People were suspicious of the requirement that they sign up with a Gmail account, and the request for personal information, such as health status and risk factors. “You don’t necessarily want to share that with Google,” Aboelata said.

Then there was the language in the privacy policy that allows for sharing data with third parties. “That always is going to raise suspicion and concern in our community,” she said.

The people who ended up in the Verily-registered line, she said, tended to be white and to come from wealthier ZIP codes outside East Oakland. And because Verily never changed the website language describing Roots as a drive-thru site, many were angry at having to walk up.

“We had people coming from all over the Bay Area who were frustrated that they had to park in Oakland, where they had probably never been and didn’t seem to want to be,” she said. “They were creating quite a scene, and some were saying, ‘I want to talk to the manager.’” She had to ask a few people to leave. “One of them was saying, ‘This is so Oakland, and I hope you all get the virus.’ It was pretty awful.”

The Roots line for clients who did not register through Verily, on the other hand, was made up mostly of people of color from the community who long had come to the clinic for medical care, she said.

When Aboelata looked at the data, the disparities were obvious: 12.9% of people tested in the non-Verily line were positive for COVID-19, while just 1.5% of people tested in the Verily-registered line were positive. For Aboelata, it was clear that the two lines were testing two entirely different populations.

After just six days of testing, Aboelata asked Verily to leave.

“From where we sit, this is an old story,” she said. “Corporations that are not really invested in the community come helicoptering in, bearing gifts, but what they’re taking away is much more valuable.” That thing of value, Aboelata believes, is the data Verily requests from everyone who signs up for a test.

In San Francisco, Verily mobile testing clinics have also been sidelined. County officials declined to provide an explanation. However, multiple people with knowledge of the testing efforts said the Verily registration process proved chaotic for homeless people and others in the Tenderloin district, one of the city’s poorest neighborhoods.

Kenneth Kim, clinical director of Glide, an outreach center that helped run the Tenderloin site, said many homeless residents coming in for testing had Gmail accounts, as Verily required, but could not remember their passwords. When staffers at the testing site tried to help them retrieve their passwords, they found that Google’s two-factor authentication process required users to have the same phone number as when they signed up, which few of the homeless participants did.

Dr. Jonathan Fuchs, who leads San Francisco County’s testing strategy at the Department of Public Health, confirmed that the partnership with Verily was “currently on hold.” He declined to provide further details.

In response to questions, Verily spokesperson Kathleen Parkes said the program requires users to register with Gmail accounts because Google’s authentication procedures safeguard sensitive data and protect “against unknown individuals sending or receiving information with serious consequences for health or well-being.” Conversations with San Francisco and Alameda remain “active,” Parkes said. The company did not respond to specific questions about the testing disparities cited by community leaders.

Verily’s role in COVID-19 testing has been shadowed by controversy since President Donald Trump told reporters at a Rose Garden news conference in March that “Google” was developing a screening website and testing tool. “Google has 1,700 engineers working on this right now,” he said. “They’ve made tremendous progress.”

At the time, COVID tests were in short supply and Trump was under pressure to increase capacity as infections ballooned in California, New York and other states. But Google was not building such a website. Instead, Verily, another Alphabet Inc. subsidiary focused on life sciences, was in the early stages of developing a website to help triage people in need of COVID testing, Google clarified in a tweet. It planned to unveil a pilot program in two Bay Area counties.

Days later, Newsom announced a California partnership with Verily that so far has paid the company $55 million to establish both mobile and brick-and-mortar testing sites. In addition, Verily has partnered with Rite Aid to manage testing at approximately 300 sites in multiple states under a $122.6 million federal contract between the pharmacy chain and the U.S. Department of Health and Human Services. California’s Verily contracts are in place through Nov. 30; the HHS contract is set to expire in January.

Participants in the Verily initiative sign an authorization form that says their information can be shared with multiple third parties involved in the testing program, including unnamed contractors and state and federal health authorities.

“While the form tells you that Verily may share data with ‘entities that assist with the testing program,’ it doesn’t say who those entities are. If one of those unnamed and unknown entities violates your privacy by misusing your data, you have no way to know and no way to hold them accountable,” said Lee Tien, senior staff attorney for the Electronic Frontier Foundation, a nonprofit that advocates for digital privacy.

The policy states Verily will not use the data collected for its own research or meld it with other Google products without the user’s permission. But it notes participants may be invited to share their data for such research, and the testing portal prominently features links inviting participants to sign up for other Verily research.

In California, as of Oct. 8, the Verily sites had processed an average of 1,583 patient samples per day over the prior seven days, according to the California Department of Public Health. Verily, the state health department and Alameda County all declined requests to provide race and ethnicity data by testing site.

Dr. Kim Rhoads, a UCSF professor and former colorectal surgeon who leads a COVID testing project for Black communities, said Aboelata’s experience with Verily is emblematic of widespread racial disparities in the testing and treatment of COVID-19. “We can’t keep talking about the consequences being unintended,” Rhoads said. “We are six months into this pandemic and anyone who is surprised by the repetitive findings of inequity in testing, the spread of virus and COVID-19 mortality just isn’t paying attention.”

In an interview, Ghaly, California’s health secretary, said he believed the state’s partnerships with Verily and other companies continue to be a national model for addressing problems with testing disparities, including setting up venues for minority and rural populations. For example, in counties in northern parts of the state, sometimes the only regular testing available was through mobile testing set up under the program, he said.

“I think there’s lots of success and lots of lessons learned and we continue to apply them,” Ghaly said. “Until the entire effort is completed, I always look at where we are as part success and part opportunity to keep learning.”

In a September response to the Oakland COVID-19 disparities task force, Ghaly outlined several actions the state had taken or would take in response to the concerns, including having Verily update its platform to include additional languages and work with testing vendors on alternative methods for data collection to address privacy concerns.

“Some of the things we learned specifically in our experience in Alameda and other parts of the Bay Area is language matters,” Ghaly told KHN.

After working with the homeless for 25 years, Dr. Margot Kushel, director of the UCSF Benioff Homelessness and Housing Initiative, said she wasn’t surprised to learn some community leaders ran into problems with Verily.

“It turns out that in public health, the highest-tech solution is usually not the right one,” she said. To bring COVID cases down, she explained, requires a “laser focus” on the highest-risk communities. And people in those communities often don’t want to turn over the protected information Verily asks for, whether because of fears about their immigration status or a history of mistrust of the medical establishment and policing.

“You can imagine a million and a half reasons why people would distrust it,” Kushel said. “The very structure of this is set up to fail. And by failing the communities who need it most, we fail everybody.”

California Healthline correspondent Angela Hart contributed to this report.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.


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Déjà Vu for California Voters on Dialysis

SACRAMENTO, Calif. — The survival of California’s dialysis clinics is in the hands of its voters this November.

Sound familiar?

Voters heard the same dire campaign claim two years ago, when the dialysis industry spent a record $111 million to defeat a statewide ballot measure that would have limited clinic revenues.

Industry giants DaVita and Fresenius Medical Care are back on the defense again this year with their checkbooks open, flooding voters’ mailboxes and screens with political ads highlighted by heartfelt testimonials from patients against Proposition 23. With just a week left before Election Day, the industry is on track to break its own spending record.

This time, the measure’s sponsor, the Service Employees International Union-United Healthcare Workers West, which represents more than 95,000 health care workers in California, focused the ballot measure less on dialysis clinic profits and more on patient safety.

The union, which has tried but failed to organize dialysis clinic workers, has been the driving force behind both ballot measures, putting voters squarely in the middle of a long-running brawl — and forcing them to make decisions that could affect the health of tens of thousands of Californians.

“There’s no reasonable evidence that this would improve patient health,” said Erin Trish, associate director of the University of Southern California’s Leonard D. Schaeffer Center for Health Policy & Economics. “It seems largely to be driven by retaliation by SEIU-United Healthcare Workers West, who are mad the dialysis facilities wouldn’t let their workers unionize.”

Proposition 23 would require dialysis clinics to have a licensed physician on-site during all dialysis treatments, but that doctor wouldn’t need to be a nephrologist, a kidney specialist. Clinics would have to report infection data every three months to the California Department of Public Health, and those that plan to close would need state approval.

About 80,000 patients visit the state’s 600 licensed chronic dialysis clinics, three-quarters of which are owned or operated by DaVita or Fresenius, the largest dialysis companies in the country, according to a report by the nonpartisan state Legislative Analyst’s Office.

Patients with kidney failure often need a dialysis machine to filter toxins and remove excess fluid from their blood when their kidneys can no longer do the job. The treatment is arduous, taking roughly four hours at least three times a week.

Dialysis patients are susceptible to infection for a variety of reasons: Their immune systems are already compromised by their kidney failure, they are around other sick patients while receiving treatment, they require catheters to access their veins, and their blood is cycled through a machine.

Even though mortality rates have dropped among outpatient dialysis patients nationwide, infections remain a leading cause of death. In California, about one-third of outpatient clinics have fallen short of federal performance standards so far this year, resulting in lower Medicare payments to those clinics, according to federal payment records.

“With this initiative, we’ll make sure that they put more of those huge profits back into the clinics to improve safety and improve care,” said Steve Trossman, spokesperson for the union.

Dialysis clinics are once again threatening to close if the measure passes and they’re faced with higher operating costs.

Shama Aslam, 50, spoke at the behest of the union. Aslam, who visits a dialysis clinic in Stockton three times a week, described swatting fruit flies off her face and arms for hours while hooked up to a dialysis machine. She has polycystic kidney disease and has been waiting three years for a kidney transplant.

“It was really bad today,” Aslam said on a recent October afternoon. “It’s very uncomfortable. And because we’re dealing with blood all the time, we don’t want any infection. That’s a huge thing, at least for me.”

Aslam wishes she could see a doctor more than once a month. Nephrologists oversee their patients’ dialysis care, but clinic staff members administer the treatments. Federal regulations require a medical director, who is a board-certified physician, to oversee every dialysis clinic in the country. But there is no requirement that those directors remain physically present at the clinic when it is open. That’s what the California ballot measure would mandate.

Rick Barnett, chief executive officer and president of Satellite Healthcare, which operates 80 dialysis clinics in Texas, Tennessee, New Jersey and California, including Aslam’s clinic, said he had not heard of fruit flies at that Stockton facility. Medicare has not penalized that clinic this year, according to the payment database.

Many nonprofits like San Jose-based Satellite Healthcare could not afford to hire on-site doctors if Proposition 23 passes, Barnett said. Currently, medical directors often oversee multiple clinics in addition to their other job responsibilities.

The Legislative Analyst’s Office estimated it would cost each clinic several hundred thousand dollars a year, while the industry says $600,000 a year. Each clinic likely would have to hire more than one doctor to cover all hours.

Barnett estimates Satellite would close up to 40% of its 67 clinics in California should the ballot measure pass.

“It comes down to an attack on the industry,” he said. “This is one of the few sectors of health care they haven’t organized.”

Trossman vehemently disagreed that the union is trying to punish the dialysis companies over its failed unionization effort, saying the union invests in improving people’s lives.

“In terms of the idea that we would spend millions of dollars because essentially we’re ticked off is just ludicrous,” he said. “We don’t spend money that way.”

The California Medical Association, which represents physicians, opposes the measure, saying it would exacerbate the state’s doctor shortage by diverting physicians into dialysis clinics.

“This will bring physicians who are not trained in kidney disease or dialysis to just be present without any role or purpose, or even a clear path to any intervention because they won’t know what to do,” said Dr. Edgard Vera, a nephrologist and the medical director of DaVita dialysis clinics in Southern California’s High Desert towns of Hesperia and Victorville.

Critical emergencies, such as wild swings in blood pressure, already are handled by technicians and nurses certified in dialysis care, Vera said. Should a patient go into cardiac arrest, “if a physician is there, they are going to call the ambulance anyway,” he said.

DaVita alone had given nearly $67 million to the “No on 23” campaign as of Wednesday, more than half of the $105 million raised so far by the industry, according to campaign finance reports filed with the California secretary of state. The campaign’s other contributors include Fresenius, Satellite Healthcare, U.S. Renal Care and Dialysis Clinic Inc.

The “Yes on 23” campaign has reported just a fraction of that, with nearly $9 million in contributions. SEIU-United Healthcare Workers West gave the bulk of the money, with the rest — about $40,000 — coming from non-monetary donations from the California Democratic Party.

Proposition 23 follows an uneven record of wins and losses for the union on dialysis issues in California. The union tried but failed to organize dialysis workers three years ago, arguing that they needed safer working conditions and job protection. It also lost its 2018 ballot initiative that would have capped dialysis clinic profits.

But, last year, the union helped persuade state lawmakers to adopt a bill that aimed to stop a billing practice dialysis companies use to get higher insurance reimbursements for some low-income patients. A federal judge in January temporarily blocked the law from taking effect while the court considers its constitutionality.

“It’s not unusual for us to be voting on similar issues over and over again if they’re backed by powerful enough interests,” said Danielle Joesten Martin, associate professor of political science at California State University-Sacramento, pointing to other repeat ballot measures on the November ballot, such as the Realtor-backed Proposition 19. That measure would give Californians over 55 years old a property tax break when buying a new home.

They’re “powerful interest groups who didn’t get what they wanted the last time around.”

This KHN story first published on California Healthline, a service of the California Health Care Foundation.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.


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KHN’s ‘What the Health?’: A Little Good News and Some Bad on COVID-19

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For the first time in a long time, there is some good news about the coronavirus pandemic: Although cases continue to climb, fewer people seem to be dying. And there are fewer cases than expected among younger pupils in schools with in-person learning. But the bad news continues as well — including a push for “herd immunity” that could result in the deaths of millions of Americans.

Meanwhile, the Trump administration is doubling down on efforts to allow states to require certain people with low incomes to prove they work, go to school or perform community service in order to keep their Medicaid health benefits. The administration is appealing a federal appeals court ruling to the Supreme Court and just granted Georgia the right to impose a work requirement.

This week’s panelists are Julie Rovner of Kaiser Health News, Margot Sanger-Katz of The New York Times, Paige Winfield Cunningham of The Washington Post and Alice Miranda Ollstein of Politico.

Among the takeaways from this week’s podcast:

  • Opinions seem to be slowly shifting on opening schools around the country. As fall approached, many people were hesitant to send their children back to school because they feared a resurgence of coronavirus infections, but early experiences seem to show that there has been little transmission among young kids in classrooms.
  • Even with good results in those school districts that have reopened, however, the debate about whether schools should be conducting in-person learning is quite polarized. President Donald Trump repeatedly calls for all schools to resume, while groups, such as unions representing teachers and other employees, are more likely to be calling for continued online learning.
  • California, which had a strong resurgence of the virus during the summer, is seeing signs of success in fighting back. The state has been among the most aggressive in shutting down normal activities to reduce case levels. It devised a county-specific method to determine closures, restrictions and reopenings — and it appears to be working.
  • A proposal by some researchers to move the country toward a “herd immunity” plan, in which officials would expect the virus to spread among the general population while also trying to protect the most vulnerable — such as people living in nursing homes — is gaining support among some of Trump’s advisers. Public health advocates are raising alarms because it would likely lead to hundreds of thousands more deaths. They also fear the administration’s focus on restoring normalcy would by default move in this direction.
  • Federal researchers this week announced that nearly 300,000 excess deaths have been recorded this year and much of it is attributed to COVID-19 or the lack of other health care by people who could not or did not seek treatments because they were frightened by the pandemic.
  • With the Senate poised to confirm Amy Coney Barrett, who opposes abortion, to the Supreme Court within days, the fate of the landmark Roe v. Wade decision is in question. If the court overruled that decision, abortion policies would likely fall back to individual states. A recent report on the effects of such a scenario finds that a huge swath of the South and the Midwest would be left without a local facility offering abortion services.

Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read too:

Julie Rovner: Cook’s Illustrated’s “The Best Reusable Face Masks,” by Riddley Gemperlein-Schirm, and The Washington Post’s “Consumer Masks Could Soon Come With Labels Saying How Well They Work,” by Yeganeh Torbati and Jessica Contrera

Margot Sanger-Katz: The Hill’s “Republicans: Supreme Court Won’t Toss ObamaCare,” by Peter Sullivan

Paige Winfield Cunningham: The Wall Street Journal’s “Some California Hospitals Refused Covid-19 Transfers for Financial Reasons, State Emails Show,” by Melanie Evans, Alexandra Berzon and Daniela Hernandez

Alice Miranda Ollstein: ProPublica’s “Inside the Fall of the CDC,” by James Bandler, Patricia Callahan, Sebastian Rotella and Kirsten Berg

To hear all our podcasts, click here.

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Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.


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Californians Asked to Pony Up for Stem Cell Research — Again

SACRAMENTO, Calif. — In an election year dominated by a chaotic presidential race and splashy statewide ballot initiative campaigns, Californians are being asked to weigh in on the value of stem cell research — again.

Proposition 14 would authorize the state to borrow $5.5 billion to keep financing the California Institute for Regenerative Medicine (CIRM), currently the second-largest funder of stem cell research in the world. Factoring in interest payments, the measure could cost the state roughly $7.8 billion over about 30 years, according to an estimate from the nonpartisan state Legislative Analyst’s Office.

In 2004, voters approved Proposition 71, a $3 billion bond, to be repaid with interest over 30 years. The measure got the state agency up and running and was designed to seed research.

During that first campaign, voters were told research funded by the measure could lead to cures for cancer, Alzheimer’s and other devastating diseases, and that the state could reap millions in royalties from new treatments.

Yet most of those ambitions remain unfulfilled.

“I think the initial promises were a little optimistic,” said Kevin McCormack, CIRM’s senior director of public communications, about how quickly research would yield cures. “You can’t rush this kind of work.”

So advocates are back after 16 years for more research money, and to increase the size of the state agency.

Stem cells hold great potential for medicine because of their ability to develop into different types of cells in the body, and to repair and renew tissue.

When the first bond measure was adopted in 2004, the George W. Bush administration refused to fund stem cell research at the national level because of opposition to the use of one kind of stem cell: human embryonic stem cells. They derive from fertilized eggs, which has made them controversial among politicians who oppose abortion.

Federal funding resumed in 2009, and thus far this year the National Institutes of Health has spent about $321 million on human embryonic stem cell research.

But advocates for Proposition 14 say the ability to do that research is still tenuous. In September, Republican lawmakers sent a letter to President Donald Trump urging him to cut off those funds once again.

The funding from California’s original bond measure was used to create the new state institute and fund grants to conduct research at California hospitals and universities for diseases such as blood cancer and kidney failure. The money has paid for 90 clinical trials.

A 2019 report from the University of Southern California concluded the center has contributed about $10.7 billion to the California economy, which includes hiring, construction and attracting more research dollars to the state. CIRM funds more than 56,500 jobs, more than half of which are considered high-paying.

Despite the campaign promises, just two treatments developed with some help from CIRM have been approved by the Food and Drug Administration in the past 13 years, one for leukemia and one for scarring of the bone marrow.

But it’s a bit of a stretch for the institute to take credit for these drugs, said Jeff Sheehy, a CIRM board member who does not support the new bond measure. He said the agency funded the researcher whose lab discovered and developed the drugs, but CIRM holds no rights to those drugs and doesn’t receive royalties from them.

The state has received about $518,000 in revenue from licensing other institute-funded discoveries, such as devices, McCormack said.

McCormack also pointed to some promising stem cell therapies still in clinical trials, such as a treatment that has cured 50 children of severe combined immunodeficiency, a genetic disorder often called “bubble baby” disease, and others that have led to “dramatic” improvements in paralysis and blindness, he said.

The campaigns for both bond measures may be giving people unrealistic expectations and false hope, said Marcy Darnovsky, executive director of the Center for Genetics and Society. “It undermines people’s trust in science,” Darnovsky said. “No one can promise cures, and nobody should.”

Robert Klein, a real estate developer who wrote both ballot measures, disagrees. He was inspired to invest in stem cell research after he lost his youngest son to Type 1 diabetes. He said some of CIRM’s breakthroughs are helping patients right now.

“What are you going to do if this doesn’t pass? Tell those people we’re sorry, but we’re not going to do this?” Klein said. “The thought of other children needlessly dying is unbearable.”

Sheehy, who has served on the agency’s board for 16 years, said he’s proud of the work the institute has done but believes it should be funded through the legislature, not by borrowing more money.

“The promise was that it would pay for itself and it hasn’t,” Sheehy said. “We can’t really afford it, and this is the worst way to pay for it.”

Even if CIRM isn’t turning a profit, some researchers and private companies are benefiting from the public money. Take the company Forty Seven Inc., named after a human protein and co-founded by Irving Weissman, director of Stanford University’s stem cell research program. The state stem cell agency awarded more than $15 million to Forty Seven, and $30 million to Weissman at Stanford for research.

That money fueled research that uncovered a promising treatment for several different cancers. Gilead Sciences, the pharmaceutical giant, bought Forty Seven in 2018 for $4.9 billion. Of that, $21.2 million went back to CIRM to pay back Forty Seven’s research grants, with interest.

“Gilead will make far more than that if it turns out to be lucrative,” said Ameet Sarpatwari, a professor of medicine at Harvard Medical School who studies drug development.

Because this kind of work is both expensive and risky, private companies are reluctant to pay for early research, when scientists have no idea if their work will yield results, let alone profits, Sarpatwari said. So the state pays for this work, and drug companies come in to finance later-stage research once a molecule looks promising — and ultimately reap the profits.

Case in point: Fedratinib, one of the two FDA-approved drugs funded partly by CIRM, can cost about $20,000 for 120 capsules, according to GoodRx.

“We’re socializing the risk of drug development and privatizing the gains,” Sarpatwari said.

On paper, the institute has stricter pricing regulations than the NIH, which does not require that drugs developed with public money are accessible to the public. In California, companies have to submit plans for how uninsured patients will get medicine and are required to sell those medications to the state’s public health programs at a specified rate.

But in practice, the regulations have never really been tested.

Proposition 14 would add a new rule. It would take the money California makes from royalties and use it to help patients afford those treatments. It also benefits drug companies: Whatever revenue the state makes from these drugs will go back to the companies in the form of state-financed patient subsidies.

The measure also would establish a new working group (complete with 15 new, full-time staffers) that would help make clinical trials more affordable for patients by paying for lodging and transportation to the trials.

And it would increase the size of CIRM’s governing board from 29 to 35. This contradicts recommendations from the Institute of Medicine, which suggested shrinking the board to avoid conflicts of interest. Klein argues the extra board positions are necessary to represent different regions and areas of expertise.

Ultimately, California voters must weigh the possibility of new treatments against the cost of financing them with debt.

“We want to develop new therapies, and initiatives like what California is doing are well positioned to do that,” Sarpatwari said. “But at the end of the day, they’re only as good as people being able to access them affordably.”

This KHN story first published on California Healthline, a service of the California Health Care Foundation.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.


This story can be republished for free (details).

‘All You Want Is to Be Believed’: The Impacts of Unconscious Bias in Health Care

In mid-March, Karla Monterroso flew home to Alameda, California, after a hiking trip in Utah’s Zion National Park. Four days later, she began to develop a bad, dry cough. Her lungs felt sticky.

The fevers that persisted for the next nine weeks grew so high — 100.4, 101.2, 101.7, 102.3 — that, on the worst night, she was in the shower on all fours, ice-cold water running down her back, willing her temperature to go down.

“That night I had written down in a journal, letters to everyone I’m close to, the things I wanted them to know in case I died,” she remembered.

Then, in the second month, came a new batch of symptoms: headaches and shooting pains in her legs and abdomen that made her worry she could be at risk for the blood clots and strokes that other COVID-19 patients in their 30s had reported.

Still, she wasn’t sure if she should go to the hospital.

“As women of color, you get questioned a lot about your emotions and the truth of your physical state. You get called an exaggerator a lot throughout the course of your life,” said Monterroso, who is Latina. “So there was this weird, ‘I don’t want to go and use resources for nothing’ feeling.”

It took four friends to convince her she needed to call 911.

But what happened in the emergency room at Alameda Hospital only confirmed her worst fears.

At nearly every turn during her emergency room visit, Monterroso said, providers dismissed her symptoms and concerns. Her low blood pressure? That’s a false reading. Her cycling oxygen levels? The machine’s wrong. The shooting pains in her leg? Probably just a cyst.

“The doctor came in and said, ‘I don’t think that much is happening here. I think we can send you home,’” Monterroso recalled.

Her experiences, she reasons,  are part of why people of color are disproportionately affected by the coronavirus. It is not merely because they’re more likely to have front-line jobs that expose them to it and the underlying conditions that make COVID-19 worse.

“That is certainly part of it, but the other part is the lack of value people see in our lives,” Monterroso wrote in a Twitter thread detailing her experience.

I’m writing this because all the coverage of Latinx and Black death as a result of Covid is being covered like it’s JUST the pre-existing conditions of racism that make us susceptible. That is certainly part of it, but the other part is the lack of value people see in our lives.

— Karla Monterroso (@karlitaliliana) May 14, 2020


Research shows how doctors’ unconscious bias affects the care people receive, with Latino and Black patients being less likely to receive pain medications or get referred for advanced care than white patients with the same complaints or symptoms, and more likely to die in childbirth from preventable complications.

In the hospital that day in May, Monterroso was feeling woozy and having trouble communicating, so she had a friend and her friend’s cousin, a cardiac nurse, on the phone to help. They started asking questions: What about Karla’s accelerated heart rate? Her low oxygen levels? Why are her lips blue?

The doctor walked out of the room. He refused to care for Monterroso while her friends were on the phone, she said, and when he came back, the only thing he wanted to talk about was Monterroso’s tone and her friends’ tone.

“The implication was that we were insubordinate,” Monterroso said.

She told the doctor she didn’t want to talk about her tone. She wanted to talk about her health care. She was worried about possible blood clots in her leg and she asked for a CT scan.

“Well, you know, the CT scan is radiation right next to your breast tissue. Do you want to get breast cancer?” Monterroso recalled the doctor saying to her. “I only feel comfortable giving you that test if you say that you’re fine getting breast cancer.”

Monterroso thought to herself, “Swallow it up, Karla. You need to be well.” And so she said to the doctor: “I’m fine getting breast cancer.”

He never ordered the test.

Monterroso asked for a different doctor, for a hospital advocate. No and no, she was told. She began to worry about her safety. She wanted to get out of there. Her friends, all calling every medical professional they knew to confirm that this treatment was not right, came to pick her up and drove her to the University of California-San Francisco. The team there gave her an EKG, a chest X-ray and a CT scan.

“One of the nurses came in and she was like, ‘I heard about your ordeal. I just want you to know that I believe you. And we are not going to let you go until we know that you are safe to go,’” Monterroso said. “And I started bawling. Because that’s all you want is to be believed. You spend so much of the process not believing yourself, and then to not be believed when you go in? It’s really hard to be questioned in that way.”

Alameda Health System, which operates Alameda Hospital, declined to comment on the specifics of Monterroso’s case, but said in a statement that it is “deeply committed to equity in access to health care” and “providing culturally-sensitive care for all we serve.” After Monterroso filed a grievance with the hospital, management invited her to come talk to their staff and residents, but she declined.

She believes her experience is an example of why people of color are faring so badly in the pandemic.

“Because when we go and seek care, if we are advocating for ourselves, we can be treated as insubordinate,” she said. “And if we are not advocating for ourselves, we can be treated as invisible.”

Unconscious Bias in Health Care

Experts say this happens routinely, and regardless of a doctor’s intentions or race. Monterroso’s doctor was not white, for example.

Research shows that every doctor, every human being, has biases they’re not aware of, said Dr. René Salazar, assistant dean for diversity at the University of Texas-Austin medical school.

“Do I question a white man in a suit who’s coming in looking like he’s a professional when he asks for pain meds versus a Black man?” Salazar said, noting one of his own possible biases.

Unconscious bias most often surfaces in high-stress environments, like emergency rooms — where doctors are under tremendous pressure and have to make quick, high-stakes decisions. Add in a deadly pandemic, in which the science is changing by the day, and things can spiral.

“There’s just so much uncertainty,” he said. “When there is this uncertainty, there always is a level of opportunity for bias to make its way in and have an impact.”

Salazar used to teach at UCSF, where he helped develop unconscious-bias training for medical and pharmacy students. Although dozens of medical schools are picking up the training, he said, it’s not as commonly performed in hospitals. Even when a negative patient encounter like Monterroso’s is addressed, the intervention is usually weak.

“How do I tell my clinician, ‘Well, the patient thinks you’re racist?’” Salazar said. “It’s a hard conversation: ‘I gotta be careful, I don’t want to say the race word because I’m going to push some buttons here.’ So it just starts to become really complicated.”

A Data-Based Approach

Dr. Ronald Copeland said he remembers doctors also resisting these conversations in the early days of his training. Suggestions for workshops in cultural sensitivity or unconscious bias were met with a backlash.

“It was viewed almost from a punishment standpoint. ‘Doc, your patients of this persuasion don’t like you and you’ve got to do something about it.’ It’s like, ‘You’re a bad doctor, and so your punishment is you have to go get training,” said Copeland, who is chief of equity, inclusion and diversity at the Kaiser Permanente health system. (KHN is an editorially independent program of KFF, which is not affiliated with Kaiser Permanente.)

Now, KP’s approach is rooted in data from patient surveys that ask if a person felt respected, if the communication was good and if they were satisfied with the experience.

KP then breaks this data down by demographics, to see if a doctor may get good scores on respect and empathy from white patients, but not Black patients.

“If you see a pattern evolving around a certain group and it’s a persistent pattern, then that tells you there’s something that from a cultural, from an ethnicity, from a gender, something that group has in common, that you’re not addressing,” Copeland said. “Then the real work starts.”

When doctors are presented with the data from their patients and the science on unconscious bias, they’re less likely to resist it or deny it, Copeland said. At his health system, they’ve reframed the goal of training around delivering better quality care and getting better patient outcomes, so doctors want to do it.

“Folks don’t flinch about it,” he said. “They’re eager to learn more about it, particularly about how you mitigate it.”

Still Unwell

It’s been nearly six months since Monterroso first got sick, and she’s still not feeling well.

Her heart rate continues to spike and doctors told her she may need gallbladder surgery to address the gallstones she developed as a result of COVID-related dehydration. She decided recently to leave the Bay Area and move to Los Angeles so she could be closer to her family for the long recovery.

She declined Alameda Hospital’s invitation to speak to their staff about her experience, concluding it wasn’t her responsibility to fix the system. But she wants the broader health care system to take responsibility for the bias perpetuated in hospitals and clinics.

She acknowledges that Alameda Hospital is public, and it doesn’t have the kind of resources that KP and UCSF do. A recent audit warned that the Alameda Health System was on the brink of insolvency. But Monterroso is the CEO of Code2040, a racial equity nonprofit in the tech sector and even for her, she said, it took an army of support for her to be heard.

“Ninety percent of the people that are going to come through that hospital are not going to have what I have to fight that,” she said. “And if I don’t say what’s happening, then people with much less resources are going to come into this experience, and they’re going to die.”

This story is part of a partnership that includes KQED, NPR and KHN.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.


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Health Care Groups Dive Into Property Tax Ballot Fight, Eyeing Public Health Money

SACRAMENTO — A November ballot initiative to raise property taxes on big-business owners in California is drawing unconventional political support from health care power players and public health leaders.

They see Proposition 15 as a potential savior for chronically underfunded local health departments struggling to respond to the worst public health crisis in more than a century. The initiative would change California’s property tax system to tax some commercial properties higher than residential properties, which backers say could generate billions to help local governments pay for critical public health infrastructure and staffing.

Without such additional state or federal funding, local governments could be forced to make deeper budget cuts in health and other departments next year as the COVID-19 pandemic continues to strain city and county finances.

“When you’re talking about health care, you’re talking about money,” said Anthony Wright, executive director of Health Access California, a Sacramento-based consumer advocacy group. “This is the major revenue measure on the ballot this year, and it’s an opportunity to fund public health at the place where the main responsibility for public health lies — at the county level.”

At least that’s how health care advocates are casting the tax hike. But there’s no guarantee that if the measure passes counties would use new revenue to address COVID-19 or other health care needs. And some rural counties fear they would lose money if the ballot measure passes, which could undercut public health efforts.

Support within the health care and local government worlds is not unanimous. The powerful California Hospital Association opposes the measure because it would result in higher taxes on private and investor-owned hospitals, said spokesperson Jan Emerson-Shea. Nonprofit hospitals, including those run by Sutter Health, Kaiser Permanente and Dignity Health, are exempt from paying property taxes despite their regular high revenue. They would remain exempt under the initiative. (KHN, which produces California Healthline, is not affiliated with Kaiser Permanente.)

“This new tax will mean millions of dollars will be taken away from patient care, in perpetuity,” Emerson-Shea said.

Proposition 15 would amend California’s landmark 1978 property tax initiative, Proposition 13, which capped commercial and residential property tax rates at 1% of assessed value at the time of purchase, and limited annual increases thereafter to 2%. The drop in property taxes as a result of the initiative decimated a major revenue source for public schools and social welfare programs, leaving many underfunded.

Voters are now being asked to allow higher taxes for business owners with commercial holdings valued at more than $3 million. If passed, the measure could generate up to $11.5 billion a year, according to the nonpartisan state Legislative Analyst’s Office. It would not apply to residential properties.

Forty percent of annual revenue would be distributed to K-12 schools and community colleges, with 60% sent to cities and counties. Nothing in the measure would require new local revenue to be spent on health care, but supporters say it’s their best hope after losing $134 million in state public health money this year as one-time funding for specific programs expired. At the same time, slammed by a projected $54 billion deficit, Gov. Gavin Newsom and state lawmakers declined this year to increase funding for local health departments to combat COVID-19 and rebuild public health infrastructure.

Sponsors of Proposition 15, including the California Teachers Association and the Service Employees International Union California, argue it’s an overdue change that would tax wealthier enterprises in exchange for funding vital school and health care programs. They point out that the initiative, supported by Newsom and Democratic presidential nominee Joe Biden, would require schools and local governments to disclose all new revenue they receive and how money is spent.

If passed, money from the measure would begin flowing to schools and counties in 2022 at the earliest.

Opponents of the measure, including the California Chamber of Commerce, the California Republican Party and the Howard Jarvis Taxpayers Association, say hiking taxes on commercial property owners would harm struggling businesses hit hard by COVID-related closures.

“This is being pushed as a panacea cure-all, but at the end of the day, there is no accountability for where these funds go,” said Michael Bustamante, a spokesperson for the “No on Prop 15” campaign. “There are, without question, an infinite number of needs, but there is no specificity with what it can or can’t be spent on.”

Kat DeBurgh, executive director of the Health Officers Association of California, which represents the state’s 61 local health officers and has not taken a position on the initiative, said ongoing, unrestricted revenue could actually benefit counties by allowing them to spearhead public health programs that address local needs.

At present, counties are limited in what they can do with their public health dollars, she said. Most additional funding in recent years has largely been earmarked for specific programs or diseases, such as hepatitis C and HIV, and counties are not allowed to spend it on their COVID-19 response or other public health activities.

“Maybe your community’s highest priority is not something easily funded by one of these grants. Many rural areas in our state don’t have access to clean drinking water, for example,” DeBurgh said. “And our greatest demand — more public health workers — can’t be funded with grants or one-time money.”

Health care leaders also argue the initiative could help support community clinics and public hospitals that provide care for uninsured people, who have also suffered financially during the pandemic.

“What we’re really trying to avoid is having to balance the budget on the backs of people who need services,” said Jodi Hicks, president and CEO of Planned Parenthood Affiliates of California. “Our public health system has clear inequities that we need to address, and additional funding can help fill in the gaps at the county level.”

Hicks said Planned Parenthood, which provides sex education in California public schools, is supporting the initiative not only to improve public health, but also because she worries programs like sex education will be on the chopping block as the state experiences unprecedented job and economic losses.

“Those types of programs are the first to get cut when there’s not enough funding,” she said.

Small, rural counties could also lose funding, county assessors said.

While the initiative would likely raise taxes on large commercial property owners who have seen their land and property appreciate in value over the years, it would eliminate property taxes for other business assets, such as machinery and equipment, for the first $500,000 in value.

Counties that haven’t seen land values climb as high as those in coastal regions like the Bay Area may not collect more property taxes while also losing revenue from the tax cut on other business assets.

Chuck Leonhardt, the elected assessor for rural Plumas County, projects that his county could be one of the losers.

“This would take $90 million in assessed value from our tax roll at the beginning, and then I’d have to reassess 2,000 commercial properties,” he said. “Many of us rural counties don’t feel we’ll benefit from doing these reappraisals and my expectation is we could lose some money.”

Even among supporters in public health, some fear that any potential windfall for counties would be allocated based on the whims of local politics.

“Even though I support it, I am skeptical that this money will go to the public health programs and basic infrastructure we so desperately need because public health has no constituency,” said Bruce Pomer, a public health expert and chief lobbyist for the California Association of Public Health Laboratory Directors.

He pointed to Sacramento County, where the sheriff’s department received a larger share of the $181 million in federal COVID-19 relief money than the county public health department.

“I’m worried we’ll see the same thing we saw with Sacramento County,” Pomer said.

This KHN story first published on California Healthline, a service of the California Health Care Foundation.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.


This story can be republished for free (details).

KHN on the Air This Week

California Healthline correspondent Angela Hart discussed how the coronavirus pandemic has derailed California’s efforts to deal with homelessness on KPBS “Midday Edition” on Oct. 8.

KHN Midwest correspondent Lauren Weber discussed the difference between D.O.s and M.D.s with Newsy’s “Morning Rush” on Tuesday.

KHN correspondent Anna Almendrala discussed how L.A. County’s enforcement of workplace coronavirus protocols has cut COVID-19 deaths with KPCC’s “Take Two” on Tuesday.

KHN senior correspondent Sarah Jane Tribble discussed rural hospitals and KHN’s “Where It Hurts” podcast with Illinois Public Media’s “The 21st” on Oct. 5 and “Tradeoffs” on Oct. 8.

KHN chief Washington correspondent Julie Rovner joined C-SPAN’s “Washington Journal” on Tuesday to discuss the Affordable Care Act case before the Supreme Court next month and what else to expect in the realm of health care after the election.

KHN freelancer Priscilla Blossom discussed Halloween safety tips with KUNC’s “Colorado Edition” on Tuesday.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.


This story can be republished for free (details).

COVID Crackdowns at Work Have Saved Black and Latino Lives, LA Officials Say

Los Angeles County officials attribute a dramatic decline in COVID-19 death and case rates among Blacks and Latinos over the past two months to aggressive workplace health enforcement and the opening of tip lines to report violations.

Now, officials intend to cement those gains by creating workplace councils among employees trained to look for COVID-19 prevention violations and correct or report them — without fear of being fired or punished.

Cal/OSHA, the state’s workplace safety and health authority, is overwhelmed with complaints and tips about COVID-19 violations, and the county’s health investigators — there were officially 346 of them as of last Friday — can’t possibly keep tabs on all of Los Angeles’ more than 240,000 businesses, labor advocates say.

The councils could help keep Los Angeles from backsliding on its progress in mitigating cases and racial disparities in the fall as more businesses are likely to reopen, said Tia Koonse, a researcher with the UCLA Labor Center and co-author of an assessment of the workplace council proposal. The L.A. County Board of Supervisors is expected to approve an ordinance this month requiring businesses to permit employees to form the councils, which would troubleshoot compliance issues and report to the health department when necessary.

Critics, including many business leaders, say the measure will create more red tape at the worst possible time for the economy. But labor groups and some businesses say it is crucial to fighting the pandemic. Workers around the country have been sacked or reprimanded for complaining about COVID-related safety violations, and laws protecting them are spotty.

“Workers have a right to be in a safe space and shouldn’t face any retaliation” for noting poor practices, said Barbara Ferrer, director of the L.A. County Public Health Department. Low-wage workers have been “tremendously disadvantaged” by having to work outside the home in contact with other people, often without sufficient protection, she said.

During the upsurge of COVID cases that followed Memorial Day weekend family gatherings and business openings, Latinos in Los Angeles were dying at a rate more than four times higher than that of whites, while Blacks were twice as likely as whites to die of the disease. Two months later, death rates among Blacks and Latinos had fallen by more than half and were approaching the rate for whites, according to age-adjusted data from the county health department.

While four times as many Latinos as whites were reported COVID-positive in late July, the Latino case rates were only 64% higher by mid-September. The positivity rate among Blacks was 60% higher than that of whites in late July, but the disparity had waned by mid-September.

Experts can’t be certain that any one policy is responsible for the decline in deaths among Blacks and Latinos in Los Angeles — and state and county rates have declined for the entire population in recent weeks. But Ferrer attributed the progress to her department’s focus on workplace enforcement of health orders, which include rules about physical distancing, providing face coverings for workers and requiring face coverings for customers.

“If you’re in violation, at this point we can either issue citations, or there are cases where we just close the place down because the violations are egregious,” she said.

The sharp racial disparities that characterized the pandemic from the beginning are under even more scrutiny now that California has become the first state to make “health equity” a factor in its decisions to allow expanded reopening.

Large counties may not advance toward full reopening until their most disadvantaged neighborhoods, and not just the county as a whole, meet or are lower than the targeted levels of disease. The criteria prod local governments to invest more in testing, contact tracing and education in poor neighborhoods with high levels of the disease.

Ferrer’s focus on workplaces crystallized during a crackdown on Los Angeles Apparel, a clothing factory that had pivoted to face mask manufacturing during the pandemic. Despite the ready inventory of masks, an outbreak at the factory resulted in at least 300 cases — and four deaths.

The health department, acting on a tip from community health centers flooded with sick Los Angeles Apparel workers, shut down the factory on June 27. That action highlighted the need to bring the government and labor unions together to fight the pandemic, said Jim Mangia, CEO of St. John’s Well Child & Family Center, a chain of community health centers in South L.A.

“At St. John’s, almost all of our patients are the working poor,” Mangia said. “They were getting infected at work and bringing it home to their families, and I think intervening at the workplace is what really made all the difference.”

Early in the pandemic, Ferrer had also set up an anonymous complaint line for employees who want to report workplace violations. It gets about 2,000 calls a week, she said. As of Oct. 10, the department’s website lists 132 workplaces that have had three or more confirmed COVID-19 cases, with a total of 2,191 positives. Another table dated Oct. 7 lists 124 citations — mostly to gyms and places of worship — for failing to comply with a health officer order.

“Fortunately, we’re not like Cal/OSHA, in the sense that it doesn’t take us months to complete an investigation,” Ferrer said. “We’re able to move more swiftly under the health officer orders to actually make sure that we’re protecting workers.”

Public health councils are the next phase in Ferrer’s plan to keep workers safe. The plan stemmed from the response of Overhill Farms, a frozen-food factory in Vernon, California, after an outbreak of more than 20 cases and one death. The factory and its temporary job agency were hit with more than $200,000 in proposed penalties from Cal/OSHA in September, but before the fines landed, the factory leadership was already responding by beginning to hold meetings with workers to improve safety there.

“They found that the workers helped them bring down infection rates and helped solve problems,” said Roxana Tynan, executive director of the Los Angeles Alliance for a New Economy, a worker advocacy organization.

While it’s not exactly a feel-good story about corporate beneficence, the turnaround at Overhill Farms added credence to the benefits of workplace councils, said Koonse of UCLA.

No company would have to spend more than 0.44% of its payroll cost on the health councils, she estimated.

Still, the idea has gotten a mixed reception from businesses. In an Aug. 24 statement, CEO Tracy Hernandez of the L.A. County Business Federation wrote that the proposal would add “burdensome and convoluted programs that will further hinder an employer’s ability to meet demands, get back on their feet, and adequately serve their employees and customers.”

But Jim Amen, president of the eight-store Super A Foods grocery chain, said businesses should welcome the councils as a way to keep lines of communication open. Such practices have kept infection rates low at his stores, even without a mandate, Amen said.

“All I know is, for Super A, our employees are heavily involved in everything we do,” Amen said.

Labor groups see the councils as a crucial way for workers to raise concerns without fear of retaliation.

“In low-wage industries like the garment industry, workers coming together gets them fired,” said Marissa Nuncio, director of the Garment Worker Center, a nonprofit that mainly serves immigrants from Mexico and Central America.

While disparities are narrowing in L.A. County, some shops are still unsafe and potential whistleblowers aren’t confident their reports to the county’s tip line are being acted on, she said.

“We continue to get calls from our members who are sick, have COVID and are hospitalized,” Nuncio said. “And the most obvious location for them to have been infected is in their workplace, because so many precautions are not being taken.”

KHN data reporter Hannah Recht contributed to this article.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.


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Limbix digital therapeutic for adolescent mental health finds niche amid Covid-19 pandemic

The Silicon Valley startup plans to start its registration-directed study of Limbix Spark in the earlier part of next year and – if successful – would anticipate FDA clearance in early 2022.

Pandemic Erects Barriers for Prized Bloc of Voters in Nursing Homes, Senior Facilities

The convergence of the coronavirus pandemic and election season has complicated this year’s voting for residents of nursing homes, assisted living facilities and other long-term care centers.

Many seniors who need help to get or fill out their ballots may be stymied by shifting rules about family visits. Voting procedures — whether in person or by mail — are under increased scrutiny, adding to the confusion. Facilities that used to host voting precincts likely won’t do so this year because of concerns about the spread of COVID-19.

“We’re basically not allowed to go out into the public right now, we’re more vulnerable, and our immune systems are compromised anyway,” said Janice Phillips, a 14-year resident of Village Square Healthcare Center, a skilled nursing facility in San Marcos, California. “We’re basically locked in.”

Phillips, 75, who has rheumatoid arthritis, has voted by absentee ballot for years without problems. This year she is encouraging her fellow residents to vote by mail as well. She works with the facility’s activities staff, going resident by resident, to make sure folks are registered. As president of the resident council, Phillips has also raised the issue at community meetings.

Older Americans are a consistent voting bloc courted by both parties.

According to AARP, 71% of Americans 65 and older voted in the 2016 presidential election, compared with 46% of people 18-29. “For many older adults, it’s a point of pride for them that they’ve voted in every election since they were 18,” said Leza Coleman, the executive director of California’s Long-Term Care Ombudsman Association.

But hardly anyone has been allowed inside skilled nursing facilities since the start of the pandemic, except for staff members and the occasional state health official, or family members in certain circumstances. In California and beyond, facilities are beginning to open up in counties with low transmission rates, since federal rules changed in September to allow for more lenient visiting policies.

At the same time, outbreaks continue to plague some senior facilities, despite improved testing of staff and other safety measures. On Wednesday, Santa Cruz County health officials reported a major outbreak at the Watsonville Post-Acute Center, which has infected 46 residents, killing nine of them, and infecting 15 staff members.

California officials are pressing nursing homes and senior centers to give residents who want to vote the opportunity. The Department of Public Health on Oct. 5 sent a letter to all those facilities, explaining they have an obligation to inform and assist residents with voting, including what actions are permissible for staffers to undertake in helping voters. It also includes advice about maintaining a safe environment through the election by limiting nonessential visitors, properly using protective gear such as gloves and handling ballots as little as possible.

In years past, civic groups such as the League of Women Voters would stop by to give presentations on what’s on the ballot. Candidates for local office would hit nursing homes to make pitches. “In the context of a pandemic, we just can’t do it this year,” said Michelle Bishop, voter access and engagement manager with the National Disability Rights Network.

Before the pandemic, nursing homes and assisted living facilities also often served as polling places. Residents could easily access voting booths, often set up in a lobby or community room. That was especially important because nursing homes are likely to be accessible to people with mobility problems, Bishop said.

Otherwise, facilities would often organize bus trips and outings to polling places.

In California, the last day to register to vote online or by mail is Oct. 19, though voters can register in person up to and including Election Day. All registered voters will receive a ballot in the mail, and those postmarked by Nov. 3 will still be counted in California for 17 days after the election. Advocates say it’s important for newer residents at skilled nursing facilities to make sure they’ve registered at their new address or have plans to get their ballot delivered to them from their former homes.

Other states are also sending ballots to all registered voters by mail this year on various time frames. All states permit seniors or people who have trouble reaching polling stations to request an absentee ballot.

Once they have a ballot in hand, some older adults need help from family or staff at their facilities to complete it correctly and send it back to election officials. The federal directive to relax visiting rules could ease some of that pressure, but the situation varies by facility. For people whose relatives cannot help them, it may fall to staff members to set up calls and video chats between residents and their families, or provide the assistance to residents themselves.

Some states don’t allow nursing home staffers to help with ballots to avoid influencing votes. Even if they can assist, employees may be stretched too thin to help. In a year when nursing home staff members are spending an extra hour each day putting on protective gear, there isn’t always extra time to make sure every resident is registered and voting, said Dr. Karl Steinberg, chief medical officer for Mariner Health Central, a nursing home management company in California.

“There’s a perennial workforce shortage in nursing homes and it’s been exacerbated by this” pandemic, Steinberg said. “This year with all the chaos, there may be less staff time available to help people with voting.”

Tracy Greene Mintz, whose business, Senior Care Training, trains senior care workers, is responsible for staffing at 100 nursing homes in California. She said she started ringing alarm bells about voting rights in August.

“Elected officials do not care about nursing homes, period,” Greene Mintz said. “They assume residents don’t vote and don’t make contributions.”

She asked the California Department of Public Health, which surveys skilled nursing facilities every six weeks about COVID-19 infection control, to add a question on how facilities were planning for elections. The department declined.

So she set up webinars with facility administrators and the Los Angeles County Registrar-Recorder/County Clerk to go over information on how to submit and track absentee ballots.

She has also urged state officials to provide a statewide plan that facilities could use as a blueprint. She wrote one herself that was emailed out by a trade group, the California Association of Health Facilities.

Still, California is in better shape than some other states, said Raúl Macías, a lawyer with the Democracy Program at the Brennan Center for Justice, a law and public policy institute. Elsewhere, residents may have to apply for an absentee ballot, and sometimes must provide a reason they can’t vote in person.

California also has the Voter Bill of Rights, which allows individuals to designate someone to help them fill out and drop off their ballot. In some states, such as North Carolina, assistance can come only from designated bipartisan voting assistance teams, which may be harder to recruit during a pandemic, Macías said.

No matter the state, state and county elections officials and facility administrators should draft voting plans, said Bishop, of the Disabilities Rights Network. It will help staff know the proper way to assist residents without influencing their votes, and residents know their voting rights.

“There is a bit of a gray area on whose responsibility this is,” Bishop said. “It’s one of the years when we start asking ‘Whose responsibility is it?’ Who cares? We have to get it done.”

If they can’t get access to ballots or need help, California residents can contact the state’s long-term care ombudsman program, which can investigate complaints, help them resolve the issue and take the problem to the Department of Public Health if it can’t be fixed.

This KHN story first published on California Healthline, a service of the California Health Care Foundation.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.


This story can be republished for free (details).

CRISPR gene-editing discoverers awarded Nobel Prize in chemistry

The prize went to Jennifer Doudna of the University of California Berkeley and Emmanuelle Charpentier of the Max Planck Institute. Charpentier published her research on the biology behind the technology in 2011 and collaborated with Doudna. The two discovered it was possible to control the mechanism.

Hard Lives Made Harder by COVID: Homeless Endure a ‘Slow-Moving Train Wreck’

CALEXICO, Calif. — The message wasn’t lost on Daniel Gonzalez.

Early in the pandemic, one of the first things Imperial County did to ward off the virus was close the public bathrooms and, later, public cooling centers. In this sprawling Southern California desert, where summer brings blistering triple-digit heat, that lack of access could amount to a death sentence for people without shelter.

People like Gonzalez, homeless the past two years, were simply not a priority.

Months into the coronavirus shutdown, Gonzalez, 47, felt lonely. Calexico’s quiet downtown had emptied out. July highs were topping 110, and it was uncomfortable wearing a mask in the swelter. But not having a place to rinse off or wash up, that was just a hazard.

Standing outside a closed restroom in Calexico’s Border Friendship Park, looking out over the complex of metal bars and security equipment that marks the U.S.-Mexico border, he waited for dinner. Every night at 7:30 p.m., volunteers assembled at the park to serve a hot meal to anyone in need. A few weeks before, pressured by the organizers, the county started dropping off hand-washing stations right before the meal, only to whisk them away as soon as it was served.

Gonzalez lined up. At least it was something.

This was supposed to be the year that California finally did something about its epidemic of homelessness. On February 19, Gov. Gavin Newsom stood before lawmakers in the state Capitol, and delivered an unprecedented State of the State address devoted entirely to the homelessness crisis. California is home to one-quarter of the nation’s homeless population, a grim distinction painfully visible not only on city sidewalks, but also along the state’s freeways and farm levees, in its urban parks and suburban strip malls.

Past administrations had mostly ignored the problem, Newsom said, but he’d be different. “It’s a disgrace that the richest state in the richest nation — succeeding across so many sectors — is falling so far behind to properly house, heal and humanely treat so many of its own people,” he told the crowd.

But even as Newsom spoke, a different epidemic was advancing silently across the state. Exactly one month later, he would order a far-reaching statewide shutdown, asking every person in California not working in an essential industry to shelter at home in an effort to stave off COVID-19.

It was a complicated ask for the more than 150,000 Californians without a home.

For two weeks in March, Newsom’s top homelessness adviser, Jason Elliott, gathered with academics, service providers and county representatives at the emergency operations center just outside Sacramento to confront the menace that COVID-19 presented for tens of thousands of people living outside, often without access to clean water or basic hygiene. They pored over data showing how California’s homeless population had gotten larger, older and sicker in recent years. More than 40% of homeless Californians are age 65 or older or have underlying health conditions such as heart disease, according to the state’s internal estimates — factors that put them at greater risk of infection and death from COVID-19.

“When you take the attack rate and apply it to more than 100,000 unsheltered people,” Elliott said, “you very quickly find out that tens of thousands of homeless people are potentially susceptible to dying of coronavirus.”

They would need to act quickly. The crowded shelters, in short supply and usually considered safe ground for homeless people, suddenly posed a risk of transmission and would have to be thinned out. Instead, the very conditions lambasted as California’s shameful legacy of neglect — people subsisting in makeshift shanties and battered tents in parks and alleys and freeway underpasses — emerged as a safer alternative. The federal Centers for Disease Control and Prevention advised that people sleeping outside should be left alone; the encampments that pre-pandemic were routinely dismantled would be largely left in place, state officials decided.

But California still would need somewhere to house people considered most at risk: those who are older and have chronic health conditions. His plan wasn’t ready for prime time, but Newsom had been quietly pursuing an ambitious idea to buy up hotel and motel rooms to get people off the streets and into housing with supportive services. Now, with the declaration of a state and national emergency, it looked as if the Federal Emergency Management Agency might help pay to rent them temporarily. Newsom set a goal of 15,000 rooms.

In the months since, the state’s efforts to shelter homeless residents amid COVID-19 have played out in starkly contrasting storylines, bent and molded by local politics and resources. The state and federal governments have pledged millions for Project Roomkey, the state’s signature public health effort to move the most vulnerable into housing, with local counties expected to foot a quarter of the bill, as well as arrange meals, security and support services. For now, the counties taking part are fronting all the funding and say they have no idea when they’ll be reimbursed.

Still, most counties are participating and have procured nearly 16,500 rooms, according to state data, housing 22,300 people at various times since March. And homeless services providers, particularly in the state’s urban centers, say the unprecedented promise of funds has allowed them to work small miracles, linking desperate people to social services, health care and sometimes jobs.

But if the hotel rooms have been lifesaving for those lucky enough to get inside, providers across the state also were forceful in noting they are reaching just a sliver of those in need. In some cases, hotel owners have been unwilling to participate in Project Roomkey, while elsewhere city and county leaders have been hesitant or flat-out opposed.

In the meantime, the prolonged closure of shelters, churches and charities — along with the restaurants and retailers that offer access to electricity, water and food — has made life far more brutal for the tens of thousands of homeless people who weren’t selected for a room. In many counties, the life hacks and cobbled-together supports that homeless people rely on for survival have disintegrated. The squalid encampments have only gotten larger, fueled by COVID-spurred prison and jail releases and an unprecedented economic shutdown that community leaders say has landed scores more people on the streets.

If the state’s goal was to ward off a deadly COVID-19 outbreak among the homeless, it can claim success. Quick work to thin out the shelters has so far prevented widespread homeless deaths from the virus, authorities say.

But suffering comes in other forms. And interviews with dozens of homeless people, activists and local officials in 12 counties reveal a new magnitude of hardship and indignity for California’s homeless — and no easy answers ahead. What follows are a few of their stories.

Imperial County

“I’m one of the ones that it would probably kill me quick if I got that virus. I’m just staying away from everyone.” — Carl Wilkinson, 60, El Centro

Carl Wilkinson had been living for several weeks on a stretch of dirt beside a plowed field in sight of the lone indoor mall in El Centro. Wilkinson has chronic obstructive pulmonary disease and probably qualifies for a COVID hotel room through Project Roomkey. But he lost his ID a while back, so he hasn’t even tried applying.

Wilkinson has no idea how he’ll get an ID; money is tighter than usual because the recycling centers, where he takes the cans and bottles he collects, have closed. He’s become so desperate that he has resorted to panhandling, though that hasn’t gone well either, since so many people are staying inside. “It’s all-around tougher,” he said.

In May, the only men’s shelter in Imperial County closed temporarily after seven of the 20 men staying there caught the coronavirus. Though the shelter spaced beds farther apart and hung plastic dividers, men say they are afraid to return. The Salvation Army, which typically offers meals and a place to shower, has closed several times as staffers have fallen ill.

Instead, Wilkinson has been bathing in the dingy waters of the irrigation ditch next to his tent.

He knew about the federal guidelines saying people are safer from the virus if they can stay in one place. That had given him and two neighbors some hope there would be at least one silver lining to the pandemic: not getting rousted by cops. But the sheriff had shown up the day before saying they had to pack up. He wasn’t sure where they’d go. “They move us around like cattle in a pasture when it’s grazed,” Wilkinson said.

Imperial County, which hugs the border with Mexico, is a desert valley transformed into an agricultural hub nearly a century ago by water diverted from the Colorado River. The county of 181,000 people has an official homeless count of 1,527, including several hundred people who live off the grid in a remote area known as Slab City. Imperial has the highest death rate from COVID-19 of any county in California.

The largest city in the county is El Centro, home to one of the county’s two hospitals, and, until its church leaders were arrested last year, a ministry the FBI accused of luring homeless people into forced labor. Though the homeless population has steadily grown in the past few years, the county has little in the way of services for the homeless.

Sgt. James Thompson of the El Centro Police Department and Anna Garcia, a code enforcement officer, serve as the lone homeless outreach team for the city but are limited in what they can do. “A lot of people are confused about my role,” Thompson said. “We have not gotten into the homeless business; it’s an effort to curb the quality-of-life issues.” The pair know many of the people who are homeless in El Centro by name. They know who gets in trouble with the law, who has an issue with drug use and who has a mental illness.

Before COVID-19, Thompson had a daily routine. Get in at 8, hit the streets to talk to people who are homeless. He’d move them, make sure they weren’t getting into trouble, offer help when he could. Then in June, a colleague on the force got into a physical altercation with a homeless man, contracted COVID-19 and died. Thompson’s chief has been a lot more cautious with his officers in the weeks since.

Before their work was curbed, Thompson and Garcia helped several people fill out paperwork for a hotel room. None got in. “They met the criteria, they did do what they were supposed to do. But for whatever reason, there was no funding when it was time for them to be placed,” Garcia said. She feels it fits a pattern of services going to those who are easiest to help, whether it’s families or people who just can’t make rent. People who chronically live on the streets are not the easiest to help.

In August, months into the pandemic, county officials had 36 hotel rooms to work with, and had placed 274 homeless people in rooms or trailers at some point. Among them were 27 people who had COVID-19, although there were almost certainly more since the county isn’t routinely testing homeless groups.

And the El Centro officers say they worry there’s been a spike in other types of deaths. Three people died of overdoses over three days in the same dusty parking lot this summer, said Thompson. One was a young woman who’d experienced years of family abuse. They had been working to get her off the streets. He’d thought she was doing better.

Twenty minutes south, Maribel Padilla has organized the nightly feeding program in Border Friendship Park since 2015. She’s seen how the closing of fast-food restaurants and local businesses have made it harder for the people she helps. When the county closed the public bathrooms early in the pandemic, the folks her Brown Bag Coalition feeds no longer had a place to wash their hands.

It took a protracted battle and her loud mouth to change that, Padilla said. County officials told her they were concerned the virus would spread through hand-washing stations, a concern that makes Padilla spew profanities.

“They’ve been out there and exposed to so much shit,” Padilla said. Thousands go back-and-forth between Mexico and the U.S. each day; farmworkers cram into crowded buses to get to work; elderly and homeless residents travel together via public transportation.

“It’s going everywhere,” she fumed “and you’re worried about the soap dispenser?”

Alameda County

“Due to the number of deaths especially in the African American community, I have reasonable concern of the likelihood of harm and injury, possibly death.” — Andre Alberty, 53, Oakland, in a grievance filed with the California Department of Corrections and Rehabilitation

Andre Alberty was born and raised in Oakland, like his parents. Except for the years he spent in prison, it has always been home. When he returned to the neighborhood after an early release from San Quentin, a maximum-security prison in one of the wealthiest counties in the country, he was blown away by the number of RVs, tents and live-in cars lining the streets. It was a striking testament to housing costs that had soared out of reach. “There needs to be more affordable housing for people,” he said. “I never saw it like this.”

Alberty’s most recent prison stint was for burglary. He contracted COVID-19 in San Quentin after the California Department of Corrections and Rehabilitation moved dozens of inmates to the Bay Area prison from the California Institute for Men in Chino while it was in the midst of a major coronavirus outbreak. “What makes you think it’s not going to come in here when it went around the world in four months?” he remembers thinking. “You don’t think it’s going to jump a hallway?”

When Alberty, 53, and his cellmate developed symptoms, they knew that telling the guards would get them thrown into solitary, a place usually used as punishment that has been turned into a de facto medical isolation wing. And so, for several weeks in June and July, he was alone in “the hole,” with nothing but his thoughts and a virus to keep him company. By the end of September, COVID-19 had killed 28 inmates at San Quentin and infected 2,241 others, as well as 290 staff members.

It was demoralizing, to be infected and confined in solitary as a result. “Psychologically, that affects you,” Alberty said. “You feel like you ain’t nobody. Then how do you expect us to come out here and try to make ourselves somebody?”

That’s where his mind was in mid-July when his sentence was cut short, part of a massive early-release program Newsom ordered as COVID-19 carved a deadly swath through the state’s 35 prisons. Since then, Alberty has alternated between staying on a sick friend’s couch and in a friend’s RV, part of a large community of locals camping along Mandela Parkway in the heart of West Oakland because they’ve been priced out.

Prison releases are just one of the ways the homeless population has grown since the pandemic began. Californians have experienced unprecedented job loss, with the unemployment rate at 13%. A moratorium on evictions has helped millions stay in their homes, but the protections are loosely enforced and many tenants aren’t aware of their rights. Others were kicked out of the homes of family and friends who weren’t eager to have someone sleeping on the couch or floor in the middle of a pandemic.

“This is a slow-moving train wreck on a scale that we have never seen,” said Dr. Anthony Iton, senior vice president for healthy communities at the California Endowment.

To Alberty’s south, in East Oakland, Megan Ruskofsky-Zuccato, 25, was living under an overhead rail line in an old RV with her partner and a friend. Though she’d been homeless on and off, they had a place when the pandemic hit — until April, when, without explanation, the landlord asked them to move out. “I wish I would have known that Gov. Gavin Newsom put that [eviction moratorium] in effect, because then I would have never left,” she said.

Her partner got the RV as a trade for unpaid work as a welder at the start of the pandemic. She finds the whole situation humiliating. “When you live out here, people just look at you like you’re a bad person,” she said.

Jennifer Friedenbach is executive director of the Coalition on Homelessness in San Francisco, which advocates for housing and social justice in the city. On a daily basis, she sees both the opportunity — and nightmare — of the pandemic response. She is thrilled nearly 3,000 people in San Francisco had a hotel to sleep in at some point during the pandemic. And that San Francisco has put out more portable hand-washing stations and bathrooms.

The problem is, there’s not nearly enough to go around. Not enough rooms, not enough sanitation, not enough enforcement of tenant protections, not enough places to charge a phone. The number of tenants calling an anti-eviction hotline has doubled to 200 a week since 2019, and Friedenbach thinks more should have been done for rental assistance. Vehicles are often a first stop for people when they lose their homes, she said, and she’s seeing a lot more people sleeping in cars.

And while homeless people aren’t dying from COVID-19 in the numbers once feared, they are dying nonetheless. Deaths among the homeless tripled in San Francisco in the early months of the pandemic. In Los Angeles County, homeless deaths were up 27% over 2019.

Friedenbach worries that’s about to get worse. “Everything is coming to a screeching halt; the placement in hotels is halted,” she said. “Things are going to start getting really bad again in terms of a lot of people being out on the streets.”

Fresno County

“It’s hard times and we are suffering. My voices are getting stronger and stronger.” — Juan Gallardo, 53, Selma

Luciana Lopez sat in the back seat of a van rumbling across rutted roads in the rural outskirts southeast of Fresno. Her eyes scanned the dusty expanse of orchards and vineyards looking for the telltale hollows. Her attention was tuned to a bitter reality in this breadbasket-feeding-a-nation: the dozens of people living underground in the farm fields, subsisting in burrows hand-dug into the ground and irrigation levees — where they can hide from the sun, immigration authorities, violence, judgment.

Just days before, after local landowners complained, law enforcement had descended on this encampment, known casually as “The Hole,” and rousted an estimated 60 people from their dirt caves, many of them seniors. Outreach workers said maybe two landed in a shelter. The rest, a mix of addicts, itinerant farmhands and those with a run of bad luck, had dispersed to god-knows-where.

For Lopez, who works as an outreach worker for a homeless services provider that contracts with Fresno County, it was yet another COVID setback. Whatever trust had been built, whatever efforts underway to connect these men and women with ID cards, food stamps, disability payments, medical services — the chances of follow-through had largely evaporated.

Nearly five months into the pandemic, finding housing for Fresno County’s homeless seemed an insurmountable challenge. A January count pegged the homeless population of Fresno and Madera counties at more than 3,600, a 45% rise from 2019. Even in non-COVID times, this region of mega-farms and meatpacking plants had relatively little to offer in terms of government-sponsored shelters and supportive housing outside the city of Fresno. Instead, social workers looked to the relatively cheap housing stock as a solution, using federal and state funds to rent apartments for their clients.

But COVID has changed the real estate arithmetic. Local providers say large numbers of middle-income residents have lost jobs in the state’s months-long shutdown and are relocating to less expensive rentals. The units once available for $600 or $800 a month — and affordable for someone living on government assistance — are disappearing amid pitched demand.

Hotel and motel operators in Fresno County have not enthusiastically embraced Project Roomkey. Under the program, the county is sparingly using just one hotel to house homeless people infected with COVID-19. Drawing on other state and federal funds, the county managed to rent out two additional hotels, open to anyone who is homeless and vulnerable, in Selma and the nearby town of Sanger. As of late September, all 82 rooms were filled, with waiting lists stretching dozens long. Vacancies at four other converted sites, with about 350 beds, are quickly filled.

“It’s heartbreaking, we go through the breakdowns with them, we go through all the frustrations to get them ready for housing, just for the freaking system to spit them out and say there’s nothing for you,” Lopez said.

Her crew had resorted to basics, driving the farm roads southeast of the city to distribute water, snacks and masks to people living in ragtag encampments amid bountiful acres of fruit and nuts. They did so not knowing who might be carrying the virus, because there has been so little testing.

Juan Gallardo, 53, was on one of Lopez’s stops on a muggy morning in mid-July. Homeless most of his life, Gallardo had set up camp under suspended tarps on a dirt field just below the Golden State Highway near Selma. When the stores and churches shut down, he was cut off from the critical supports he’d developed for a life on the streets: odd jobs; gathering cans and bottles for recycling. There was nowhere close by to charge a phone or buy groceries, no access to clean water. He had taken to bathing in a nearby drainage canal, though it triggered rashes. For drinking water, he’d haul back a couple of pails for boiling.

“It’s hard to get food on your table right now, you have to hustle even more,” Gallardo said, as he rinsed clothes in a bucket. “It’s hard being in the crisis; you never know who can have [the virus]. But I try not to think about it, because the more you think about it, you start getting worried and then you stop doing what you’re supposed to be doing.”

Gallardo, who has untreated bipolar disorder and arthritis in both his knees, said he had lost access to medication and it was getting harder to cope. “My voices are getting stronger,” he said.

About a mile away, in downtown Selma, Delfina Vazquez said the pandemic has exposed a whole new level of desperation in her county. Vazquez heads Selma Community Outreach Ministries, a charity run out of a converted storefront that launched a daily food pantry at the start of the pandemic. As other local charities shuttered, she said, “We knew people would still need to eat. We looked to the Lord, who said, ‘Open your doors.’”

What started as a hot midday meal expanded into a food delivery service to families in a circle of farm towns, from Selma to Reedley to Parlier and Orange Cove. Vazquez said her ministry, funded primarily by donations and government contracts, is now providing 10,000 meals a month, mostly to homeless people and farmworker families struggling amid the shutdown. “People are becoming homeless because of COVID,” she said. “It’s absolutely growing.”

Through her ministry, Vazquez also oversees a Super 8 in Selma and Townhouse Motel in Sanger that have been converted to COVID shelters for the homeless. All 30 rooms at the Super 8 are full, she said, providing housing for 14 families, including 30 children. The waitlist stands at 60.

Like many advocates working with the homeless amid COVID-19, she worries about what will happen when the state and federal emergency funding wind down at year’s end. If the newly converted hotels close down, she said, “that’s 81 families out on the street.” And where would they go? The real estate offices “don’t want to flat-out say we don’t want to rent” to homeless people, she said, so instead have started demanding that applicants earn three times the rent to qualify.

Vazquez is already working on a Phase Two: talking with local officials about raising money to buy land in Selma where they could build a community of tiny homes. “Realistically, no one wants to rent to someone evicted,” she said. “There’s no second chance here. That’s where we’re at right now.”

Los Angeles

“He was really afraid of finding out what his true identity was, but we assured him he’s staying here no matter what. We’re not kicking him out.” — Dr. Coley King, speaking about Charles Poindexter, 71, Santa Monica

For people who did get indoors during the pandemic, the rooms have, in many cases, been life-changing.

Dr. Coley King, a physician with the Venice Family Clinic and director of homeless services, practices “street medicine,” bringing health care directly to people on the street. His patients have complex histories, and it’s rare that he gets clear signs their health is improving. But during the pandemic, it’s happened several times after patients have received housing. One patient with uncontrolled diabetes started having normal blood sugar readings. One of his “super users,” who makes regular visits to the emergency room, hadn’t been to a hospital in months. And multiple clients with addiction issues were getting sober.

Then there was, perhaps, the most dramatic case, involving the tall, sturdy man he’d seen on the streets of Santa Monica over the years. The man had previously confided in King that he wasn’t sure who he was, and the doctor noted signs of memory loss. In June, the street medicine team found him a space in a Santa Monica hotel. It took just a few days to find a diagnosis for his cognitive issues: untreated syphilis and a traumatic brain injury from a bus accident.

They also found his name: Charles Poindexter.

“He’s telling me, ‘I don’t know if I did something wrong out there, and I don’t know if I want to know who I am,’” King said. “It turned out good because he’s not wanted by the law anywhere, and we’re all good.”

These stories can be found across the state. In Fresno, Cammie Bethel, 37, could bring her six children back to live with her after getting into transitional housing. Cornelio Mendoza, 52, who in December became homeless for the first time, was able to get sober after getting a city-sanctioned tent in Santa Rosa. “Being here, I’m grateful,” he said.

Seeing the transformation that can happen when someone has a safe place to sleep makes it all the more tragic how limited resources are, advocates say.

Across the state, counties have marshaled thousands of rooms and safe camping sites for hundreds of tents. The state gave counties more than 1,300 trailers to isolate people infected with or exposed to COVID-19. Still, lack of interest from hotel owners and opposition from neighbors have blunted the program’s reach. That’s true also in Los Angeles, which set its own goal of renting 15,000 rooms and fell far short.

In L.A., rooms are not evenly distributed across the sprawling county. Less-affluent areas like South Los Angeles, a historically Black neighborhood that’s now predominantly Latino and experiencing high rates of COVID-19, have few hotels available. Whiter, wealthier cities like Santa Monica, meanwhile, have bolstered the county supply by renting hotels with their own budgets.

In Bakersfield, neighbors and a hospital pushed back on two different plans to rent motel rooms. Kern County, where Bakersfield is located, has not made available any new hotel rooms to the homeless during the pandemic.

And officials in liberal cities — including on Newsom’s home turf of San Francisco — say the governor must do more to persuade business owners and financiers to participate in housing the homeless.

“I’m surprised and honestly a bit disappointed that the state hasn’t been more forceful and proactive to secure the adequate number of hotel rooms,” said San Francisco Supervisor Matt Haney, whose district includes the Tenderloin, a neighborhood where hundreds of people sleep on sidewalks and in alleys. “I would like to see more leadership from the governor on some larger negotiated statewide solution with hotels and unions.”

The hotel rooms weren’t meant for everyone unsheltered, said Kim Johnson, director of the California Department of Social Services. For those who didn’t have mental and physical health conditions that put them at extreme risk, “the right environment wasn’t necessarily a hotel room,” she said.

Newsom said he is staying the course on his vow to make this the year California finally starts tackling its epidemic of homelessness. In some ways, the pandemic gave him a leg up — he would have been hard-pressed to find even temporary housing for the 22,300 people moved into hotels and motels in recent months.

But it’s also a short-term response to a long-term public health crisis. To battle homelessness, the state needs more housing.

Counties across the state say they are already winding down Project Roomkey. The state has launched a new program called “Project Homekey,” which will allocate an estimated $800 million in federal and state emergency funding to cities and counties to purchase hotels and motels, vacant apartment buildings and other structures, then convert them into supportive housing. So far the state has approved $450 million worth of projects in 34 jurisdictions, stretching from El Centro to Ukiah. If successful, they’d open more than 3,300 housing units — a valiant effort but a fraction of what experts say is needed.

Newsom has acknowledged the extraordinary task ahead but said solving homelessness in the age of COVID-19 remains his priority.

“We need a permanent response,” Newsom said at a recent news conference. “I can assure you, we are just winding up.”

This KHN story first published on California Healthline, a service of the California Health Care Foundation.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.


This story can be republished for free (details).

Distrusting Trump, States Plan to Vet COVID Vaccines Themselves. Bad Idea, Say Experts.

As trust in the Food and Drug Administration wavers, several states have vowed to conduct independent reviews of any COVID-19 vaccine the federal agency authorizes.

But top health experts say such vetting may be misguided, even if it reflects a well-founded lack of confidence in the Trump administration — especially now that the FDA has held firm with rules that make a risky preelection vaccine release highly unlikely.

At least six states and the District of Columbia have indicated they intend to review the scientific data for any vaccine approved to fight COVID-19, with some citing concern over political interference by President Donald Trump and his appointees. Officials in New York and California said they are convening expert panels expressly for that purpose.

“Frankly, I’m not going to trust the federal government’s opinion and I wouldn’t recommend [vaccines] to New Yorkers based on the federal government’s opinion,” New York Gov. Andrew Cuomo said last month.

“We want to make sure — despite the urge and interest in having a useful vaccine — that we do it with the utmost safety of Californians in mind,” Dr. Mark Ghaly, California’s health and human services secretary, said at a recent news conference.

The District of Columbia, Colorado, Michigan, Oregon and West Virginia also have said they’ll review vaccine data independently.

But scientists who study vaccine policy said such plans could backfire, confusing the public, eroding confidence in any eventual vaccine and undermining the best strategy to end the pandemic, which has sickened nearly 7.5 million Americans and killed more than 210,000.

“Do you really want a situation where Texas, Alabama and Arkansas are making drastically different vaccine policies than New York, California and Massachusetts?” asked Dr. Saad Omer, an epidemiologist who leads the Yale Institute for Global Health.

Separate state vaccine reviews would be unprecedented and disruptive, and a robust regulatory process already exists, said Michael Osterholm, an epidemiologist and director of the Center for Infectious Disease Research and Policy at the University of Minnesota.

“States should stay out of the vaccine review business,” Osterholm said. “I think the Food and Drug Administration is doing their job right now. Unless there’s something that changes that, I do believe that they will be able to go ahead.”

The administration has given reasons for states to worry. Trump has repeatedly signaled a desire for approval of a vaccine by the Nov. 3 election, arousing fears that he will steamroll the normal regulatory process.

The president wields “considerable power” over the FDA because it’s part of the executive branch of government, said Lawrence Gostin, faculty director of the O’Neill Institute for National and Global Health Law. The president nominates the FDA commissioner and can replace that official at any time.

Trump has already contradicted the advice of his own scientific advisers in order to promote unproven therapies to fight COVID-19. The FDA approved two treatments — hydroxychloroquine and convalescent plasma — without strong evidence of safety and efficacy after Trump pushed for the therapies to be widely available.

Late Monday, The New York Times reported that top White House officials planned to block FDA guidelines that would bolster requirements for emergency authorization of a COVID vaccine — because the new guidelines would almost certainly delay approval until after the election.

The White House’s actions undermine the agency, said Dr. Paul Offit, an infectious disease expert at Children’s Hospital of Philadelphia and a member of the FDA advisory committee on vaccines.

“Trump has perverted the FDA,” Offit said. “He has scared people into thinking that normal systems aren’t in place there anymore.”

But the FDA seems to be maintaining plans that would make it virtually impossible for a vaccine to be approved by Election Day.

Dr. Peter Marks, who heads the FDA division responsible for vaccine approval, has repeatedly said career scientists at the agency are working to ensure that political pressure isn’t a factor in any decision.

FDA reviewers are determined to “keep our hands over our ears to the noise that’s coming in from all sides and keep our eyes on the prize,” Marks said Monday in a JAMA webinar.

On Tuesday, the FDA pushed back against White House interference by publishing stricter guidance for vaccine developers on its website. The document instructs vaccine companies to follow patients for two months after their last shot in order to give researchers more time to detect serious side effects and ensure the vaccine works.

For now, supporters of the normal regulatory process are pinning their hopes on two advisory groups of respected scientists who will evaluate vaccines for safety and efficacy and send their recommendations to federal agencies.

The FDA’s advisory group, known as VRBPAC, will review data submitted by the pharmaceutical companies and the agency for any vaccine. The Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices, or ACIP, will weigh in on its use. Their recommendations aren’t binding, but the federal government has rarely contravened them.

Before jumping to independent reviews, states should allow ACIP and VRBPAC to do their jobs, said Dr. Marcus Plescia, chief medical officer of the Association of State and Territorial Health Officials. That’s the best defense against any political pressure, he said, and individual states likely wouldn’t have access to the data — or, perhaps, the expertise — to conduct their own reviews.

ACIP Chairman Dr. José Romero, who also is the chief medical officer for the Arkansas Department of Health, said the group has been meeting regularly since spring to discuss COVID vaccines and they’ve been able to proceed “in an unfettered fashion.”

“I have not felt pressured by the CDC, other government agencies or pharmaceutical companies to arrive at any particular recommendation,” he said.

Other safeguards are in place as well. Trump cannot simply override the FDA’s authority to approve drugs and vaccines, which comes from Congress.

“The president can influence the FDA, but it must be consistent with the FDA’s statutory mandate,” Gostin said. “The White House may not, for example, direct the agency to ignore science or use a lower scientific standard.”

Congress could sue the FDA for failing to follow its own standards, and a judge could issue a temporary restraining order blocking release of a COVID vaccine, Gostin said. Courts would require the FDA commissioner or health and human services secretary to have “valid, evidence-based reasons” for any decision.

“The commissioner or secretary may not act arbitrarily or according to political preferences alone,” Gostin said.

Individual states could not overrule the FDA’s authorization or approval of a vaccine, but they could wield their power in other ways. States distribute vaccines through contracts with the CDC, noted Dr. Kelly Moore, associate director of immunization education for the Immunization Action Coalition. They could say, “‘We will not place any orders until we’re sure,’” she said.

States probably could not prevent private companies, such as pharmacy chains, from distributing vaccines that are shipped directly to them. Pharmacies would likely sue any states that try to prevent them from distributing vaccines, Gostin said.

Although federal and state agencies play a crucial role in ensuring patient safety, they’re not the only entities looking out for patient interests, said Dr. Joshua Sharfstein, a former FDA deputy commissioner who is now a vice dean at the Johns Hopkins Bloomberg School of Public Health. Doctors and other medical providers won’t recommend a vaccine they don’t trust, he said.

“We have an entire health care system standing between politics and the patients,” Sharfstein said. “I think doctors are going to be very concerned if a vaccine is rushed.”

Even pharmaceutical companies that stand to profit from vaccines have a huge stake in protecting the integrity of the approval process. Nine rival vaccine makers took the unusual step last month of pledging not to release a COVID vaccine until it has been thoroughly tested for safety.

The bigger consideration, however, is how state-by-state vetting would affect consumer trust in a COVID vaccine — or any vaccine in the future, Plescia said. A recent KFF poll found 54% of Americans would not submit to a COVID vaccine authorized before Election Day.

“Are people going to mistrust the entire process?” he said. “We will get through COVID one way or another, but if we undermine confidence in public health, that would be a disaster.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.


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One School, Two Choices: A Study in Classroom vs. Distance Learning

Cozbi Mazariegos stays in shape these days by running room to room inside her Marin City apartment to answer questions from her kids, ages 7, 10 and 12. They’re all working at home on laptops issued by their school, Bayside Martin Luther King Jr. Academy.

Meanwhile, Shannon Bynum’s son, Kamari, 10, and daughter, Keyari, 8, who live nearby, are back on the Bayside MLK campus. Bynum had warned them, however, that if he heard they weren’t wearing masks, they’d have to learn remotely, too.

The two households, less than 3 miles apart, have found different answers to one of the most perplexing questions this fall: Should parents send their children back to school for classes during an ongoing pandemic or keep them at home?

At Bayside MLK, a K-8 school serving the ethnically and economically diverse community of Marin City, 103 children are attending class in person, including the Bynum children. The Mazariegos kids are among 12 learning remotely.

In March, the coronavirus consigned nearly all of the nation’s 55 million schoolchildren to home schooling. One by one, school districts across the country are weighing the risks of reopening. Some that have reopened have seen a spike in coronavirus cases among students who returned to class.

Bayside MLK was one of 15 Marin County schools that received waivers from the local public health department to reopen full time on Sept. 8, but officials gave parents the choice whether to send their children to campus or keep them home.

The start of classes was delayed for a week when one school employee contracted the virus, said Principal David Finnane. Once they started, the challenges mounted.

“This is the most mind-numbing time I’ve ever had as an educator,” said Finnane, who’s been a school principal for two decades.

“These are crazy days of temperature checks, telling third grade Jenny she entered the second grade gate at the wrong time, telling Xavier to use sanitizer on his elbow after he sneezes, reminding students not to touch this thing or that thing. It’s a job this school has never had to do and now we’re doing it every day, all day long.”

Health and safety protocols enacted by the school include staggered arrival times for students (via parent drop-offs), smaller classes, spaced-out desks, routine temperature and health checks, and an intensified cleaning schedule.

Mazariegos, 52, spent a difficult summer deciding whether to send Emily, 12, Ezekiel Jr., 10, and 7-year-old Evelyn back to class if and when school reopened in the fall.

But her husband, Ezekiel, a 42-year-old construction worker, had made up his mind. “He said, ‘Are you crazy? We can’t send our kids back to school without a vaccine,’” she recalled. “‘How do we know they’d be safe?’”

Mazariegos, who was a schoolteacher in her native Guatemala but now stays at home with her kids, has juggled the roles of teacher, tech consultant and even hall monitor in recent weeks.

School hadn’t been back in session for a week before her home Wi-Fi connection crashed. The two eldest kids could not connect to their Zoom instruction sessions, so Mazariegos called the school for help. To make sure they didn’t resort to computer games in the interim, she gave them textbooks to read.

“The phone was ringing, the kids were all calling my name from different rooms,” she said. “It was crazy.”

Single father Bynum, on the other hand, chose to send his two kids back to school.

“Kids learn from other kids, not just teachers,” said the 29-year-old real estate developer. “In school, they know what’s expected of them. It’s the best place for them to be.”

Finnane, the principal, had hoped all 115 students would return to classrooms. “Many kids doing distance learning just don’t have the same support network,” he said. “They might not have the resources, a quiet place to work, a supportive adult right there who can mentor and encourage them.”

And then there are the technical issues. Students who have stayed at home have experienced internet failures, Zoom glitches and computer bandwidth problems — “or when a teacher gives out the wrong Zoom link, all of which has already happened,” Finnane said.

A recent study by the Economic Policy Institute on the educational challenges posed by the pandemic found that remote-learning programs are effective only if students have consistent access to the internet and computers and if teachers receive targeted training and support for online instruction.

While researchers acknowledged the risk of virus infection is greater at school, they found that students who have not returned to the classroom are falling behind.

“Children’s academic performance is deteriorating during the pandemic, along with their progress on other developmental skills,” the study said.

When Bayside MLK resorted to remote teaching for the entire school in the spring, officials identified 41 students who were demonstrably falling behind, Finnane said. Standardized tests given to students this academic year will provide a report card on students’ success, he added.

Over the summer, Bayside MLK teachers received one day of training to perform online classes in addition to their at-school duties.

“A full day of online-learning training helps, but when it comes to the constant challenges of teaching, especially those with special needs, I’m not sure that’s sufficient,” said Emma García, who co-authored the Economic Policy Institute study.

Mazariegos knows this all too well. Her daughter Emily has comprehension issues that have kept her back a grade.

A quiet girl who loves animals and science, and who one day wants to become a veterinarian, the sixth grader relies on her mother to spend extra time reviewing lessons.

“She has to touch and feel things, to have a lesson demonstrated before she can best understand,” her mother said. “She can’t just sit in front of a computer reading some concept over and over and over.”

Mazariegos understands her daughter may fall another year behind but says she’ll take that chance. “If we lose her to COVID-19, that year is nothing,” she said. “This is a hard decision for any mother. But Emily is so afraid of the virus that sending her back to school would just be traumatizing.”

Bynum, whose fourth grade son, Kamari, suffers from attention deficit disorder, believes the classroom is the best place for the restless child. In March, when the school was closed at the start of the pandemic, Bynum got a taste of the demanding task of being a teacher.

“With two kids in two different grades asking me questions, I struggled to explain things,” he said. “It would have been easy for me to just tell them the answer, but the object of a good instructor is to teach them to find it themselves. And I had to learn that.”

Bynum has developed his own protocol. He requires his children to shower the moment they return from school, and they get regular lectures about hand-washing and common sense.

“If I even suspect they’re not wearing their masks, I’ll say, ‘OK, it’s back to the house and your laptop,’ and they’ll say, ‘Oh yeah, Dad, I’m wearing my mask.’”

Mazariegos remains comfortable with her decision, especially when she reads about all the COVID-19 outbreaks at schools and colleges.

Her kids aren’t so sure.

Second grader Evelyn, an outgoing girl, recently joined a Zoom lesson that included classmates she hadn’t seen in person for months.

“She cried,” her mother said. “She wanted to be back at school to see her friends.”

This KHN story first published on California Healthline, a service of the California Health Care Foundation.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.


This story can be republished for free (details).

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Campus Dorm Resident Assistants Adjust to a New Role: COVID Cop

Breaking up parties, confiscating booze and answering noise complaints — being a resident adviser has always required a willingness to be the “bad guy” and uphold university policy despite the protests of friends and peers.

Now there’s a new element to the job description: COVID cop.

The worst part of his job as a resident adviser and dormitory hall security manager is verifying residents’ ID cards in the evening and dealing with the mask policy, said Marco Maldonado. But the positions help him afford his annual $20,000 tuition at the University of Massachusetts-Amherst.

Almost every night, he said, at least one person tries to enter the building without a mask. While most will take advantage of the box of disposable masks at the security desk, “every once in a while, you’ll meet someone who’s like, ‘Oh, it’s all bulls—. Stop — I don’t want to hear it,’” said Maldonado, 20, a political science and legal studies double major.

And sometimes people get aggressive. “Pardon my French, but they could say, ‘Who the f— do you think you are? Get the f— out of here!’”

It can be frightening and even dangerous to enforce mask-wearing and social distancing. Public tantrums and physical assaults on employees enforcing COVID-19 policies prompted federal officials to issue guidance for retail workers on how to de-escalate situations and avoid violence.

It’s particularly tricky for students whose job involves monitoring their peers. Residential staff members, including security monitors and resident assistants, represent the front line of enforcement in dormitories.

Many say the