Only a Smokescreen? Big Tobacco Stands Down as Colorado and Oregon Hike Cigarette Taxes


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Big Tobacco did something unusual in Marlboro Country last fall: It stood aside while Colorado voters approved the state’s first tobacco tax hike in 16 years.

The industry, led by Altria Group, one of the world’s largest tobacco companies, has spent exorbitantly in the past to kill similar state ballot initiatives. In 2018, Altria’s lobbying arm spent more than $17 million to help defeat Montana’s tobacco tax ballot initiative. That same year, it spent around $6 million to help defeat South Dakota’s similar measure.

And four years ago, Altria was the leading funder in a successful $16 million campaign to quash Colorado’s previous proposed tobacco tax increase.

In November, by contrast, Altria didn’t spend a penny in opposition and Colorado voters overwhelmingly approved the tax with two-thirds support. Likewise, in Oregon, Big Tobacco stayed on the sidelines while a tax hike passed there.

The tax measures are major wins for anti-smoking advocates after a string of defeats but, in an example of how politics makes strange bedfellows, Colorado’s tax might not have been possible without Altria’s help. And, advocates said, the way those measures passed could provide a blueprint for states to follow in future elections.

In Colorado, Altria, the parent company of Marlboro cigarette maker Philip Morris, insisted that a minimum price be included in the proposal, according to The Colorado Sun, citing emails between political consultants and Gov. Jared Polis’ office. So while supporters see an increased tobacco tax as more revenue for the state, a disincentive for kids to smoke and a win for public health, the measure could also allow America’s premium tobacco companies to gain market share.

The Colorado measure will increase the total state-levied tax from 84 cents to eventually $2.64 per pack by 2027. The tax rate on vaping products, not currently taxed, will be 30% of the manufacturer’s list price in 2021, gradually increasing to 62% by 2027. The proposition also set the minimum price per pack of cigarettes at $7 as of Jan. 1 and that floor rises to $7.50 in 2024. The change could effectively help premium cigarette companies corner the market, since discount cigarettes would rise to at least $7.

Discount cigarette companies Liggett Group, Vector Tobacco and Xcaliber International — which funded opposition to the tax initiative, Proposition EE — tried to sue the state over the minimum tax provision, alleging “Philip Morris will reap huge benefits from the new legislation” and the changes will “destroy their ability to compete in Colorado.” In December, a federal judge rejected the company’s request for a preliminary injunction. A spokesperson for Liggett said the company plans to appeal.

“When it came to entities like Altria and other stakeholders that we engaged in the legislative process, I think that they saw the writing on the wall,” said Jake Williams, executive director of Healthier Colorado and one of the key organizers behind Proposition EE. “And it helped us get through the legislative process, not just with Democratic votes, but Republican votes to refer the measure to the ballot.”

Altria officials said in a statement that their tobacco companies oppose excise tax increases, but they did not say whether they had worked with Colorado lawmakers.

“Altria did not advocate for or against Proposition EE, and after evaluating the content and intent of this measure, Colorado voters decided to vote in favor of it, some aspects of which were focused on tobacco harm reduction and may help transition adult smokers to a non-combustible future,” the statement said.

Polis’ office did not respond to a request for comment. The Colorado Attorney General’s Office said it would not comment on matters under active litigation. State Democratic Sen. Dominick Moreno and Rep. Julie McCluskie, both state sponsors for the legislation, declined to comment for the same reason. Fellow Democrats Rep. Yadira Caraveo and Sen. Rhonda Fields, also state sponsors for the legislation, did not respond to requests for comment.

Colorado campaign finance records show Altria and Altria’s lobbying arm in 2020 contributed to funds that support both Democratic and Republican candidates in the state — a pattern playing out nationally.

Williams said Altria’s absence of public opposition wasn’t the only factor in the initiative’s success. The tax revenue will initially fund revenue lost during the covid-19 pandemic, then fund tobacco use prevention and eventually preschool education.

The American Lung Association, which supported the Colorado measure, said it believes tobacco taxes are among the most effective ways to reduce tobacco use, especially among youths, who are more sensitive to changes in price. The organization cites studies that found every 10% increase in the price of cigarettes reduces consumption by about 4% for adults and 7% for teens.

“Without tobacco industry opposition, it’s very popular among the public,” Thomas Carr, the association’s director of national policy, said of the tax increase. “We’ve long seen it in polling on the subject.”

There was no major industry opposition to the Oregon increase, either. Its tobacco tax increase — Measure 108 — also got a resounding two-thirds of support. But Oregon didn’t negotiate with Altria lobbyists or set a minimum price provision, according to Elisabeth Shepard, campaign manager for Yes for a Healthy Future.

“I don’t know what the [Colorado] deal was,” Shepard said. “All I know is that before it even made it to the ballot, Altria indicated that they were not going to oppose the measure and stuck with their word.”

While Shepard worried until Election Day whether Big Tobacco would swoop in with opposition in Oregon, it didn’t. She believes her campaign worked because the effort had early resources and money, the tax was targeted to fund the Oregon Health Plan (the state’s Medicaid), and her campaign’s coalition had 300 endorsers, including those in health and business communities.

“We had the left, we had the right, we had the far-right, we had the far-left,” Shepard said.

Her campaign paid its advisory committee members, including representatives from affected communities such as Indigenous Oregonian tribes. At least 30% of American Indian and Alaska Native adults in the state smoke cigarettes. Oregon’s measure increases tobacco taxes $2 per pack, from $1.33 to $3.33, as well as creates a new tax for e-cigarettes. The revenues will help fund an estimated $300 million for the state’s health plan.

Altria did not respond to a request for comment about Oregon tobacco taxes, but the company has previously said it opposed Oregon’s measure.

Shepard believes her campaign model could work in other states. Other anti-smoking advocates took note of the 2020 election.

“We certainly support establishing minimum prices for all tobacco products in conjunction with tobacco tax increases, as we know increasing the price of tobacco products is one of the most effective ways to reduce tobacco use,” said Cathy Callaway, director of state and local campaigns for the American Cancer Society Cancer Action Network.

It could just come down to a state’s voters and its politics, according to Mark Mickelson, a former Republican in South Dakota’s legislature. Mickelson was behind creating his state’s failed 2018 tobacco tax ballot initiative.

“We just got beat,” Mickelson said. The opposition “got ahead of us on the message. They had a lot more money and had just played on doubts that the [tax revenue] money would go to tech ed.”

The average state cigarette tax is $1.88 per pack, but it varies across the country — as high as $4.35 in New York but only 44 cents in North Dakota, where a 2016 ballot initiative to increase that to $2.20 was defeated.

Tax increases can translate into hundreds of millions of dollars in new revenue for states, said Richard Auxier, senior policy associate at the nonpartisan Urban-Brookings Tax Policy Center.

“It’s a little easier to pass a tax on someone else, which is often how this is seen — passing this tax on smokers, rather than passing it on all working people, [compared to] if you were to increase income tax or … a sales tax.”

But not all voters get a say.

In Kentucky, which isn’t a referendum state, Republican state Rep. Jerry Miller said there’s not a lot of sympathy for tobacco companies anymore.

“The agriculture community, which used to be on the same page with cigarette companies, are now always in opposition because the cigarette companies are always trying to tweak their formula to use cheaper tobacco,” he said.

Miller’s recent vaping tax bill failed in the state legislature, but he’s working on a new one.

“We don’t have that tradition or the mechanism that somebody collects 10,000 signatures and they get a referendum on a ballot,” he said. “That’s why things like this have to go through the legislature — and so it really just depends on the state [government].”

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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Black Women Find Healing (But Sometimes Racism, Too) in the Outdoors

It would be the last hike of the season, Jessica Newton had excitedly posted on her social media platforms. With mild weather forecast and Colorado’s breathtaking fall foliage as a backdrop, she was convinced an excursion at Beaver Ranch Park would be the quintessential way to close out months of warm-weather hikes with her “sister friends.”


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Still, when that Sunday morning in 2018 arrived, she was shocked when her usual crew of about 15 had mushroomed into about 70 Black women. There’s a first time for everything, she thought as they broke into smaller groups and headed toward the nature trail. What a sight they were, she recalled, as the women — in sneakers and hiking boots, a virtual sea of colorful headwraps, flowy braids and dreadlocks, poufy twists and long, flowy locks — trekked peacefully across the craggy terrain in the crisp mountain air.

It. Was. Perfect. Exactly what Newton had envisioned when in 2017 she founded Black Girls Hike to connect with other Black women who share her affinity for outdoor activities. She also wanted to recruit others who had yet to experience the serenity of nature, a pastime she fell for as a child attending an affluent, predominately white private school.

But their peaceful exploration of nature and casual chatter — about everything from food and family to hair care and child care — was abruptly interrupted, she said, by the ugly face of racism.

“We had the sheriff called on us, park rangers called on us,” recalled Newton, now 37, who owns a construction industry project development firm in Denver.

“This lady who was horseback riding was upset that we were hiking on her trail. She said that we’d spooked her horse,” she said of a woman in a group of white horseback riders they encountered. “It just didn’t make any sense. I felt like, it’s a horse and you have an entire mountain that you can trot through, run through, gallop through or whatever. She was just upset that we were in her space.”

Eventually, two Jefferson County sheriff’s deputies, with guns on their hips, approached, asking, “What’s going on here?” They had been contacted by rangers who’d received complaints about a large group of Black women being followed by camera drones in the park; the drones belonged to a national television news crew shooting a feature on the group. (The segment aired weeks later, but footage of the confrontation wasn’t included.)

“‘Move that mob!’” attendee Portia Prescott recalled one of the horseback riders barking.

“Why is it that a group of Black women hiking on a trail on a Sunday afternoon in Colorado is considered a ‘mob?’” Prescott asked.

A man soon arrived who identified himself as the husband of one of the white women on horseback and the manager of the park, according to the Jefferson County Sheriff’s Office incident report, and began arguing with the television producers in what one deputy described in the report as a “hostile” manner.

The leader of the horseback tour told the deputies that noise from the large group and the drones startled the horses and that when she complained to the news crew, they told her to deal with it herself, the report said. The news crew told deputies that the group members felt insulted by the horseback riders use of the term “mob.” The woman leading the horseback riders, identified in the incident report as Marie Elliott, said that she did not remember calling the group a mob, but she told the officers she “would have said the same thing if the group had been a large group of Girl Scouts.”

In the end, Newton and her fellow hikers were warned for failing to secure a permit for the group. Newton said she regrets putting members in a distressing — and potentially life-threatening — situation by unknowingly breaking a park rule. However, she suspects that a similarly sized hiking group of white women would not have been confronted so aggressively.

“You should be excited that we are bringing more people to use your parks,” added Newton. “Instead, we got slammed with [threats of] violations and ‘Who are you?’ and ‘Please, get your people and get out of here.’ It’s just crazy.”

Mike Taplin, spokesperson for the Jefferson County Sheriff’s Office, confirmed that no citations were issued. The deputies “positively engaged with everyone, with the goal of preserving the peace,” he said.

Newton said the “frustrating” incident has reminded her why her group, which she has revamped and renamed Vibe Tribe Adventures, is so needed in the white-dominated outdoor enthusiasts’ arena.

With the tagline “Find your tribe,” the group aims to create a sisterhood for Black women “on the trails, on waterways and in our local communities across the globe.” Last summer, she secured nonprofit status and expanded Vibe Tribe’s focus, adding snowshoeing, fly-fishing, zip lining and kayaking to its roster. Today, the Denver-based group has 11 chapters across the U.S. (even Guam) and Canada, with about 2,100 members.

Research suggests her work is needed. The most recent National Park Service survey found that 6% of visitors are Black, compared with 77% white. Newton said that must change — especially given the opportunities parks provide and the health challenges that disproportionately plague Black women. Research shows they experience higher rates of chronic preventable health conditions, including diabetes, hypertension and cardiovascular disease. A 2020 study found that racial discrimination also may increase stress, lead to health problems and reduce cognitive functioning in Black women. Newton said it underscores the need for stress-relieving activities.

“It’s been studied at several colleges that if you are outdoors for at least five minutes, it literally brings your stress level down significantly,” said Newton. “Being around nature, it’s like grounding yourself. That is vital.”

Newton said participation in the group generally tapers off in winter. She is hopeful, though, that cabin fever from the pandemic will inspire more Black women to try winter activities.

Atlanta member Stormy Bradley, 49, said the group has added value to her life. “I am a happier and healthier person because I get to do what I love,” said the sixth grade teacher. “The most surprising thing is the sisterhood we experience on and off the trails.”

Patricia Cameron, a Black woman living in Colorado Springs, drew headlines this summer when she hiked 486 miles — from Denver to Durango — and blogged about her experience to draw attention to diversity in the outdoors. She founded the Colorado nonprofit Blackpackers in 2019.

“One thing I caught people saying a lot of is ‘Well, nature is free’ and ‘Nature isn’t racist’ — and there’s two things wrong with that,” said Cameron, a 37-year-old single mother of a preteen.

“Nature and outside can be free, yes, but what about transportation? How do you get to certain outdoor environments? Do you have the gear to enjoy the outdoors, especially in Colorado, where we’re very gear-conscious and very label-conscious?” she asked. “Nature isn’t going to call me the N-word, but the people outside might.”

Cameron applauds Newton’s efforts and those of other groups nationwide, like Nature Gurlz, Outdoor Afro, Diversify Outdoors, Black Outdoors, Soul Trak Outdoors, Melanin Base Camp and Black Girls Run, that have a similar mission. Cameron said it also was encouraging that the Outdoor Industry Association, a trade group, pledged in the wake of the racial unrest sparked by George Floyd’s death to help address a “long history of systemic racism and injustice” in the outdoors.

Efforts to draw more Black people, especially women, outdoors, Cameron said, must include addressing barriers, like cost. For example, Blackpackers provides a “gear locker” to help members use pricey outdoor gear free or at discounted rates. She has also partnered with businesses and organizations that subsidize and sponsor outdoor excursions. During the pandemic, Vibe Tribe has waived all membership fees through this month.

Cameron said she dreams of a day when Black people are free from the pressures of carrying the nation’s racial baggage when participating in outdoor activities.

Vibe Tribe member and longtime outdoor enthusiast Jan Garduno, 52, of Aurora, Colorado, agreed that fear and safety are pressing concerns. For example, leading up to the presidential election she changed out of her “Let My People Vote” T-shirt before heading out on a solo walk for fear of how other hikers might react.

Groups like Vibe Tribe, she said, provide camaraderie and an increased sense of safety. And another plus? The health benefits can also be transformative.

“I’ve been able to lose about 40 pounds and I’ve kept it off,” explained Garduno.

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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Live Free or Die if You Must, Say Colorado Urbanites — But Not in My Hospital

ERIE, Colo. — Whenever Larry Kelderman looks up from the car he’s fixing and peers across the street, he’s looking across a border. His town of 28,000 straddles two counties, separated by County Line Road.

Kelderman’s auto repair business is in Boulder County, whose officials are sticklers for public health and have topped the county website with instructions on how to report COVID violations. Kelderman lives in Weld County, where officials refuse to enforce public health rules.

Weld County’s test positivity rate is twice that of its neighbor, but Kelderman is pretty clear which side he backs.

“Which is worse, the person gets the virus and survives and they still have a business, or they don’t get the virus and they lose their livelihood?” he said.

Boulder boasts one of the most highly educated populations in the nation; Weld boasts about its sugar beets, cattle and thousands of oil and gas wells. Summer in Boulder County means concerts featuring former members of the Grateful Dead; in Weld County, it’s rodeo time. Boulder voted for Biden, Weld for Trump. Per capita income in Boulder is nearly 50% higher than in Weld.

Even their COVID outbreaks are different: In Boulder County, the virus swirls around the University of Colorado. In Weld County, some of the worst outbreaks have swept through meatpacking plants.

It’s not the first time County Line Road has been a fault line.

“I’ve been in politics seven years and there’s always been a conflict between the two counties,” said Jennifer Carroll, mayor of Erie, once a coal mining town and now billed as a good place to raise a family, about 30 minutes north of Denver.

Shortly before the coronavirus hit Colorado, Erie’s board of trustees extended a moratorium on new oil and gas operations in the town. Weld County was not pleased.

“They got really angry at us for doing that, because oil and gas is their thing,” Carroll said.

Most of the town’s businesses are on the Weld side. To avoid public health whiplash, Carroll and other town leaders have asked residents to comply with the more restrictive stance of the Boulder side.

The feud got ugly in a dispute over hospital beds. At one point, the state said Weld County had only three intensive care beds, while Weld County claimed it had 43.

“It made my job harder, because people were doubting what I was saying,” said Carroll. “Nobody trusted anyone because they were hearing conflicting information.”

Weld’s number, it turned out, included not just the beds in its two hospitals, but also those in 10 other hospitals across the county line, including in the city of Longmont.

Longmont sits primarily in Boulder County but spills into Weld, where its suburbs taper into fields pockmarked with prairie dog holes. Its residents say they can tell snow is coming when the winds deliver a pungent smell of livestock from next door. Longmont Mayor Brian Bagley worried that Weld’s behavior would deliver more than a stench: It might also deliver patients requiring precious resources.

“They were basically encouraging their citizens to violate the emergency health orders … with this cowboy-esque, you know, ‘Yippee-ki-yay, freedom, Constitution forever, damn the consequences,’” said Bagley. “Their statement is, ‘Our hospitals are full, but don’t worry, we’re just going to use yours.’”

So, “for 48 hours, I trolled Weld County,” he said. Bagley asked the city council to consider an ordinance that could have restricted Weld County residents’ ability to receive care at Longmont hospitals. Bagley, who retracted his proposal the next day, said he knew it was never going to come to fruition — after all, it was probably illegal — but he wanted to prove a point.

“They’re going to be irresponsible? Fine. Let me propose a question,” he said. “If there is only one ICU bed left and there are two grandparents there — one from Weld, one from Boulder — and they both need that bed, who should get it?”

Weld County commissioners volleyed back, calling Bagley a “simple mayor.” They wrote that the answer to the pandemic was “not to continually punish working-class families or the individuals who bag your groceries, wait on you in restaurants, deliver food to your home while you watch Netflix and chill.”

“I know we’re all trying to get along, but people are starting to do stupid and mean things and so I’ll be stupid and mean back,” Bagley said during a Dec. 8 council meeting.

In another Longmont City Council meeting, Bagley (who suspects the commissioners don’t know what “Netflix and chill” typically means) often referred to Weld simply as “our neighbors to the East,” declining to name his foe. The council shrugged off his statement about withholding medical treatment but demanded that Weld County step up to fight the pandemic.

“We would not deny medical care to anybody. It’s illegal and it’s immoral,” said council member Polly Christensen. “But it is wrong for people to expect us to bear the burden of what they’ve been irresponsible enough to let loose.”

“They’re the reason why I can’t be in the classroom in front of my kids,” said council member and teacher Susie Hidalgo-Fahring, whose school district straddles the counties. “I’m done with that. Everybody needs to be a good neighbor.”

The council decided Dec. 15 to send a letter to Weld County’s commissioners encouraging them to enforce state restrictions and to make a public statement about the benefits of wearing masks and practicing physical distancing. They’ve also backed a law allowing Democratic Gov. Jared Polis to withhold relief money from counties that don’t comply with restrictions.

Weld County Commissioner Scott James said his county doesn’t have the authority to enforce public health orders any more than a citizen has the authority to give a speeding ticket.

“If you want me as an elected official to assume authority that I don’t have and arbitrarily exert it over you, I dare you to look that up in the dictionary,” said James, who is a rancher turned country radio host. “It’s called tyranny.”

James doesn’t deny that COVID-19 is ravaging his community. “We’re on fire, and we need to put that fire out,” he said. But he believes that individuals will make the right decisions to protect others, and demands the right of his constituents to use the hospital nearest them.

“To look at Weld County like it has walls around it is shortsighted and not the way our health care system is designed to work,” James said. “To use a crudity, because I am, after all, just a ranch kid turned radio guy, there’s no ‘non-peeing’ section in the pool. Everybody’s gonna get a little on ’em. And that’s what’s going on right now with COVID.”

The dispute is not just liberal and conservative politics clashing. Bagley, the Longmont mayor, grew up in Weld County and “was a Republican up until Trump,” he said. But it is an example of how the virus is tapping into long-standing Western strife.

“There’s decades of reasons for resentment at people from a distance — usually from a metropolis and from a state or federal governmental office — telling rural people what to do,” said Patty Limerick, faculty director at the Center of the American West at the University of Colorado-Boulder, and previously state historian.

In the ’90s, she toured several states performing a mock divorce trial between the rural and urban West. She played Urbana Asphalt West, married to Sandy Greenhills West. Their child, Suburbia, was indulged and clueless and had a habit of drinking everyone else’s water. A rural health care shortage was one of many fuels of their marital strife.

Limerick and her colleagues are reviving the play now and adding COVID references. This time around, she said, it’ll be a last-ditch marriage counseling session for high school classes and communities to adopt and perform. It likely won’t have a scripted ending; she’s leaving that up to each community.

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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At Risk of Extinction, Black-Footed Ferrets Get Experimental COVID Vaccine

In late summer, as researchers accelerated the first clinical trials of COVID-19 vaccines for humans, a group of scientists in Colorado worked to inoculate a far more fragile species.

About 120 black-footed ferrets, among the most endangered mammals in North America, were injected with an experimental COVID vaccine aimed at protecting the small, weasel-like creatures rescued from the brink of extinction four decades ago.

The effort came months before U.S. Department of Agriculture officials began accepting applications from veterinary drugmakers for a commercial vaccine for minks, a close cousin of the ferrets. Farmed minks, raised for their valuable fur, have died by the tens of thousands in the U.S. and been culled by the millions in Europe after catching the COVID virus from infected humans.

Vaccinating such vulnerable species against the disease is important not only for the animals’ sake, experts say, but potentially for the protection of people. Some of the most pernicious human diseases have originated in animals, including the new coronavirus, which is believed to have spread from bats to an intermediary species before jumping to humans and sparking the pandemic.

The worry when it comes to animals like farmed minks, which are kept in crowded pens, is that the virus, contracted from humans, can mutate as it spreads rapidly in the susceptible animals, posing a new threat if it spills back to people. Danish health officials in November reported detecting more than 200 COVID cases in humans that had variants associated with farmed minks, including a dozen with a mutation scientists feared could undermine the effectiveness of vaccines. However, officials now say that variant appears to be extinct.

In the U.S., scientists have not found similar COVID mutations in the domestic farmed mink populations, though they recently noted with concern the discovery of the first case of the virus in a wild mink in Utah.

“For highly contagious respiratory viruses, it’s really important to be mindful of the animal reservoir,” said Dr. Corey Casper, a vaccinologist and chief executive of the Infectious Disease Research Institute in Seattle. “If the virus returns to the animal host and mutates, or changes, in such a way that it could be reintroduced to humans, then the humans would no longer have that immunity. That makes me very concerned.”

For the newly vaccinated ferrets, the main risk is to the animals themselves. They’re part of a captive population at the National Black-footed Ferret Conservation Center outside Fort Collins, Colorado, where there have been no cases of COVID-19 to date. But the slender, furry creatures — known for their distinctive black eye mask, legs and feet — are feared to be highly vulnerable to the ravages of the disease, said Tonie Rocke, a research scientist at the National Wildlife Health Center who is testing the ferret vaccine. They’re all genetically similar, having come from a narrow breeding pool, which weakens their immune systems. And they likely share many of the features that have made the disease so deadly to minks.

“We don’t have direct evidence that black-footed ferrets are susceptible to COVID-19, but given their close relationship to minks, we wouldn’t want to find out,” Rocke said.

Rocke began working on the experimental vaccine in the spring, as she and Pete Gober, black-footed ferret recovery coordinator for the U.S. Fish and Wildlife Service, watched reports about the new coronavirus with growing alarm. An exotic disease is “the biggest nemesis for ferret recovery,” said Gober, who has worked with black-footed ferrets for 30 years. “It can knock you right back down to zero.”

The ferrets are a native species that once roamed vast areas of the American West. Their ranks declined precipitously over many decades as populations of prairie dogs, the ferrets’ primary source of food and shelter, were decimated by farming, grazing and other human activity.

In 1979, black-footed ferrets were declared extinct — until a small population was discovered on a ranch in Wyoming. Most of those rare animals were then lost to disease, including sylvatic plague, the animal version of the Black Death that has plagued humans. The species survived only because biologists rescued 18 ferrets to form the basis of a captive breeding program, Gober said.

With the threat of new disease looming, Gober doubled-down on the strict infection prevention precautions at the center, which houses more than half of the 300 black-footed ferrets in captivity. An additional 400 have been reintroduced to the wild. Then he called Rocke, who previously created a vaccine shown to protect ferrets from sylvatic plague. It uses a purified protein from Yersinia pestis, the bacterium that causes the disease.

Would the same technique work against the virus that causes COVID-19? Under the research authority granted by the Fish and Wildlife Service, the scientists were free to try.

“We can do these sorts of things experimentally in animals that we can’t do in humans,” Rocke noted.

Rocke acquired purified protein of a key component of the SARS-CoV-2 virus, the spike protein, from a commercial producer. She mixed the liquid protein with an adjuvant, a substance that enhances immune response, and injected it under the animals’ skin.

The first doses were given in late spring to 18 black-footed ferrets, all male, all about a year old, followed by a booster dose a few weeks later. Within weeks of getting the second shots, tests of the animals’ blood showed antibodies to the virus, a good — and expected — sign.

By early fall, 120 of the 180 ferrets housed at the center were inoculated, with the rest remaining unvaccinated in case something went wrong with the animals, which generally live four to six years in captivity. So far, the vaccine appears safe, but there’s no data yet to show whether it protects the animals from disease. “I can tell you, we have no idea if it will work,” said Rocke, who plans to conduct efficacy tests this winter.

But Rocke’s effort makes sense, said Casper, who has created several vaccines for humans. Rocke’s approach — introducing an inactivated virus in an animal to stimulate an immune response — is the basis for many common vaccines, such as those that prevent polio and influenza.

Vaccines containing inactivated virus to prevent COVID-19 have been tested in certain animals — and in human vaccines, including CoronaVac, created by the Chinese firm Sinovac Life Sciences. But the effort in Colorado may be among the first aimed at preventing COVID-19 in a specific animal population, Rocke said.

Gober said he is optimistic that the ferrets are protected, but it will take a well-designed study to settle the question. Until then, he’ll work to keep the fragile ferrets free of COVID-19. “The price of peace is eternal vigilance, they say. We can’t let our guard down.”

The tougher task is doing the same for people, Gober observed.

“We’re just holding our breath, hoping we can get all the humans vaccinated in the country. That will give us all a sigh of 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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Ski Resorts Work to Stay Open as COVID Cases Snowball

TELLURIDE, Colo. — The day after Thanksgiving, Dr. Jana Eller and Dr. Shiraz Naqvi were seated beside an outdoor fire pit at the base of Telluride Ski Resort, taking a short break from skiing.

The two physicians from Houston had driven more than 18 hours to get here for the holiday weekend, and they were staying (and preparing meals) in a rented home. They traveled with another couple and their kids, colleagues they’ve been “bubbling” with in Houston.

“We got a COVID test prior to leaving and will get another when we return,” Naqvi said.

The skiing itself doesn’t feel much different during the pandemic, Eller said, but “the après ski scene is just gone.”

In March, at the beginning of the pandemic, Colorado Gov. Jared Polis issued an executive order requiring the state’s ski resorts to close in response to COVID-19, which had hit the state’s ski towns early and hard. Now, as the resorts enter their busy season, the state has taken pains to avoid blanket closures even though cases of COVID-19 are reaching their highest levels yet.

How to stay open amid the pandemic is an issue resorts across the U.S. are facing. Mandatory face coverings have become the norm, but other COVID mitigation efforts vary by site. Vermont resorts ask skiers to certify their compliance with rules governing interstate travel during the pandemic when buying a lift ticket, and in Colorado’s Pitkin County (home to Aspen), visitors will be required to confirm they’ve had a negative COVID test result within 72 hours of travel or pledge to quarantine for 14 days after arrival or until they obtain a negative test result.

Telluride is an internationally renowned destination trying to operate safely while protecting the 8,000 or so permanent residents in the area. Located in a remote southwestern part of Colorado, its economy depends on tourism, and the resort posts as many as 6,500 visitors on its busiest days.

On Nov. 25, with its COVID case numbers skyrocketing and its positivity rate hitting 4.6%, San Miguel County, which includes Telluride, closed its bars and restricted its restaurants to takeout and outdoor dining only. Signs posted throughout the resort remind visitors of the “five commitments of containment” — wear a mask, maintain 6 feet of physical distance, minimize group size, wash hands frequently and, when you feel sick, stay home and get tested.

How bad would things have to get to close the resort? That’s hard to gauge, said Grace Franklin, public health director for the county. People are going to do what they will regardless, she said.

“If we shut down the ski resort, how many people will take to the backcountry and get injured or trigger avalanches where the impact is greater? It’s a ‘damned if you do, damned if you don’t’ situation,” Franklin said.

Instead, Franklin said, the question becomes “How do we create safer, engineered events so people have an outlet, but we minimize as much risk as possible?”

Skiing itself poses relatively little risk, said Kate Langwig, an epidemiologist at Virginia Tech. “You’re outside with a lot of airflow, you’ve got something strapped to your feet so you’re not in super close contact with other people, and most of the time you’re riding the lift with people in your group.”

Gathering in the lodge or bar is by far the biggest COVID risk associated with skiing, said Langwig, who grew up skiing in northern New York. “In my family, one of the things you do after a day of skiing is connect with friends and have a beer in the lodge,” and it’s this social aspect of skiing that’s too risky right now, she said.

In an effort to discourage tourists and residents from congregating, local governments, medical facilities and the ski resort released a co-signed letter in November urging people to cancel any plans to gather with those outside their immediate household and celebrate the holidays solely with people from their own household. Keeping the resort open will require everybody to do their part, said Lindsey Mills, COVID public information consultant for San Miguel County.

“We are not telling anybody not to come, at least not yet,” said Todd Brown, Telluride’s mayor pro tem. But local officials are broadcasting a strong message to everyone in the area — “Chill out. Don’t have the big party with five families.”

Officials aren’t worried only about coronavirus transmission; they’re also concerned about overtaxing their medical facilities. San Miguel County has an urgent care center but no hospital, and its medical center experienced a 22% staffing shortage at the end of November, mostly because so many employees are in quarantine. Hospitals in nearby Mesa County reached their ICU capacity last month, and other hospitals in the region are also pinched.

“We can’t have a situation where people break their legs on the slopes and we can’t get them care,” said Franklin.

The resort has taken steps to facilitate physical distancing among visitors. Reservations aren’t required at Telluride, but lift tickets must be purchased in advance, and the resort can restrict ticket sales if necessary, said Jeff Proteau, vice president of operations and planning at the Telluride Ski Resort. Gondolas are operating with the windows open and each load is restricted to members of the same household.

To reduce contact in and around the lifts, workers have created “ghost lines” of empty space to ensure a 6-foot distance between groups while they wait in lift lines. People from the same household can stand in line together and ride the two- to four-person lifts next to one another, Proteau said, but when riding a lift with someone from another household, guests are asked to leave a vacant seat between them.

Langwig was a children’s ski instructor for many years and worries about ski school. “You interact pretty closely with the kids,” she said, noting that runny noses are common. “You spend a lot of time getting kids bundled up and to and from the bathroom.” This could be especially challenging if indoor spaces are closed, she said. “Hot chocolate breaks are one of the ways you get kids through the day, and that’s not safe anymore.”

In anticipation of visitors needing to take breaks to warm up, the resort has installed six temporary structures around the mountain with insulated ceilings and heated panels. When the sides are rolled up, they’re considered outdoor spaces, Proteau said, but they can be closed into confined spaces with limited occupancy as needed, especially on a blustery day.

The risk for most employees on the mountain should be relatively minimal, Langwig said, at least at work. “Lift attendants are outside wearing thick gloves and a mask most of the time. Compared to someone who works in a restaurant, their risk is pretty low.”

Employees are generally assigned to work in small groups that can be quarantined, if necessary, without wiping out a whole department, Proteau said. There’s also contact tracing in place for resort employees.

Arizona native Joey Rague moved to Telluride last year and works as a ski valet on the mountain. He said there’s a huge incentive among employees to keep the resort open. With affordable housing sparse in Telluride, “all of us are struggling seasonally to be able to pay rent.”

So far, he said, most visitors have been respectful and conscientious of the rules.

“It seems as though people understand that if we want to stay open, we have to come together,” 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

KHN Midwest correspondent Lauren Weber discussed how the COVID-19 backlash undermines public health on Newsy on Thursday.

California Healthline editor Arthur Allen discussed COVID vaccines with KIQI 1010AM’s “Hecho en California” on Thursday. (The interview, conducted in Spanish, begins around the 2:50 mark.)

California Healthline correspondent Angela Hart co-moderated a panel on the future of the Affordable Care Act in California at the Sacramento Press Club on Tuesday.

KHN senior correspondent Phil Galewitz discussed COVID vaccine distribution on Newsy on Tuesday.

KHN Editor-in-Chief Elisabeth Rosenthal discussed COVID prevention PSAs and why they should be scarier on WNYC’s “The Takeaway” on Tuesday. She also discussed COVID and President-elect Joe Biden’s health care team on WBUR’s “On Point” on Dec. 11.

KHN Midwest correspondent/editor Laura Ungar discussed COVID primary care closures on Minnesota Public Radio on Dec. 11.

KHN chief Washington correspondent Julie Rovner discussed the surge in COVID cases and efforts for a relief bill in Congress with WAMU’s “1A” on Dec. 11.

KHN senior Colorado correspondent Markian Hawryluk discussed contact tracing in a Latino immigrant community with KUNC’s “Colorado Edition” on Dec. 10.

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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This Health Care Magnate Wants to Fix Democracy, Starting in Colorado

In the final weeks before the Nov. 3 election, supporters of a down-in-the-weeds effort to overturn a tax law in Colorado received a cascade of big checks, for a grand total of more than $2 million.

All came from Kent Thiry, the former CEO of DaVita, one of the largest kidney care companies in the country. This was not the first time he donated big to a ballot initiative aimed at tweaking the nitty-gritty details of how Colorado functions. Nor will it be the last.

Thiry has given at least $5.9 million to Colorado ballot measures since 2011 — and all of them won, according to a KHN review of Colorado campaign finance data. According to data from the National Institute on Money in Politics, Thiry’s donations to ballot measures in that state are second only to those of billionaire Pat Stryker. Campaign finance records show that before that, he gave to ballot issue committees in California, where he used to live, dating to at least 2007.

It’s the same playbook his former company has successfully used in California. As KHN has reported, in 2018 DaVita was among several companies to break an industry record in campaign spending for a ballot measure by any one side in California. This year, the industry came close to breaking that record to defeat a measure that would have further regulated dialysis clinics and that DaVita said would have limited access to care.

Ballot initiatives, which are allowed in about half the states, enable individuals and groups to circumvent legislatures and ask voters to decide on a law. And in many states, the campaigns for and against them are bankrolled by the rich: either corporations fighting to preserve their profits or multimillionaires with a political shopping list.

“Wealthy individuals have been pouring money into ballot measures, even seemingly unrelated to their industry, for over a century,” Daniel Smith, a political scientist studying direct democracy at the University of Florida, wrote in an email to KHN.

Given that health care is a $3.6 trillion industry, its top executives are among the ranks of those who can have an enormous impact in ballot measure politics. This year, Kent Thiry and Mike Fernandez, chairman and CEO of private equity firm MBF Healthcare Partners, were among the 19 individuals or couples who spent $1 million or more on ballot issue campaigns this year, according to Bloomberg. In previous elections, medical equipment company owner Loren Parks has also given big money to ballot initiatives.

Overall, those in the health industry have spent more on ballot measures in Colorado than in any other state except Missouri and California, according to data from the National Institute on Money in Politics, and that’s largely due to Thiry.

“He really has become the 800-pound gorilla of the ballot initiative process in Colorado,” said Josh Penry, a Republican campaign strategist in Denver who has worked with Thiry, including on a ballot measure campaign Thiry helped fund. “He wields more power in an informal way than virtually all the elected officials, if you look at the impact he’s had.”

Even though Thiry and his wife, Denise O’Leary, a former venture capitalist on the board of directors of medical device company Medtronic, have made hefty earnings from health care, Thiry’s ballot initiative donations as an individual have nothing to do with the industry.

“I prefer things that have systemic impact,” said Thiry. Measures he has bankrolled have eliminated the caucus system for presidential primaries, brought unaffiliated voters into the primaries and created a system intended to eliminate gerrymandering.

“Democracy is not a spectator sport,” he said.

Thiry previously donated to ballot measure committees in California, to prevent changes to term limits and to create a system for redistricting led jointly by Democrats, Republicans and citizens unaffiliated with a political party.

After moving his company’s headquarters from Los Angeles to Denver in 2010, he began backing ballot measures in his new state, too, with equal success and bigger sums, jumping from the tens of thousands to the millions. He spent more than $2 million backing a pair of measures to allow unaffiliated voters to participate in primaries.

In 2018, while his company was helping break an election spending record to defeat a California measure that would have capped the industry’s profits, Thiry was putting more than $1.2 million toward redistricting efforts in Colorado very similar to the one he backed in his previous home state to help reduce gerrymandering.

His latest donations went to a measure that successfully overturned a tax law from the 1980s that may have helped Colorado homeowners, but which critics said left public services like education and fire districts underfunded in some rural areas.

Thiry doesn’t just shell out cash. As the online newspaper The Colorado Independent has pointed out, Thiry’s offices played a large role in bringing two warring groups with different ideas about redistricting to the same table. His efforts tend to revolve around raising the power of unaffiliated voters, who make up about 40% of Colorado’s active voters, according to state data.

Fernandez, the private equity billionaire, said he has similar motivations. He donated $7.3 million to a Florida initiative to change how primaries work in that state and bring unaffiliated voters like himself into the fold.

“I’ve never spent so much money [on] something that I have no business reason to be in at all,” he said.

The effort was, he said, nearly “a one-man show” in terms of financing. But it still failed, garnering 57% of votes when it needed 60% to pass. Fernandez said he’ll try again in 2022.

“I come from a country where you can see that control of a government by a single party is deadly,” said Fernandez, who was born in Cuba. “Florida has been controlled by the Republican Party for the last three decades. And when I was a Republican, that was great.”

But, he said, it quickly became clear that bringing the issue to legislators was a dead end. That’s expected, according to John Matsusaka, executive director of the Initiative and Referendum Institute at the University of Southern California. Ballot initiatives are a natural route to tweak electoral machinery, he said, because legislators have a conflict of interest on issues like gerrymandering and term limits.

In fact, Matsusaka thinks the U.S. could use national ballot initiatives, which other democracies have, as a route to restoring confidence in the federal government.

“I don’t look at ballot propositions as a way to drive a progressive agenda or conservative agenda or any sort of agenda,” he said. “I view it as a way to put the people in control. And they can go where they want to go.”

Even if that means eroding their own power a little. One of the first initiatives Thiry donated to in Colorado is something Matsusaka considers “anti-democracy” — an effort called Raise the Bar, a ballot initiative about ballot initiatives. It required petitioners to get signatures from every corner of the state to put an initiative on the ballot. Some view this as problematic.

“You have to now collect signatures in every senate district of Colorado,” said Corrine Rivera Fowler, director of policy and legal advocacy with the Ballot Initiative Strategy Center, a national organization that supports progressive ballot initiatives. “That’s a tremendous undertaking for grassroots communities.”

Thiry, meanwhile, intends to take what he’s learned in Colorado and apply it elsewhere. He said he’s getting more involved in several national democracy reform groups, including Unite America, an effort to break what’s been called the “doom loop” of partisanship. Thiry said he hopes to help create “a tidal tsunami of political momentum.”

“One of my goals is to have this democracy reform energy in places like Colorado — or elsewhere — move from being an ad hoc collection of activist projects to a true movement,” he said. “Kind of like the civil rights movement, kind of like the gay marriage movement, and like the #MeToo movement or Black Lives Matter.”

He no longer works for DaVita, after stepping down as executive chairman earlier this year.

“I have no title anymore. Just ‘citizen.’ It’s a title I wear with great pride and energy,” he said.

As for the next measure Thiry will back, he’s open to recommendations.

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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Tracking COVID’s Spread Inside a Tight-Knit Latino Community

Early in the pandemic, Ximena Rebolledo León, a registered nurse at Telluride Regional Medical Center in southwestern Colorado, needed to find everyone who’d been in contact with a sick Latino worker whose boss had told him he would lose his job if he didn’t show up.

The man had gone to work and infected four co-workers, all Latinos, with COVID-19 — so Rebolledo León then had to track down their movements to determine who else had been exposed to the coronavirus in the wealthy ski resort community.

“I ended up calling 13 different families, and I put a total of 85 people in isolation or quarantine,” Rebolledo León recalled.

People fighting the spread of COVID-19 face many unique challenges when doing contact tracing among low-income Latino immigrants in tight-knit communities. Long-standing health care disparities, job insecurity, immigration status, language barriers and a profound distrust of government all complicate the already tricky task.

COVID-19 has also highlighted how essential those immigrants are to their communities. While Telluride is known for its glitzy resort tucked into the mountains, the place functions because of the workers — many of them first-generation immigrants — within the surrounding San Miguel County. When the medical center implemented new COVID-cleaning protocols, it fell to the cleaning staff of Latinos. Grocery stores, restaurants and many other businesses remained open only because their Hispanic workers continued to come to work.

“They are the backbone of what makes this town go round,” Rebolledo León said.

That’s why Latino front-line workers in Telluride and across the country suffer some of the greatest consequences of COVID-19. Hispanic people in the U.S. face higher rates of infection than the general population. And while they make up about 17% of the population, they have accounted for 24% of COVID deaths.

San Miguel County had 267 confirmed cases of COVID-19 as of Dec. 6, but no deaths. Hispanics account for about 11% of the population of roughly 8,000 but 23% of the cases from March to August.

Even so, it took weeks as the pandemic unfolded for the county health department to provide information about the virus in either Spanish or Chuj, a Mayan language spoken by many of the county’s residents from Guatemala.

“We were in crisis mode, and I think one of the first things that falls by the wayside is health equity,” said Grace Franklin, director of the health department. “It took a little bit of time for us to check back in and say, ‘What are we missing? Who are we missing?’”

So public health officials, like those in Telluride and the surrounding county, are leaning on trusted voices such as Rebolledo León from within those immigrant communities to track and contain the virus, and to help vulnerable people access the care and resources they need.

“Trust is a huge factor,” said Maggie Gómez, deputy director of the Center for Health Progress, a Denver-based health advocacy group. “When you show up in a Latinx community in a suit, and you’re knocking on the door and they don’t know who you are, they can tell you’re not from there — they’re going to be pretty suspicious.”

Many of the people Rebolledo León was calling hadn’t received even the most basic information about COVID-19 in words they could understand. She said they hadn’t gotten clear messages on why they had to stay home if they weren’t feeling sick or why a negative COVID test didn’t mean they were in the clear. She was calling homes every morning, checking to see if anybody had developed symptoms, or needed food or other support to remain in quarantine. She gave them her personal cellphone number.

“I wanted them to have access to a nurse,” Rebolledo León said. “So it became a round-the-clock job.”

A woman with diabetes called asking whether she’d be safe working in a restaurant. A house cleaner wondered if it was safe for her to clean if the owners were at home. They would call her late at night, wondering if they should go to the emergency room when having trouble breathing.

“If you’re insured? Yeah, you go to the ER,” she said. “But if you’re uninsured? You’re terrified of that $2,000 bill.”

Whenever new information became available, Rebolledo León, who emigrated from Mexico more than 20 years ago, recorded Spanish-language videos on her phone, posting them on Facebook and texting them out. She doesn’t speak Chuj, but the health department hired an interpreter and posted a COVID video in Chuj on its website.

The videos went viral among the Latino communities in the county. So much so that many people Rebolledo León had never met recognized her as Nurse Ximena from the videos.

But by summer, Rebolledo León was overwhelmed and had to step back to focus on her work at Telluride Medical Center. The county health department in April had hired Dominique Bruneau Saavedra, an architect who emigrated from Chile in 2016 and had been working at a local nonprofit. Bruneau Saavedra took over the bulk of contact tracing among Spanish-speaking residents.

In one case, Bruneau Saavedra asked four Latino men to isolate. One lost his job because of it. Many of the people she contacted worked multiple jobs. That expanded their potential contacts.

Housing intended for four people often sheltered six or seven, she said. Some homes had a single bathroom, making it hard for one person to isolate from the rest of the household. For many immigrants, she said, their entire social circle is the people at work. When asked to stay away from their jobs, they may not have other friends outside their home who can help with food or other needs.

Bruneau Saavedra also discovered that many who worked multiple jobs used different names or nicknames with different employers. In trying to track possible cases, at times she discovered two people on her list were one and the same, having the same cellphone number. But she also found households where multiple residents shared a single number.

Bruneau Saavedra said that, when she called non-Hispanics, she noticed a contrast in their level of concern. Some chose to isolate by going camping alone in the woods, she said, almost like a vacation. For low-income immigrants, isolation can be an economic and legal crisis. In Colorado, an estimated 1 out of 3 immigrants are undocumented.

While social services could help with food and other assistance, the agencies needed to know Social Security numbers, immigration status and who else lived in the home. Those were nonstarters for many who had status issues or undocumented family members living with them.

“It’s been a fight every single step,” Rebolledo León said. “If you’re undocumented in this country, you are aware that the information you are sharing could put so many others in serious problems.”

Telluride is small enough that when one person is infected, it’s not hard to find connections to half the town.

On the other hand, Bruneau Saavedra said, the county is lucky because it is a small community.

“It feels like contact tracing is manageable and is possible, unlike in an urban infrastructure,” Bruneau Saavedra said. “Everybody knows each other.”

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 Happened When the Only ER Doctor in a Rural Town Got COVID

Kurt Papenfus, a doctor in Cheyenne Wells, Colorado, started to feel sick around Halloween. He developed a scary cough, intestinal symptoms and a headache. In the midst of a pandemic, the news that he had COVID-19 wasn’t surprising, but Papenfus’ illness would have repercussions far beyond his own health.

Papenfus is the lone full-time emergency room doctor in the town of 900, not far from the Kansas line.

“I’m chief of staff and medical director of everything at Keefe Memorial Hospital currently in Cheyenne County, Colorado,” he said.

With Papenfus sick, the hospital scrambled to find a replacement. As coronavirus cases in rural Colorado, and the state’s Eastern Plains especially, surge to unprecedented levels, Papenfus’ illness is a test case for how the pandemic affects the fragile rural health care system.

“He is the main guy. And it is a very large challenge,” said Stella Worley, CEO of the hospital.

If she couldn’t find someone to fill in while he was sick, Worley might have to divert trauma and emergency patients nearly 40 miles north to Burlington.

“Time is life sometimes,” she said. “And that is not something you ever want to do.”

‘The ‘Rona Beast Is a Very Nasty Beast’

As deaths from the coronavirus have surpassed 250,000 in the U.S., new data show the pandemic has been particularly lethal in rural areas — it’s taking lives in those areas at a rate reportedly nearly 3.5 times higher than in metropolitan communities.

About 63 people in Cheyenne County have been diagnosed with COVID-19, most of them in the past three weeks.

Papenfus, a lively 63-year-old, was discharged after a nine-day stay at St. Joseph’s Hospital in Denver, and he was eager to sound the alarm about the disease he calls the ‘rona.

“The ‘rona beast is a very nasty beast, and it is not fun. It has a very mean temper. It loves a fight, and it loves to keep coming after you,” Papenfus said.

He isn’t sure where he picked it up but thinks it might have been on a trip east in October. He said he was meticulous on the plane, sitting in the front, last on, first off. But on landing at Denver International Airport, Papenfus boarded the crowded train to the terminal, and soon alarm bells went off in his head.

“There are people literally like inches from me, and we’re all crammed like sardines in this train,” Papenfus said. “And I’m going, ‘Oh, my God, I am in a superspreader event right now.’”

An airport spokeswoman declined to comment about Papenfus’ experience.

A week later, the symptoms hit. He tested positive and decided to drive himself the three hours to the hospital in Denver. “I’m not going to let anybody get in this car with me and get COVID, because I don’t want to give anybody the ‘rona,” he said. County sheriff’s deputies followed his car to ensure he made it.

Once in the hospital, chest X-rays revealed he’d developed pneumonia.

“Dude, I didn’t get a tap on the shoulder by ‘rona, I got a big viral load,” he texted a reporter, sending images of his chest scans that show large, opaque, white areas of his lung. Just a week earlier, his chest X-ray was normal, he said.

Back in Cheyenne Wells, Dr. Christine Connolly picked up some of Papenfus’ shifts, although she had to drive 10 hours each way from Fort Worth, Texas, to do it. She said the hospital staff is spread thin already.

“It’s not just the doctors; it’s the nurses, you know. It’s hard to get spare nurses,” she said. “There’s not a lot of spares of anything out that far.”

Besides himself, six other employees — out of a staff of 62 at Keefe Memorial — also recently got a positive test, Papenfus said.

Hospitals on the Plains often send their sickest patients to bigger hospitals in Denver and Colorado Springs. But with so many people around the region getting sick, Connolly is getting worried hospitals could be overwhelmed. Health care leaders created a new command system to transfer patients around the state to make more room, but Connolly said there is a limit.

“It’s dangerous when the hospitals in the cities fill up, and when it becomes a problem for us to send out,” she said.

‘Bank Robbers Wear Masks Out There’

The impact of Papenfus’ absence stretches across Colorado’s Eastern Plains. He usually worked shifts an hour to the northwest, at Lincoln Community Hospital in Hugo. Its CEO, Kevin Stansbury, said the town mostly dodged the spring surge and his facility could take in recovering COVID patients from Colorado’s cities. Now, Stansbury said, the virus is reaching places such as Lincoln County, population 5,700. It has had 144 cases, according to state data, and neighboring Kit Carson has had 301. Crowley County to the south, home to a privately managed state prison, has had 1,239 cases. It is far and away the No. 1 most affected county per capita in the state.

“So those numbers are huge,” Stansbury said. He said that as of mid-November about a half-dozen hospital staffers had tested positive for the virus; they think that outbreak is unrelated to Papenfus’ case.

Lincoln Community Hospital is ready once again to take recovering patients. Finances in rural health care are always tight, and accepting new patients would help.

“We have the staff to do that, so long as my staff doesn’t get ravaged with the disease,” Stansbury said.

Rural communities are particularly vulnerable. Residents tend to suffer from underlying health conditions that can make COVID-19 more severe, including high rates of cigarette smoking, high blood pressure and obesity. And Brock Slabach of the National Rural Health Association said 61% of rural hospitals do not have an intensive care unit.

“This is an unprecedented situation that we find ourselves in right now,” Slabach said. “I don’t think that in our lifetimes we’ve seen anything like what is developing in terms of surge capacity.”

A couple of hours east of Cheyenne Wells, COVID-19 recently hit Gove County, Kansas, hard.

The county’s emergency management director, the local hospital CEO and more than 50 medical staff members tested positive. In a nursing home, most of the more than 30 residents caught the virus; six have died since late September, according to The Associated Press. A county sheriff ended up in a hospital more than an hour from home, fighting to breathe, because of the lack of space at the local medical center.

Papenfus fretted about his home county and its odds of fighting off the virus.

“The western prairie isn’t mask country,” he said. “People don’t wear masks out there; bank robbers wear masks out there.” He is urging Coloradans to stay vigilant, calling the virus an existential threat. “It’s a huge wake-up call.”

Since being released from the hospital, Papenfus has had a rocky recovery. His wife, Joanne, drove him back to Cheyenne Wells, wearing an N95 mask and gloves, while he rode in the back on oxygen, coughing through the three-hour drive.

Once back at home after that initial nine-day stay, Papenfus hunkered down, with the occasional trip outside to hang out with his pet falcon.

But a week after going home, he started having nightly fevers. He had a CT scan done at Keefe Memorial, the hospital where he works. It revealed pneumonia in his lungs, so he went back to Denver, getting readmitted at St. Joseph’s Hospital. This time, Papenfus arrived via ambulance.

Finding a replacement for Papenfus at Keefe has been hard. The hospital is working with services that provide substitute physicians, but these days, with the coronavirus roaring across the country, the competition is fierce.

“They’re really scrambling to get coverage,” Papenfus texted from his hospital bed. “Whole county can’t wait for my return but this illness has really taken me down.”

He said he was now at Day 35 from his first symptoms, lying in his hospital bed in Denver, “wondering when I’ll ever get back.” Papenfus noted that COVID-19 has affected his critical thinking and that he will need to be cleared cognitively to return to work. He said he knows he won’t have the physical stamina to get back to full duty “for a while, if ever.”

This story is from a reporting partnership that includes Colorado Public RadioNPR 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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Need a COVID-19 Nurse? That’ll Be $8,000 a Week

DENVER — In March, Claire Tripeny was watching her dream job fall apart. She’d been working as an intensive care nurse at St. Anthony Hospital in Lakewood, Colorado, and loved it, despite the mediocre pay typical for the region. But when COVID-19 hit, that calculation changed.

She remembers her employers telling her and her colleagues to “suck it up” as they struggled to care for six patients each and patched their protective gear with tape until it fully fell apart. The $800 or so a week she took home no longer felt worth it.

“I was not sleeping and having the most anxiety in my life,” said Tripeny. “I’m like, ‘I’m gonna go where my skills are needed and I can be guaranteed that I have the protection I need.’”

In April, she packed her bags for a two-month contract in then-COVID hot spot New Jersey, as part of what she called a “mass exodus” of nurses leaving the suburban Denver hospital to become traveling nurses. Her new pay? About $5,200 a week, and with a contract that required adequate protective gear.

Months later, the offerings — and the stakes — are even higher for nurses willing to move. In Sioux Falls, South Dakota, nurses can make more than $6,200 a week. A recent posting for a job in Fargo, North Dakota, offered more than $8,000 a week. Some can get as much as $10,000.

Early in the pandemic, hospitals were competing for ventilators, COVID tests and personal protective equipment. Now, sites across the country are competing for nurses. The fall surge in COVID cases has turned hospital staffing into a sort of national bidding war, with hospitals willing to pay exorbitant wages to secure the nurses they need. That threatens to shift the supply of nurses toward more affluent areas, leaving rural and urban public hospitals short-staffed as the pandemic worsens, and some hospitals unable to care for critically ill patients.

“That is a huge threat,” said Angelina Salazar, CEO of the Western Healthcare Alliance, a consortium of 29 small hospitals in rural Colorado and Utah. “There’s no way rural hospitals can afford to pay that kind of salary.”

Surge Capacity

Hospitals have long relied on traveling nurses to fill gaps in staffing without committing to long-term hiring. Early in the pandemic, doctors and nurses traveled from unaffected areas to hot spots like California, Washington state and New York to help with regional surges. But now, with virtually every part of the country experiencing a surge — infecting medical professionals in the process — the competition for the finite number of available nurses is becoming more intense.

“We all thought, ‘Well, when it’s Colorado’s turn, we’ll draw on the same resources; we’ll call our surrounding states and they’ll send help,’” said Julie Lonborg, a spokesperson for the Colorado Hospital Association. “Now it’s a national outbreak. It’s not just one or two spots, as it was in the spring. It’s really significant across the country, which means everybody is looking for those resources.”

In North Dakota, Tessa Johnson said she’s getting multiple messages a day on LinkedIn from headhunters. Johnson, president of the North Dakota Nurses Association, said the pandemic appears to be hastening a brain drain of nurses there. She suspects more nurses may choose to leave or retire early after North Dakota Gov. Doug Burgum told health care workers to stay on the job even if they’ve tested positive for COVID-19.

All four of Utah’s major health care systems have seen nurses leave for traveling nurse positions, said Jordan Sorenson, a project manager for the Utah Hospital Association.

“Nurses quit, join traveling nursing companies and go work for a different hospital down the street, making two to three times the rate,” he said. “So, it’s really a kind of a rob-Peter-to-pay-Paul staffing situation.”

Hospitals not only pay the higher salaries offered to traveling nurses but also pay a commission to the traveling nurse agency, Sorenson said. Utah hospitals are trying to avoid hiring away nurses from other hospitals within the state. Hiring from a neighboring state like Colorado, though, could mean Colorado hospitals would poach from Utah.

“In the wake of the current spike in COVID hospitalizations, calling the labor market for registered nurses ‘cutthroat’ is an understatement,” said Adam Seth Litwin, an associate professor of industrial and labor relations at Cornell University. “Even if the health care sector can somehow find more beds, it cannot just go out and buy more front-line caregivers.”

Litwin said he’s glad to see the labor market rewarding essential workers — disproportionately women and people of color — with higher wages. Under normal circumstances, allowing markets to determine where people will work and for what pay is ideal.

“On the other hand, we are not operating under normal circumstances,” he said. “In the midst of a severe public health crisis, I worry that the individual incentives facing hospitals on the one side and individual RNs on the other conflict sharply with the needs of society as whole.”

Some hospitals are exploring ways to overcome staffing challenges without blowing the budget. That could include changing nurse-to-patient ratios, although that would likely affect patient care. In Utah, the hospital association has talked with the state nursing board about allowing nursing students in their final year of training to be certified early.

Growth Industry

Meanwhile business is booming for companies centered on health care staffing such as Wanderly and Krucial Staffing.

“When COVID first started and New York was an epicenter, we at Wanderly kind of looked at it and said, ‘OK, this is our time to shine,’” said David Deane, senior vice president of Wanderly, a website that allows health care professionals to compare offers from various agencies. “‘This is our time to help nurses get to these destinations as fast as possible. And help recruiters get those nurses.’”

Deane said the company has doubled its staff since the pandemic started. Demand is surging — with Rocky Mountain states appearing in up to 20 times as many job postings on the site as in January. And more people are meeting that demand.

In 2018, according to data from a national survey, about 31,000 traveling nurses worked nationwide. Now, Deane estimated, there are at least 50,000 travel nurses. Deane, who calls travel nurses “superheroes,” suspects a lot of them are postoperative nurses who were laid off when their hospitals stopped doing elective surgeries during the first lockdowns.

Competition for nurses, especially those with ICU experience, is stiff. After all, a hospital in South Dakota isn’t competing just with facilities in other states.

“We’ve sent nurses to Aruba, the Bahamas and Curacao because they’ve needed help with COVID,” said Deane. “You’re going down there, you’re making $5,000 a week and all your expenses are paid, right? Who’s not gonna say yes?”

Krucial Staffing specializes in sending health care workers to disaster locations, using military-style logistics. It filled hotels and rented dozens of buses to get nurses to hot spots in New York and Texas. CEO Brian Cleary said that, since the pandemic started, the company has grown its administrative staff from 12 to more than 200.

“Right now we’re at our highest volume we’ve been,” said Cleary, who added that over Halloween weekend alone about 1,000 nurses joined the roster of “reservists.”

With a base rate of $95 an hour, he said, some nurses working overtime end up coming away with $10,000 a week, though there are downsides, like the fact that the gig doesn’t come with health insurance and it’s an unstable, boom-and-bust market.

Hidden Costs

Amber Hazard, who lives in Texas, started as a traveling ICU nurse before the pandemic and said eye-catching sums like that come with a hidden fee, paid in sanity.

“How your soul is affected by this is nothing you can put a price on,” she said.

At a high-paying job caring for COVID patients during New York’s first wave, she remembers walking into the break room in a hospital in the Bronx and seeing a sign on the wall about how the usual staff nurses were on strike.

“It said, you know, ‘We’re not doing this. This is not safe,’” said Hazard. “And it wasn’t safe. But somebody had to do it.”

The highlight of her stint there was placing a wedding ring back on the finger of a recovered patient. But Hazard said she secured far more body bags than rings on patients.

Tripeny, the traveling nurse who left Colorado, is now working in Kentucky with heart surgery patients. When that contract wraps up, she said, she might dive back into COVID care.

Earlier, in New Jersey, she was scarred by the times she couldn’t give people the care they needed, not to mention the times she would take a deceased patient off a ventilator, staring down the damage the virus can do as she removed tubes filled with blackened blood from the lungs.

She has to pay for mental health therapy out-of-pocket now, unlike when she was on staff at a hospital. But as a so-called traveler, she knows each gig will be over in a matter of weeks.

At the end of each week in New Jersey, she said, “I would just look at my paycheck and be like, ‘OK. This is OK. I can do this.’”

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 Lame-Duck Status Leaves Governors to Wing It on COVID

Not long after the world learned that President Donald Trump had lost his reelection bid, states began issuing a new round of crackdowns and emergency declarations against the surging coronavirus.

Taking action this time were Republican governors who had resisted doing so during the spring and summer. Now they face an increasingly out-of-control virus and fading hope that help will come from a lame-duck president who seems consumed with challenging the election results.

President-elect Joe Biden has promised a more unified national effort once he takes office on Jan. 20, and pressure is building on Congress to pass a new financial relief package. But with record hospitalizations and new cases, many governors have decided they can’t afford to wait.

“I don’t know any governor who’s sitting there waiting for the knight to come in on the horse,” said Lanhee Chen, a fellow at the Hoover Institution and a former senior health official in President George W. Bush’s administration. “There’s no way for these guys to just sit and wait. The virus and the crisis is getting worse hour by hour, day by day.”

As new measures trickle out across states, public health policy experts worry many don’t go far enough. For those states attempting to impose meaningful restrictions, their success depends on cooperation from a population with pandemic fatigue. And people may be reluctant to curtail their holiday gatherings.

Residents of many conservative states don’t acknowledge the depth of the health problem, especially given Trump and some of his allies have stressed the crisis is being overplayed and will end quickly.

The bottom line is that many people just aren’t sufficiently scared of the virus to do what must be done to stop the spread, said Rodney Whitlock, a health policy consultant and former adviser to Sen. Chuck Grassley (R-Iowa).

“You’re dealing with folks there who definitely put liberty over everything else because they’re not afraid enough,” Whitlock said. “Even in the face of cases, even in the face of people around them getting it. They’re just not afraid.”

Among the first governors to act was outgoing Utah Gov. Gary Herbert. The day after The Associated Press called the presidential election for Biden on Nov. 7, the Republican announced Utah’s first-ever statewide mask mandate and clamped down on social gatherings and other activities until Nov. 23.

“All of us need to work together and see if there’s a better way,” Herbert said in a news conference.

Republican and Democratic governors alike followed with measures of their own in Colorado, Iowa, Michigan, Nebraska, New York, Ohio, Oregon, Pennsylvania, Washington and other states. Strategies included partial lockdowns, limits on crowds, canceling in-person classes for schools and reducing hours and capacity for bars and restaurants.

Health policy experts largely agree that the virus’s spread, not the end of the election, is what’s driving these changes — though the end of the campaign season does take political pressure off governors inclined to issue COVID-preventive policies.

“It’s much easier to act when you don’t have attention on you than when you do, but I would hope that the action is taking place regardless of what the political circumstances are,” Chen said.

No state has yet resorted to the sort of full lockdowns enacted in the spring, which resulted in mass business closures and layoffs and sent the economy crashing.

Christopher Adolph, an associate professor at the University of Washington, and his team with the university’s COVID-19 State Policy Project have been studying states’ responses to the pandemic. Some states have made a show of taking action, without much substance behind it, he said. For example, Alaska Gov. Mike Dunleavy, a Republican, declared an emergency on Nov. 12 — but only recommended, not ordered, that people wear masks and maintain social distance.

Other governors first took small steps only to follow up with tighter restrictions. In Iowa, for example, Republican Gov. Kim Reynolds, who opposed mask mandates during the presidential campaign, initially announced that all people over age 2 would be required to wear masks at gatherings of certain sizes. On Nov. 16, she issued a simpler but stricter three-week statewide mask mandate.

North Dakota Gov. Doug Burgum, a Republican, also ordered mandatory face coverings for the first time. Hospitals there have been reporting they have more patients than capacity, and the state has been leading the country in new per capita COVID cases.

At the very least, each state should make it clear that people must not gather indoors, Adolph said. Restaurants, bars, gymnasiums and large indoor events should be closed, he said, and gatherings inside people’s homes should not happen.

“We’re not seeing enough clear, broadly communicated, well-stated, unambiguous policies,” Adolph said.

An exception is Herbert, one of two governors who will leave office in January. The two-term Utah governor will turn over the reins to his current lieutenant governor, Spencer Cox, who has been a part of the state’s response to the pandemic since the beginning. Both Republicans have promised a smooth, seamless transition between administrations.

The nation’s other lame-duck governor is Montana’s Steve Bullock, a Democrat. But unlike Herbert, the term-limited Bullock will be replaced by a governor from a different party. Republican U.S. Rep. Greg Gianforte defeated Bullock’s lieutenant governor, Mike Cooney, in the Nov. 3 election. And Bullock lost his bid for the U.S. Senate.

Bullock said in a Nov. 12 news conference that he would not take additional COVID-intervention measures without a federal aid package to blunt the economic fallout. Five days later, he reversed himself to expand a previous mask requirement and limit capacity and hours in bars, restaurants and other entertainment venues.

Gianforte has not directly answered whether he would continue Bullock’s restrictions. When asked, the governor-elect has spoken instead of personal responsibility and reopening the economy while protecting the most vulnerable people. In July, he referenced the unfounded hope that the virus would be slowed by the U.S. reaching “herd immunity” by the end of the year.

Another obstacle is that a district judge essentially ruled Bullock’s mask mandate unenforceable. State health department lawyers had asked District Judge Dan Wilson to enforce the mandate against five businesses accused of flouting the measure.

“The businesses and the owners have been put on the front line of implementing a state policy that has more exceptions than directives and would be about as effective in bailing water from the leaky boat of our present health circumstances as would a colander,” the judge said in denying the request.

That leaves Bullock with the task of managing a crisis in his final weeks of office with local officials already looking past him to a new administration.

In Flathead County, where the five businesses were sued for violating the mask mandate, local leaders were already chafing from what they saw as Bullock’s heavy hand.

“He has angered a lot of people in Flathead County,” County Commissioner Randy Brodehl, a Republican, said of Bullock. “He didn’t come here, he didn’t talk to us.”

Bullock’s troubles show that even if governors take measures to stem the spread of COVID-19, they may still have a difficult time persuading people to go along with them. That’s particularly an issue in the Upper Midwest and the Rocky Mountains, libertarian-leaning COVID hot spots where the medical infrastructure is already strained.

Some Trump supporters have followed the president’s lead in downplaying the virus and others are fatigued after months of isolation and precautions, said Whitlock.

In rural and conservative areas, people protest that COVID measures come at the expense of their personal freedom and their ability to earn a living, and some feel as though they’re being talked down to by mask advocates and public health officials, Whitlock said.

It’s going to take smart and consistent messaging to change attitudes — but that means more than Biden telling people to wear masks once he takes office, Whitlock added.

“Everybody has to own it,” he said. “You have to scream at the top of your lungs at the protests, at the celebrations, at the football games, at the concerts. It has to be, ‘Stop 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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People Proving to Be Weakest Link for Apps Tracking COVID Exposure

The app builders had planned for pranksters, ensuring that only people with verified COVID-19 cases could trigger an alert. They’d planned for heavy criticism about privacy, in many cases making the features as bare-bones as possible. But, as more states roll out smartphone contact-tracing technology, other challenges are emerging. Namely, human nature.

The problem starts with downloads. Stefano Tessaro calls it the “chicken-and-egg” issue: The system works only if a lot of people buy into it, but people will buy into it only if they know it works.

“Accuracy of the system ends up increasing trust, but it is trust that increases adoptions, which in turn increases accuracy,” Tessaro, a computer scientist at the University of Washington who was involved in creating that state’s forthcoming contact-tracing app, said in a lecture last month.

In other parts of the world, people are taking that necessary leap of faith. Ireland and Switzerland, touting some of the highest uptake rates, report more than 20% of their populations use a contact-tracing app.

Americans seem not so hot on the idea. As with much of the U.S. response to the pandemic, this country hasn’t had a national strategy. So it’s up to states. And only about a dozen, including the recent addition of Colorado, have launched the smartphone feature, which sends users a notification if they’ve crossed paths with another app user who later tests positive for COVID-19.

Within those few states, enthusiasm appears dim. In Wyoming, Alabama and North Dakota, some of the few states with usage data beyond initial downloads, under 3% of the population is using the app.

The service, built by Google and Apple and adapted by individual countries, states or territories, either appears as a downloadable app or as a setting, depending on the state and the device. It uses Bluetooth to identify other phones using the app within about 6 feet for more than 15 minutes. If a user tests positive for COVID-19, they’re given a verification code to input so that each contact can be notified they were potentially exposed. The person’s identity is shielded, as are those of the people notified.

“The more people who add their phone to the fight against COVID, the more protection we all get. Everyone should do it,” Sarah Tuneberg, who leads Colorado’s test and containment effort, told reporters on Oct. 29. “The sky’s the limit. Or the population is the limit, really.”

But the population could prove to be quite a limit. Data from early-adopter governments suggests even those who download the app and use it might not follow directions at the most critical juncture.

According to the Virginia Health Department, from August to November, about 613 app users tested positive and received a code to alert their contacts that they may have exposed them to the virus. About 60% of them actually activated it.

In North Dakota, where the outbreak is so big that human contact tracers can’t keep up, the data is even more dire. In October, about 90 people tested positive and received the codes required to alert their contacts. Only about 30% did so.

Researchers in Dublin tracking app usage in 33 regions around the world have encountered echoes of the same issue. In October, they wrote that in parts of Europe fewer people were alerting their contacts than expected, given the scale of the outbreaks and the number of active app users. Italy and Poland ranked lowest. There, they estimated, just 10% of the app users they’d expect were submitting the codes necessary to warn others.

“I’m not sure that anybody working in this field had foreseen that that could be a problem,” said Lucie Abeler-Dörner, part of a team at the Big Data Institute at Oxford studying COVID-19 interventions, including digital contact tracing. “Everybody just assumed that if you sign up for a voluntary app … why would you then not push that button?”

So far, people in the field only have guesses. Abeler-Dörner wonders how much of it has to do with people going into panic mode when they find out they’re positive.

Tessaro, the University of Washington computer scientist, asks if the health officials who provide the code need more training on how to provide clear instructions to users.

Elissa Redmiles, a faculty member at the Max Planck Institute for Software Systems who is studying what drives people to install contact-tracing apps, worries that people may have difficulty inputting their test results.

But Tim Brookins, a Microsoft engineer who developed North Dakota’s contact-tracing app as a volunteer, has a bleaker outlook.

“There’s a general belief that some people want to load the app so that they can be notified if someone else was positive, in a self-serving way,” he said. “But if they’re positive, they don’t want to take the time.”

Abeler-Dörner called the voluntary notification a design flaw and said the alerts should instead be automatically triggered.

Even with the limitations of the apps, the technology can help identify new COVID cases. In Switzerland, researchers looked at data from two studies of contact-tracing app users. They wrote in a not-yet-peer-reviewed paper that while only 13% of people with confirmed cases in Switzerland used the app to alert their contacts from July to September, that prompted about 1,700 people who had potentially been exposed to call a dedicated hotline for help. And of those, at least 41 people discovered they were, indeed, positive for COVID-19.

In the U.S., another non-peer-reviewed modeling study from Google and Oxford University looking at three Washington state counties found that even if only 15% of the population uses a contact-tracing app, it could lead to a drop in COVID-19 infections and deaths. Abeler-Dörner, a study co-author, said the findings could be applicable elsewhere, in broad strokes.

“It will avert infections,” she said. “If it’s 200 or 1,000 and it prevents 10 deaths, it’s probably worth it.”

That may be true even at low adoption rates if the app users are clustered in certain communities, as opposed to being scattered evenly across the state. But prioritizing privacy has required health departments to forgo the very data that would let them know if users are near one another. While an app in the United Kingdom asks users for the first few digits of their postal code, very few U.S. states can tell if users are in the same community.

Some exceptions include North Dakota, Wyoming and Arizona, which allow app users to select an affiliation with a college or university. At the University of Arizona, enough people are using the app that about 27% of people contacted by campus contact tracers said they’d already been notified of a possible exposure. Brookins of Microsoft, who created Care19 Alert, the app used in Wyoming and North Dakota, said that offering an affiliation option also allows people who’ve been exposed to get campus-specific instructions on where to get tested and what to do next.

“In theory, we can add businesses,” he said. “It’s so polarizing, no businesses have wanted to sign up, honestly.”

The privacy-focused design also means researchers don’t have what they need to prove the apps’ usefulness and therefore encourage higher adoption.

“Here there is actually some irony because the fact that we are designing this solution with privacy in mind somehow prevents us from accurately assessing whether the system works as it should,” Tessaro said.

In states including Colorado, Virginia and Nevada, the embedded privacy protections mean no one knows who has enabled the contact-tracing technology. Are they people who barely interact with anyone, or are they essential workers, interacting regularly with many people that human contact tracers would never be able to reach? Are they crossing paths and trading signals with other app users or, if they test positive, will their warning fall silently like a tree in an empty forest? Will they choose to notify people at all?

Colorado’s health department said it’s issuing thousands of COVID codes a day. As of Wednesday, 3,400 people have used the codes to notify their contacts, it said. An automated system issues codes for positive COVID-19 tests even if the infected people don’t have the app, making it impossible to know how many users are acting on the codes.

“I have hope that the vast majority of Coloradans will take this opportunity to give this gift of exposure notification to other people,” said Tuneberg. “I believe Coloradans will do 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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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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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:

Aborto

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.

Medicaid

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.

California

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.

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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:

Abortion

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.

Medicaid

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.

California

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.

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The Best COVID Warning System? Poop and Pooled Spit, Says One Colorado School

Carol Wilusz’s mornings now often start at 4 a.m., scanning the contents of undergraduates’ feces. Specifically, scanning the data on how much coronavirus they flushed into the shadows, destined to be extracted from 17 manholes connected to dorm buildings on Colorado State University’s Fort Collins campus.

“There are quite extensive numbers of poop jokes,” said Wilusz, a CSU molecular biologist.

Emerging research suggests infected people start shedding the coronavirus in their poop early in their infection, and possibly days before they begin shedding it from their mouths and noses. “It means that we can catch them before they’re actually spreading the infection,” she said.

In normal times, Wilusz studies stem cells and muscular dystrophy. Now, her team is on the front lines of defense against the massive COVID-19 outbreaks that, for a campus with more than 23,000 undergraduates alone, always seem to be lurking around the corner. The sewage review is part of a multipronged attack that includes the usual weapon of contact tracing plus a specialized “paired pooling” form of testing saliva samples. So far, the school has had about 500 cases since the semester started, about half that of the only somewhat bigger University of Colorado-Boulder.

Amid fluctuating scientific recommendations and a virus that still holds uncertainties, colleges across the country are taking a choose-your-own-adventure approach to COVID-19. For those holding in-person classes, the adventure includes an extra puzzle: how to concentrate a lot of people into one place without an outbreak tearing through the student body and spilling into the community, all without safety precautions that would break the bank. Testing is at the core of those plans.

“A lot of these institutions started testing just symptomatic students. And that is really not good, to put it bluntly, because as we’ve seen over the past couple of months, students tend to be asymptomatic,” said Chris Marsicano, an assistant professor at Davidson College in North Carolina who is leading an initiative tracking how universities are responding to the pandemic. “The institutions that have been the most successful are ones that are testing every student at least once a week.”

According to data collected in mid-September, only about 6% of large universities with in-person classes are routinely testing all students, according to an NPR analysis of his group’s data. The University of Illinois at Urbana-Champaign has been leading the pack, testing about 10,000 students each day using a streamlined spit-testing method. But it’s pricey. Despite driving down the cost of an individual test to about $10, Paul Hergenrother, a chemist leading the effort, said the school is still spending about $1 million a week.

At Colorado State University, Lori Lynn, co-chair of the school’s pandemic response team, said initially the school was paying $93 a pop to test students using the usual nose swab method.

“We quickly spent several million dollars on testing,” said Lynn, who added that cost is just one limiting factor. “We can’t test everybody in the community, you know, weekly or twice a week.”

Instead, Mark Zabel, a CSU molecular biologist and immunologist who typically studies neurodegenerative diseases, said his group recently figured out how to screen saliva for less than $20 a person. It involves pooling drool samples in a strategic way reminiscent of the children’s game Battleship.

Traditionally, pooling involves mixing samples from multiple people and testing them all in one go, to save time and materials. If the pool comes back negative for the virus, everyone in the pool can be considered negative. If it’s positive, samples from each person in that pool must be retested. If there are high rates of infection, that means a lot of retesting.

Instead of pooling samples willy-nilly, Zabel and his colleagues are doing something he calls paired pooling: They start with an eight-by-eight grid of saliva from 64 people, arrayed almost like a Battleship board. Each person’s spit sample gets divided up and analyzed in two pools, one pool for the row it sits in and one for the column it sits in, for a grand total of 16 pools per grid.

If the test containing samples in Row A and the test containing samples from Column One appear positive, that would indicate that the person whose spit is in the A-1 slot is a positive case.

“So, it’s super easy if we’ve got one positive among 64,” said Zabel. In that case, they’ve screened 64 people with just 16 tests. No retesting necessary.

Limited retesting is needed only if at least four pools come back positive.

They’re also using a different kind of PCR test than usual, in an effort to avoid competing for limited reagents, whose shortages have hampered labs nationwide.

Zabel said it takes between eight and 24 hours for results. However, some drawbacks exist. If retesting is necessary, total turnaround time could extend to three days. And if the outbreak were to grow beyond a certain point, in which at least 5% of people tested are positive, the process would become more cumbersome because they’d have to add more layers of testing.

It’s a shifting target and the university is continually reevaluating its testing strategy, but Zabel expects his lab could test up to 3,000 people a day, which would enable testing the entire student body every other week.

According to other researchers, that might not be enough.

Daniel Larremore and others writing in the New England Journal of Medicine said it’s time to ditch any approach that relies on highly accurate tests, and instead embrace antigen tests, which are cheap and quick — albeit less accurate — and can be administered frequently.

“You have the science of testing, which says if you’re testing everybody twice a week, you should basically have zero cases,” said Larremore, a computational biologist at the University of Colorado-Boulder, referring to modeling studies from his lab and others.

But then, there’s reality. And no testing system alone will solve the problem, Larremore said, “because there are humans involved.”

Wilusz, the CSU professor, knows how difficult this is. Often people continue shedding virus in their poop long after they’ve recovered, so over the course of the semester more and more dorms have started to yield virus-positive sewage.

“And then there’s also, we can’t stop students pooping in the wrong dorm. So one could poop in this dorm one day and then next door on the other day,” she said, making it hard to know which dorm to screen with saliva tests.

Also, only about 5,000 of the school’s 28,000 enrolled students live in dorms, though Wilusz said those close quarters create a high risk for spreading the disease because “they’re essentially like nursing homes for young people.”

She wonders how long students will remain game to spit into tubes before they get bored. Michigan State University researchers experimenting with paired pooling and saliva have made a habit of double-checking that students have submitted spit instead of something else. (Chewing tobacco and something the color of blue Gatorade have sullied a few CSU samples so far.)

But the shifting, multifaceted approach does seem to be helping at Colorado State. Back in September, Wilusz noticed a concerning spike in the amount of virus in the sewage connected to two dorms that collectively housed about 900 students. The university put the dorms on lockdown and tested everyone inside, revealing nine positive cases that hadn’t been found using other methods.

Now, with pooled-spit screening, Zabel said the team has been able to identify positives without locking down entire dorms, and can then use subsiding levels in sewage to confirm no infections slipped through the cracks.

The goal is to make it to Thanksgiving, when students return home. But then comes 2021. “We’ll see if we can keep on top of it,” Zabel said, knocking on his desk for luck.

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 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.

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Colorado Initiative Would Further Limit Access in Middle America’s ‘Abortion Desert’

Colorado voters are deciding a ballot question that seeks to limit how far into pregnancy an abortion can be legally performed. While the measure would change the law only in Colorado, it would resonate throughout the Rocky Mountain states and Midwest amid an intensifying national fight, fueled by a Supreme Court vacancy, over the future of abortion.

In 1967 — six years before the Supreme Court’s Roe v. Wade decision protected the right to an abortion in the U.S. — Colorado became the first state to pass a law widening access to legal abortion. More than 50 years later, it remains one of just seven states without gestational limits on the procedure, making Colorado one of the few options for people nationwide who need abortions later in pregnancy.

Proposition 115 seeks to change that. It would outlaw abortion in the state after 22 weeks. The proposition makes an exception to save the life of the pregnant person, but none for cases of rape or incest or to protect the health of the pregnant individual or fetus.

But the impact of the measure also would be felt by neighboring states where people have little or no access to abortion. Kelly Baden, vice president of reproductive rights at the left-leaning policy group State Innovation Exchange, called the surrounding region an abortion desert.

“Colorado really plays an important role in the region in being a haven for access for people who live in those highly restrictive states, some of which neighbor us, like Kansas, Nebraska — that whole swath of the Midwest from the Dakotas on down to Texas,” Baden said.

A study published in the Journal of Medical Internet Research in 2018 found the Midwest has fewer abortion clinics per capita than any other U.S. region, with 92 facilities across 10 states.

Colorado providers have stepped in, and approximately 1 in 10 abortions are performed on people from out of state. A billboard on Interstate 70 welcomed visitors from Utah with the message “Welcome to Colorado, where you can get a safe, legal abortion.”

Colorado voters have rejected three abortion-related ballot measures since 2008, which advocates pointed to as evidence that the state’s residents are fine with the status quo.

“Colorado has already voted on ridiculous abortion restrictions multiple times and said, ‘We don’t want them.’ It’s insulting that these extremists keep trying,” said Whitney Woods, speaking on her own behalf while on maternity leave from Planned Parenthood of the Rocky Mountains.

Over the past decade, however, those measures have been rejected by smaller and smaller margins, said Bob Enyart, a spokesperson for Colorado Right to Life — one of several groups pushing for Proposition 115 to pass.

“Coloradoans increasingly voted to recognize each unborn child as a person from 2008 to 2010 to 2014,” said Enyart.

Indeed, 2008’s Amendment 48, which proposed redefining personhood in the state constitution as starting at conception, received support from 27% of voters. Six years later, that support grew to 35% for Amendment 67.

A recent poll by 9News in Denver and Colorado Politics showed that voters are more evenly divided about the new proposition, with 45% saying they’ll vote no, 42% planning to vote yes, and a crucial 13% still undecided.

Randi Davis, a mom in Aurora, is one voter whose own experience illustrates how personal and nuanced the question can be. When she was pregnant, Davis was advised to have an abortion, as her baby’s odds of survival were slim to none. She said she opted against abortion and went on to give birth to a full-term stillborn baby.

“I’m not necessarily for abortion,” Davis said. “However, I do believe every woman should have their own choice to abort for whatever reason.”

She said she’s voting against the proposition.

Dr. Thomas Perille heads the medical advisory team for the Coalition for Women and Children (also known as Due Date Too Late), the group that petitioned to put Proposition 115 on the ballot and calls abortions later in pregnancy “too extreme.” Perille contends the new proposition “bears no relation” to the previous measures, giving it a better chance of passing.

“Those were bans on abortion, and Prop 115 is a reasonable restriction of abortion after fetal viability,” he said.

Abortion-rights activists worry that bans of abortions after the first trimester aim to gradually shift public opinion and gain traction to fully outlaw the procedure.

“They’re hoping that they can slide this under the radar and really cast it as a compromise between anti-abortion and pro-choice voters,” said Fawn Bolak, spokesperson for ProgressNow Colorado. “But that’s not what this is. This is a violation of Roe v. Wade.”

Perille said that, while first-trimester abortions are “relatively safe,” late abortions pose a “substantial risk” to the people having them. Advocates for the initiative said studies show the risk of death to the pregnant person from an abortion increases with each week of gestation.

Opponents point to another study that shows legal abortions overall tend to be safer and pose less of a threat to pregnant people’s lives than childbirth.

Colorado isn’t the only state voting on an abortion initiative this election cycle. Voters in Louisiana are considering a constitutional amendment that says nothing in the state constitution can be interpreted as protecting a right to, or requiring funding of, abortion.

The measure’s advocates say that, if Roe v. Wade is overturned, the legality of abortion in Louisiana would be up to state lawmakers. Opponents say the measure, if it passes, would eliminate legal access to abortion in the state if Roe v. Wade is dismantled.

“Constitutions are supposed to be about preserving and enshrining freedom, but this amendment takes away freedom and rights while allowing the government to tell people what they can and cannot do with their body,” said Michelle Erenberg, executive director for Lift Louisiana, a group that advocates for abortion rights.

Abortion-rights advocates also point out that Louisiana passed its own 22-week abortion ban a decade ago, and worry that Colorado could follow a similar path toward even greater restrictions.

The decisions before voters in Colorado and Louisiana come amid renewed attention nationwide on abortions since Supreme Court Justice Ruth Bader Ginsberg’s death last month. Senate Republicans are now pushing through President Donald Trump’s nominee, Judge Amy Coney Barrett. That has led voters and activists on both sides of the issue to become heavily focused on what Barrett’s appointment could mean for the future of Roe v. Wade.

Abortion opponents contend it’s not clear that Barrett’s confirmation would doom Roe.

“We have seen no evidence that Amy Coney Barrett has ever recognized that the unborn child is a person or has a right to life,” Enyart said. “We are concerned that she may disagree with the Roe opinion merely as a matter of process, not morality.”

But The Guardian recently reported on Barrett’s previous involvement with an anti-abortion organization, noting she signed a newspaper ad that called Roe “barbaric,” which put abortion-rights advocates on edge.

Erika Christensen, who helped pass New York’s Reproductive Health Act, said she is concerned but added that these new threats to abortion rights have become a rallying point for advocates.

Baden agreed, saying the renewed energy is particularly strong locally.

“We need to turn to the state level, and do whatever we can to prepare for what might come one day, be it from the Supreme Court or from another Trump executive order, or something else coming,” she said. “Roe is the floor, not the ceiling, right?”

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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Aunque preferiría cerrar, la cadena de tiendas COVID-19 Essentials se expande

Lone Tree, Colorado.- Darcy Velásquez, de 42 años, y su madre, Roberta Truax, caminaban recientemente por el centro comercial Park Meadows, 15 millas al sur del centro de Denver, buscando regalos de Navidad para los dos hijos de Velásquez, cuando vieron una tienda con un exhibición de máscaras faciales adornadas con diamantes de fantasía.

Brillantes ideales para una nena de 9 años.

La tienda se llama COVID-19 Essentials. Y bien puede ser la primera cadena minorista del país dedicada exclusivamente a una enfermedad infecciosa.

Con el cierre de muchas tiendas en los Estados Unidos durante la pandemia de coronavirus, especialmente dentro de los centros comerciales, los propietarios de esta cadena han sacado provecho del espacio vacío, así como de la creciente aceptación de que usar máscaras es una realidad que puede durar hasta 2021, o más.

Las máscaras faciales han evolucionado de ser un producto utilitario, cualquier cosa podía servir para taparte la boca, a una forma de expresar la personalidad, las inclinaciones políticas o el fanatismo deportivo.

Y los propietarios de COVID-19 Essentials están apostando a que los estadounidenses están dispuestos a poner dinero en sus bocas. Los precios van desde $19,99 por una simple máscara para niños hasta $130 por una cubierta facial con un filtro N95 y un ventilador a batería.

Casi todas las tiendas en el centro comercial Park Meadows ahora venden máscaras. Pero COVID-19 Essentials también ofrece otros accesorios para la pandemia, en un espacio exclusivo:  su logo es una imagen estilizada de una partícula de coronavirus.

Ubicado junto a la tienda de remeras UNTUCKit y frente a una sala de exhibición de Tesla, no tiene el reconocimiento de marca ni el historial de un J.C. Penney. Pero la longevidad no parece haber ayudado a que la cadena de ropa o muchas otras escaparan de la crisis por la pandemia. Según los analistas de S&P Global Market Intelligence, las quiebras minoristas de enero a mediados de agosto alcanzaron su punto más alto en 10 años.

No es que los propietarios de COVID-19 Essentials quieran que sus productos tengan demanda para siempre.

“Estoy ansioso por cerrar el negocio eventualmente”, dijo Nadav Benimetzky, un minorista de Miami que fundó COVID-19 Essentials, que ahora tiene ocho tiendas en todo el país.

Nathan Chen, propietario de la tienda Lone Tree con Benimetzky, tenía un negocio diferente en el aeropuerto de Denver, pero a medida que disminuyeron los vuelos, una alternativa  centrada en COVID se perfiló como una empresa mucho mejor.

Benimetzky abrió la primera tienda COVID-19 Essentials en el Aventura Mall en los suburbios de Miami después de ver la demanda de máscaras N95 al principio de la pandemia. “Son feas e incómodas, y todo el mundo las odia”, dijo. “Si vas a usar una máscara, también puede estar a la moda y ser bonita”.

Eso podría significar una máscara de lentejuelas o satén para ocasiones más formales, o la sonrisa de una calavera para asuntos casuales. Algunos cubrebocas tienen cremalleras para facilitar la alimentación, o un orificio para una pajita, con cierre de velcro.

La cadena tiene tiendas en la ciudad de Nueva York, Nueva Jersey, Philadelphia y Las Vegas, y está buscando abrir otras en California, donde los incendios forestales han aumentado la demanda de máscaras.

Inicialmente, los propietarios realmente no estaban seguros de que la idea funcionara. Abrieron la primera tienda justo cuando los centros comerciales volvían a abrir después de las cuarentenas.

“Realmente no comprendimos qué tan grande sería”, dijo Benimetzky. “No lo analizamos con la idea de abrir muchas tiendas. Pero hemos estado ocupados desde el momento en que abrimos “.

Nancy Caeti, de 76 años, se detuvo en la tienda Lone Tree para comprar máscaras para sus nietos. Compró una transparente para su nieta, cuyo instructor de lenguaje de señas necesita ver sus labios moverse. Le compró a su hija, profesora de música y fanática de los Denver Broncos, una máscara con el logo del equipo de fútbol americano.

“Sobreviví a la epidemia de polio”, contó Caeti. Recordó cómo su madre los puso en fila a ella y a sus hermanos para recibir la vacuna contra la polio, y dijo que ella sería la primera en la fila para recibir la vacuna para COVID.

Ese quizás sea el único “básico” que la tienda no vende. Pero tiene dispositivos similares a llaves para abrir puertas y presionar botones de ascensores sin tocarlos. Algunos tienen un abridor de botellas incorporado. Hay dispositivos de luz ultravioleta para desinfectar teléfonos y un desinfectante de manos exclusivo que los empleados rocían a los clientes como si fuera una muestra de perfume.

Pero las máscaras son el mayor atractivo porque la tienda las puede personalizar.

Al entrar, los clientes pueden verificar su temperatura con un escáner de frente digital con instrucciones audibles: “Acérquese. Acércate. Temperatura normal. Temperatura normal”.

La tienda también ha agregado un fregadero cerca de la entrada para que los clientes puedan lavarse las manos antes de tocar los productos.

Algunos pasan por la tienda desconcertados, deteniéndose para tomar fotos y publicarlas en las redes sociales. Una pareja mayor (blanca no hispana) con máscaras idénticas observó una máscara en el negocio con el lema “Black Lives Matter” y se alejó.

El negocio no toma partido politico: hay tres diseños de máscaras del presidente Donald Trump, y dos para el candidato presidencial demócrata Joe Biden.

Daniel Gurule, de 31 años, pasó por el centro comercial a la hora del almuerzo para comprar un Apple Watch, pero se aventuró a entrar en la tienda por una nueva máscara. Dijo que normalmente usaba una máscara con ventilación, pero que no todos los lugares las permiten. (Protegen a los usuarios, pero no a las personas que los rodean). Compró una por $24,99 con el logo del equipo de baloncesto Denver Nuggets.

“Nos quita un poco de nuestra personalidad cuando todo el mundo camina con máscaras desechables”, dijo Chen. “Parece un hospital, como si todo el mundo estuviera enfermo”.

La mayoría de las máscaras están cosidas específicamente para la cadena, incluidas muchas hechas a mano. Uno de sus proveedores es una familia de inmigrantes vietnamitas que cosen máscaras en su casa de Los Ángeles, dijo Benimetzky.

Chen dijo que era difícil tener máscaras en stock y que todos los días hay un nuevo diseño que es éxito de ventas.

Dorothy Lovett, de 80 años, se detuvo frente a la tienda, apoyada en un bastón con un diseño de estampado animal. “Tuve que retroceder y decir, ‘¿Qué diablos es esto?’”, dijo. “Nunca antes había visto una tienda de máscaras”.

Examinó la vitrina, notando que necesitaba encontrar una mejor opción que la versión de tela que estaba usando.

“No puedo respirar con ésta”, dijo Lovett, antes de decidirse por su favorita. “Me gusta la máscara Black Lives Matter”.

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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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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Not Pandemic-Proof: Insulin Copay Caps Fall Short, Fueling Underground Exchanges

DENVER — D.j. Mattern had her Type 1 diabetes under control until COVID’s economic upheaval cost her husband his hotel maintenance job and their health coverage. The 42-year-old Denver woman suddenly faced insulin’s exorbitant list price — anywhere from $125 to $450 per vial — just as their household income shrank.

She scrounged extra insulin from friends, and her doctor gave her a couple of samples. But as she rationed her supplies, her blood sugar rose so high her glucose monitor couldn’t even register a number. In June, she was hospitalized.

“My blood was too acidic. My system was shutting down. My digestive tract was paralyzed,” Mattern said, after three weeks in the hospital. “I was almost near death.”

So she turned to a growing underground network of people with diabetes who share extra insulin when they have it, free of charge. It wasn’t supposed to be this way, many thought, after Colorado last year was the first of 12 states to implement a cap on the copayments that some insurers can charge consumers for insulin. But as the COVID pandemic has caused people to lose jobs and health insurance, demand for insulin sharing has skyrocketed. Many patients who once had good insurance are now realizing the $100 cap is only a partial solution, applying just to state-regulated health plans.

Colorado’s cap does nothing for the majority of people with employer-sponsored plans or those without insurance coverage. According to the state chapter of Type 1 International, an insulin access advocacy group, only 3% of patients with Type 1 diabetes under 65 could benefit from the cap.

Such laws, often backed by pharmaceutical companies, give the impression that things are improving, said Colorado chapter leader Martha Bierut. “But the reality is, we have a much longer road ahead of us.”

The struggle to afford insulin has forced many people into that underground network. Through social media and word-of-mouth, those in need of insulin connect with counterparts who have a supply to spare. Insurers typically allow patients a set amount of insulin per month, but patients use varying amounts to control their blood sugar levels depending on factors such as their diet and activity that day.

Though it’s illegal to share a prescription medication, those involved say they simply don’t care: They’re out to save lives. They bristle at the suggestion that the exchanges resemble back-alley drug deals. The supplies are given freely, and no money changes hands.

For those who can’t afford their insulin, they have little choice. It’s a your-money-or-your-life scenario for which the American free-market health care system seems to have no answer.

“I can choose not to buy the iPhone or a new car or to have avocado toast for breakfast,” said Jill Weinstein, who lives in Denver and has Type 1 diabetes. “I can’t choose not to buy the insulin, because I will die.”

Exacerbated by the Pandemic

Surveys conducted before the pandemic showed that 1 in 4 people with either Type 1 or Type 2 diabetes had rationed insulin because of the cost. For many Blacks, Hispanics and Native Americans, the pinch was especially bad. These populations are more likely to have diabetes and also more likely to face economic disparities that make insulin unaffordable.

Then COVID-19 arrived, with economic stress and the virus itself hitting people in those groups the hardest.

This year, the American Diabetes Association reported a surge in calls to its crisis hotline regarding insulin access problems. In June, the group found, 18% of people with diabetes were unemployed, compared with 12% of the general public. Many are wrestling with the tough choices of whether to pay for food, rent, utilities or insulin.

Rep. Dylan Roberts, a Democrat who sponsored Colorado’s copay cap bill, said legislators knew the measure was only the first step in addressing high insulin costs. The law also tasked the state’s attorney general to produce a report, due Nov. 1, on insulin affordability and solutions.

“We went as far as we could,” Roberts said. “While I feel Colorado has been a leader on this, we need to do a whole lot more both at the state and national level.”

According to the American Diabetes Association, 36 other states have introduced insulin copay cap legislation, but the pandemic stalled progress on most of those bills.

Insulin prices are high in the U.S. because few limits exist for what pharmaceutical manufacturers can charge. Three large drugmakers dominate the insulin market and have raised prices in near lockstep. A vial that 20 years ago cost $25 to $30 now can run 10 to 15 times that much. And people with diabetes can need as many as four or five vials per month.

“It all boils down to cost,” said Gail deVore, who lives in Denver and has Type 1 diabetes. “We’re the only developed nation that charges what we charge.”

Before the COVID crisis triggered border closures, patients often crossed into Mexico or Canada to buy insulin at a fraction of the U.S. price. President Donald Trump has taken steps to lower drug prices, including allowing for the importation of insulin in some cases from Canada, but that plan will take months to implement.

The Kindness of Strangers

DeVore posts on social media three or four times a year asking if anybody needs supplies. While she’s always encountered demand, her last tweet in August garnered 12 responses within 24 hours.

“I can feel the anxiety,” deVore said. “It’s unbelievable.”

She recalled helping one young man who had moved to Colorado for a new job but whose health insurance didn’t kick in for 90 days. She used a map to choose a random intersection halfway between them. When deVore arrived on the dusty rural road after dark, his car was already there. She handed him a vial of insulin and testing supplies. He thanked her profusely, almost in tears, she said, and they parted ways.

“The desperation was obvious on his face,” she said.

It’s unclear just how widespread such sharing of insulin has become. In 2019, Michelle Litchman, a researcher at the University of Utah’s College of Nursing, surveyed 159 patients with diabetes, finding that 56% had donated insulin.

“People with diabetes are sometimes labeled as noncompliant, but many people don’t have access to what they need,” she said. “Here are people who are genuinely trying to find a way to take care of themselves.”

If insulin affordability doesn’t improve, Litchman suggested in a journal article, health care providers may have to train patients on how to safely engage in underground exchanges.

The hashtag #Insulin4all has become a common way of amplifying calls for help. People sometimes post pictures of the supplies they have to share, while others insert numbers or asterisks within words to avoid social media companies removing their posts.

Although drug manufacturers offer limited assistance programs, they often have lengthy application processes. So they typically don’t help the person who accidentally drops her last glass vial on a tile floor and finds herself out of insulin for the rest of the month. Emergency rooms will treat patients in crisis and have been known to give them an extra vial or two to take home. But each crisis takes a toll on their long-term health.

That’s why members of the diabetes community continue to look out for one another. Laura Marston, a lawyer with Type 1 diabetes who helped to expose insulin pricing practices by Big Pharma, said two of the people she first helped secure insulin, both women in their 40s, are in failing health, the result of a lifetime of challenges controlling their disease.

“The last I heard, one is in end-stage renal failure and the other has already had a partial limb amputation,” Marston said. “The effects of this, what we see, you can’t turn your back on it.”

The underground sharing is how Mattern secured her insulin before recently qualifying for Medicaid. When someone on a neighborhood Facebook group asked if anybody needed anything in the midst of the pandemic, she replied with one word: insulin. Soon, an Uber driver arrived with a couple of insulin pens and replacement sensors for her glucose monitor.

“I knew it wasn’t altogether legal,” Mattern said. “But I knew that if I didn’t get it, I wouldn’t be alive.”

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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Opposition to Obamacare Becomes Political Liability for GOP Incumbents

In the 2014 elections, Republicans rode a wave of anti-Affordable Care Act sentiment to pick up nine Senate seats, the largest gain for either party since 1980. Newly elected Republicans such as Cory Gardner in Colorado and Steve Daines in Montana had hammered their Democratic opponents over the health care law during the campaign and promised to repeal it.

Six years later, those senators are up for reelection. Not only is the law still around, but it’s gaining in popularity. What was once a winning strategy has become a political liability.

Public sentiment about the ACA, also known as Obamacare, has shifted considerably during the Trump administration after Republicans tried but failed to repeal it. Now, in the midst of the COVID-19 pandemic and the ensuing economic crisis, which has led to the loss of jobs and health insurance for millions of people, health care again looks poised to be a key issue for voters this election.

With competitive races in Colorado, Montana, Arizona, North Carolina and Iowa pitting Republican incumbents who voted to repeal the ACA against Democratic challengers promising to protect it, attitudes surrounding the health law could help determine control of the Senate. Republicans hold a slim three-vote majority in the Senate but are defending 23 seats in the Nov. 3 election. Only one Democratic Senate seat — in Alabama, where incumbent Doug Jones is up against former Auburn University football coach Tommy Tuberville — is considered in play for Republicans.

“The fall election will significantly revolve around people’s belief about what [candidates] will do for their health coverage,” said Dr. Daniel Derksen, a professor of public health at the University of Arizona.

The Affordable Care Act has been a wedge issue since it was signed into law in 2010. Because it then took four years to enact, its opponents talked for years about how bad the not-yet-created marketplace for insurance would be, said Joe Hanel, spokesperson for the Colorado Health Institute, a nonpartisan nonprofit focused on health policy analysis. And they continued to attack the law as it took full effect in 2014.

Gardner, for example, ran numerous campaign ads that year criticizing the ACA and, in particular, President Barack Obama’s assertion that “if you like your health care plan, you’ll be able to keep your health care plan.”

But now, Hanel said, the ACA’s policies have become much more popular in Colorado as the costs of health exchange plans have dropped. Thus, political messaging has changed, too.

“This time it’s the opposite,” Hanel said. “The people bringing up the Affordable Care Act are the Democrats.”

Despite Gardner’s multiple votes to repeal the ACA, he has largely avoided talking about the measure during the 2020 campaign. He even removed his pro-repeal position from his campaign website.

Democratic attack ads in July blasted Gardner for repeatedly dodging questions in an interview with Colorado Public Radio about his stance on a lawsuit challenging the ACA.

His opponent, Democrat John Hickenlooper, fully embraced the law when he was Colorado governor, using the measure to expand Medicaid eligibility to more low-income people and to create a state health insurance exchange. Now, he’s campaigning on that record, with promises to expand health care access even further.

Polling Data

Polling conducted by KFF for the past 10 years shows a shift in public opinion has occurred nationwide. (KHN is an editorially independent program of KFF, the Kaiser Family Foundation.)

“Since Trump won the election in 2016, we now have consistently found that a larger share of the public holds favorable views” of the health law, said Ashley Kirzinger, associate director of public opinion and survey research for the foundation. “This really solidified in 2017 after the failed repeal in the Senate.”

The foundation’s polling found that, in July 2014, 55% of voters opposed the law, while 36% favored it. By July 2020, that had flipped, with 51% favoring the law and 38% opposing it. A shift was seen across all political groups, though 74% of Republicans still viewed it unfavorably in the latest poll.

Public support for individual provisions of the ACA — such as protections for people with preexisting conditions or allowing young adults to stay on their parents’ health plans until age 26 — have proved even more popular than the law as a whole. And the provision that consistently polled unfavorably — the mandate that those without insurance must pay a fine — was eliminated in 2017.

“We’re 10 years along and the sky hasn’t caved in,” said Sabrina Corlette, a health policy professor at Georgetown University.

Political Messaging

Following the passage of the ACA, Democrats didn’t reference the law in their campaigns, said Erika Franklin Fowler, a government professor at Wesleyan University and the director of the Wesleyan Media Project, which tracks political advertising.

“They ran on any other issue they could find,” Fowler said.

Republicans, she said, kept promising to “repeal and replace” but weren’t able to do so.

Then, in the 2018 election, Democrats seized on the shift in public opinion, touting the effects of the law and criticizing Republicans for their attempts to overturn it.

“In the decade I have been tracking political advertising, there wasn’t a single-issue topic that was as prominent as health care was in 2018,” she said.

As the global health crisis rages, health care concerns again dominate political ads in the 2020 races, Fowler said, although most ads haven’t explicitly focused on the ACA. Many highlight Republicans’ support for the lawsuit challenging preexisting condition protections or specific provisions of the ACA that their votes would have overturned. Republicans say they, too, will protect people with preexisting conditions but otherwise have largely avoided talking about the ACA.

“Cory Gardner has been running a lot on his environmental bills and conservation funding,” Fowler said. “It’s not difficult to figure out why he’s doing that. It’s easier for him to tout that in a state like Colorado than it is to talk about health care.”

Similar dynamics are playing out in other key Senate races. In Arizona, Republican Sen. Martha McSally was one of the more vocal advocates of repealing the ACA while she served in the House of Representatives. She publicly acknowledged those votes may have hurt her 2018 Senate bid.

“I did vote to repeal and replace Obamacare,” McSally said on conservative pundit Sean Hannity’s radio show during the 2018 campaign. “I’m getting my ass kicked for it right now.”

She indeed lost but was appointed to fill the seat of Sen. Jon Kyl after he resigned at the end of 2018. Now McSally is in a tight race with Democratic challenger Mark Kelly, an astronaut and the husband of former Rep. Gabby Giffords.

“Kelly doesn’t have a track record of voting one way or another, but certainly in his campaign this is one of his top speaking points: what he would do to expand coverage and reassure people that coverage won’t be taken away,” said Derksen, the University of Arizona professor.

The ACA has proved a stumbling block for Republican Sens. Thom Tillis of North Carolina and Joni Ernst of Iowa. In Maine, GOP Sen. Susan Collins cast a key vote that prevented the repeal of the law but cast other votes that weakened it. She now also appears vulnerable — but more for her vote to confirm Brett Kavanaugh’s nomination to the Supreme Court and for not doing more to oppose President Donald Trump.

In Montana, Daines, who voted to repeal the ACA, is trying to hold on to his seat against Democratic Gov. Steve Bullock, who used the law to expand the state’s Medicaid enrollment in 2015. At its peak, nearly 1 in 10 Montanans were covered through the expansion.

As more Montanans now face the high cost of paying for health care on their own amid pandemic-related job losses, Montana State University political science professor David Parker said he expects Democrats to talk about Daines’ votes to repeal cost-saving provisions of the ACA.

“People are losing jobs, and their jobs bring health care with them,” Parker said. “I don’t think it’s a good space for Daines to be right now.”

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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Veteran’s Appendectomy Launches Excruciating Months-Long Battle Over Bill

In late August 2019, Shannon Harness awoke to serious pain in the lower right side of his abdomen — a telltale sign of appendicitis.

He booked it to the emergency room of the only hospital in the county: Heart of the Rockies Regional Medical Center in Salida, Colorado. After a CT scan, doctors told Harness he had acute appendicitis and required immediate surgery.

A surgeon performed an appendectomy that night and released Harness the next day.

But a couple of days later, Harness felt sharp pains where his appendix had been. The pain grew until he was on the floor screaming.

“It was disturbing,” said Eliza Novick-Smith, his partner. “He has a pretty high pain tolerance,” given previous injuries from military service and mountain biking.

Harness went back to the hospital, where another CT scan revealed a blood clot the size of a brick floating in his pelvic area, a rare complication that most likely came from clipping and stapling the appendix tissue in the first surgery, said his surgeon. He would need another operation to check for the source of bleeding and to remove the clot.

After four more days in the hospital, he went home. It took him a couple of months to fully recover.

Then the bill came.

Patient: Shannon Harness, 39, an operations manager for a company that builds mountain bike trails across the country and a Marine Corps veteran. At the time of this incident, Harness had no insurance.

Total Owed: The original hospital bill was $80,232 for both surgeries — the first surgery cost $35,906 and the clot surgery cost $44,326. These amounts do not include payments to the surgeon, anesthesiologist, pathologist or radiologist.

Service Provider: Heart of the Rockies Regional Medical Center, a nonprofit critical access hospital in Colorado, where the surgeries were performed. Anesthesia, radiology and pathology were performed by other providers.

Medical Services: Laparoscopic appendectomy, followed by a second surgery a few days later, to resolve complications.

What Gives: Uninsured patients are extremely vulnerable to exorbitant hospital bills. It’s difficult to negotiate with a hospital without the leverage and bargaining power of an insurance company. Worse, uninsured patients are often billed three or four times what an insurer or government program would pay for the same service, said Anthony Wright, executive director of Health Access California, an organization advocating for affordable health care in California.

“As somebody who’s uninsured, you are getting an unnegotiated rate,” Wright said, derived from the hospital’s master price list. Insurers typically pay a rate that is a tiny fraction of that cost.

Harness was uninsured for seven years before this incident. His employer didn’t offer insurance, and the Affordable Care Act plan he qualified for cost $350 a month — an amount he didn’t have.

One option for uninsured patients is a hospital’s financial assistance program, a requirement in some states. In Colorado, every hospital is supposed to have a comprehensive charity care program for uninsured patients who earn less than 250% of the federal poverty level.

Heart of the Rockies hospital determines financial assistance on a sliding scale of family size and income. They also offer a self-pay discount of 15% to uninsured patients. Harness said the hospital’s financial services office initially told him he was ineligible for their assistance program as well as the Colorado Indigent Care Program. Harness had worked overtime the previous month and missed the qualification by around $200. The hospital would use only his past two pay stubs to verify his income, he said.

The hospital wouldn’t answer any questions about Harness’ care or bills, even though he gave it permission to do so.

Another quirk of the U.S. health care system that Harness encountered is that when surgeries don’t go as planned, and need revision with another operation, the patient (or his insurer) typically pays again. Medicare and some insurers have experimented with “bundled payments,” through which the hospital gets a set fee for the surgery and any follow-up care for 90 days thereafter.

Resolution: Harness filed a grievance with the hospital with the help of Novick-Smith, who is a lawyer, to push back on the bills for the two surgeries — $35,906 for the first and $44,326 more for the second —and express concerns with the quality of care.

Healthcare Bluebook, which estimates costs based on insurers’ claims data, says a fair price for an appendectomy in Salida is around $12,600. Dr. Gina Adrales, director of minimally invasive surgery at Johns Hopkins Medicine in Baltimore, said the complication Harness experienced is not common. The complication rate for an appendectomy is fairly low, she said.

In November, the hospital decided to give Harness a 30% discount for both surgeries, leaving him with a still hefty bill of $56,162.40.

The couple followed up repeatedly with the hospital for months, often finding representatives “hard to reach.” More than six months later, in March, the hospital told Harness he would have to pay for the second surgery because it was a risk he accepted by agreeing to the appendectomy.

Adam Fox, director of strategic engagement at Colorado Consumer Health Initiative, said it’s “especially important” to push back on bills resulting from surgical complications. “It usually indicates that something didn’t go right in the first surgery and at least that second surgery should be provided at a substantially reduced cost to the individual,” he said.

By May, the hospital gave in. Lesley Fagerberg, Heart of the Rockies’ vice president of financial services, wrote a response to Harness’ grievance, reducing the total bill by roughly the amount charged for the second surgery. But she didn’t explain how the hospital had come to that decision.

“Unfortunately, there was a complication in your appendectomy surgery,” Fagerberg wrote. “As explained in the consent to treat, a surgery/procedure has inherent risk. Your case has been reviewed and the total bill has been reduced by $31,218.60.”

Harness’ final bill from the hospital, Fagerberg wrote, stands at $22,304.17 after adjustments that included a self-pay discount.

Harness and Novick-Smith said that still seemed too high to them, and after some research, offered to pay the hospital $12,000 upfront. The hospital rejected this offer.

Now, Harness is working out a payment plan with the hospital. The hospital offers an interest-free payment plan if he can pay it off in two years, but for Harness, those monthly payments would be more than his rent.

“I would not be able to do it by myself, like, I wouldn’t have another choice other than taking out a loan,” Harness said. “Before the appendectomy, I was looking for property and homes to purchase, and that is pretty much completely off the table right now.”

Novick-Smith said she’s glad the hospital ultimately wrote off the bill for the second surgery. But she still feels angry with the hospital.

“What feels particularly hard is that the hospital markets itself in our community as this vital community resource and they provide a lot of jobs,” she said. “Their lack of transparency and lack of communication with us made this all a whole lot worse especially because there’s nowhere else to go.”

The Takeaway: The United States health care system is not forgiving to the uninsured, who, paradoxically, often face the highest bills of all patients. The benefit of having insurance is in part that your plan pays much of the bill, but also that you get the benefit of being charged the plan’s highly discounted rates. If your employer doesn’t provide health insurance, check whether you’re eligible for a public program, said Wright.

Harness now has VA Health Care. He initially avoided looking into VA Health Care because he felt “other vets needed it more.”

If you’re uninsured and stuck with a huge bill, Fox said, the first step is to ask for an itemized bill to ensure it reflects the actual service you received. The next step is to check the hospital’s charity care policy. Another resource uninsured patients can turn to are organizations like the Colorado Consumer Health Initiative.

“It’s by no means a perfect solution because there’s only so much that we can do to help consumers advocate for themselves in these cases, but we do our best,” Fox said.

If all else fails, Wright said, it’s best to put pressure on the hospital before they sell the bill to a collections agency. There’s less room for negotiation once a bill goes to collections, Wright said. And if all else really fails, you could try calling the press.

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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COVID Plans Put to Test as Firefighters Crowd Camps for Peak Wildfire Season

HELENA, Mont. — Jon Paul was leery entering his first wildfire camp of the year late last month to fight three lightning-caused fires scorching parts of a Northern California forest that hadn’t burned in 40 years.

The 54-year-old engine captain from southern Oregon knew from experience that these crowded, grimy camps can be breeding grounds for norovirus and a respiratory illness that firefighters call the “camp crud” in a normal year. He wondered what the coronavirus would do in the tent cities where hundreds of men and women eat, sleep, wash and spend their downtime between shifts.

Paul thought about his immunocompromised wife and his 84-year-old mother back home. Then he joined the approximately 1,300 people spread across the Modoc National Forest who would provide a major test for the COVID-prevention measures that had been developed for wildland firefighters.

“We’re still first responders and we have that responsibility to go and deal with these emergencies,” he said in a recent interview. “I don’t scare easy, but I’m very wary and concerned about my surroundings. I’m still going to work and do my job.”

Paul is one of thousands of firefighters from across the U.S. battling dozens of wildfires burning throughout the West. It’s an inherently dangerous job that now carries the additional risk of COVID-19 transmission. Any outbreak that ripples through a camp could easily sideline crews and spread the virus across multiple fires — and back to communities across the country — as personnel transfer in and out of “hot zones” and return home.

Though most firefighters are young and fit, some will inevitably fall ill in these remote makeshift communities of shared showers and portable toilets, where medical care can be limited. The pollutants in the smoke they breathe daily also make them more susceptible to COVID-19 and can worsen the effects of the disease, according to the Centers for Disease Control and Prevention.

Also, one suspected or positive case in a camp will mean many other firefighters will need to be quarantined, unable to work. The worst-case scenario is that multiple outbreaks could hamstring the nation’s ability to respond as wildfire season peaks in August, the hottest and driest month of the year in the western U.S.

The number of acres burned so far this year is below the 10-year average, but the fire outlook for August is above average in nine states, according to the National Interagency Fire Center. Twenty-two large fires ignited on Monday alone after lightning storms passed through the Northwest.

A study published this month by researchers at Colorado State University and the U.S. Forest Service’s Rocky Mountain Research Station concluded that COVID outbreaks “could be a serious threat to the firefighting mission” and urged vigilant social distancing and screening measures in the camps.

“If simultaneous fires incurred outbreaks, the entire wildland response system could be stressed substantially, with a large portion of the workforce quarantined,” the study’s authors wrote.

This spring, the National Wildfire Coordinating Group’s Fire Management Board wrote — and has since been updating — protocols to prevent the spread of COVID-19 in fire camps, based on CDC guidelines. Though they can be adapted by managers at different fires and even by individual team, they center on some key recommendations:

  • Firefighters should be screened for fever and other COVID symptoms when they arrive at camp.
  • Every crew should insulate itself as a “module of one” for the fire season and limit interactions with other crews.
  • Firefighters should maintain social distancing and wear face coverings when social distancing isn’t possible. Smaller satellite camps, known as spike camps, can be built to ensure enough space.
  • Shared areas should be regularly cleaned and disinfected, and sharing tools and radios should be minimized.

The guidelines do not include routine testing of newly arrived firefighters — a practice used for athletes at training camps and students returning to college campuses.

The Fire Management Board’s Wildland Fire Medical and Public Health Advisory Team wrote in a July 2 memo that it “does not recommend utilizing universal COVID-19 laboratory testing as a standalone risk mitigation or screening measure among wildland firefighters.” Rather, the group recommends testing an individual and directly exposed co-workers, saying that approach is in line with CDC guidance.

The lack of testing capacity and long turnaround times are factors, according to Forest Service spokesperson Dan Hottle.

The exception is Alaska, where firefighters are tested upon arrival at the airport and are quarantined in a hotel while awaiting results, which come within 24 hours, Hottle said.

Fire crews responding to early-season fires in the spring had some problems adjusting to the new protocols, according to assessments written by fire leaders and compiled by the Wildland Fire Lessons Learned Center.

Shawn Faiella, superintendent of the interagency “hotshot crew” — so named because they work the most challenging or “hottest” parts of wildfires — based at Montana’s Lolo National Forest, questioned the need to wear masks inside vehicles and the safety of bringing extra vehicles to space out firefighters traveling to a blaze. Parking extra vehicles at the scene of a fire is difficult in tight dirt roads — and would be dangerous if evacuations are necessary, he wrote.

“It’s damn tough to take these practices to the fire line,” Faiella wrote after his team responded to a 40-acre Montana fire in April.

One recommendation that fire managers say has been particularly effective is the “module of one” concept requiring crews to eat and sleep together in isolation for the entire fire season.

“Whoever came up with it, it is working,” said Mike Goicoechea, the Montana-based incident commander for the Forest Service’s Northern Region Type 1 team, which manages the nation’s largest and most complex wildfires and natural disasters. “Somebody may test positive, and you end up having to take that module out of service for 14 days. But the nice part is you’re not taking out a whole camp. … It’s just that module.”

The total number of positive COVID cases among wildland firefighters among the various federal, state, local and tribal agencies is not being tracked. Each fire agency has its own system for tracking and reporting COVID-19, said Jessica Gardetto, a spokesperson for the Bureau of Land Management and the National Interagency Fire Center in Idaho.

The largest wildland firefighting agency is the Agriculture Department’s Forest Service, with 10,000 firefighters. Another major agency is the Department of the Interior, which BLM is part of and which had more than 3,500 full-time fire employees last year. As of the first week of August, 111 Forest Service firefighters and 40 BLM firefighters (who work underneath the broader Interior Department agency) had tested positive for COVID-19, according to officials for the respective agencies.

“Considering we’ve now been experiencing fire activity for several months, this number is surprisingly low if you think about the thousands of fire personnel who’ve been suppressing wildfires this summer,” Gardetto said.

Goicoechea and his Montana team traveled north of Tucson, Arizona, on June 22 to manage a rapidly spreading fire in the Santa Catalina Mountains that required 1,200 responders at its peak. Within two days of the team’s arrival, his managers were overwhelmed by calls from firefighters worried or with questions about preventing the spread of COVID-19 or carrying the virus home to their families.

In an unusual move, Goicoechea called upon Montana physician — and former National Park Service ranger with wildfire experience — Dr. Harry Sibold to join the team. Physicians are rarely, if ever, part of a wildfire camp’s medical team, Goicoechea said.

Sibold gave regular coronavirus updates during morning briefings, consulted with local health officials, soothed firefighters worried about bringing the virus home to their families and advised fire managers on how to handle scenarios that might come up.

But Sibold said he wasn’t optimistic at the beginning about keeping the coronavirus in check in a large camp in Pima County, which has the second-highest number of confirmed cases in Arizona, at the time a national COVID-19 hot spot. “I quite firmly expected that we might have two or three outbreaks,” he said.

There were no positive cases during the team’s two-week deployment, just three or four cases where a firefighter showed symptoms but tested negative for the virus. After the Montana team returned home, nine firefighters at the Arizona fire from other units tested positive, Goicoechea said. Contact tracers notified the Montana team, some of whom were tested. All tests returned negative.

“I can’t say enough about having that doctor to help,” Goicoechea said, suggesting other teams might consider doing the same. “We’re not the experts in a pandemic. We’re the experts with fire.”

That early success will be tested as the number of fires increases across the West, along with the number of firefighters responding to them. There were more than 15,000 firefighters and support personnel assigned to fires across the nation as of mid-August, and the success of those COVID-19 prevention protocols depend largely upon them.

Paul, the Oregon firefighter, said that the guidelines were followed closely in camp, but less so out on the fire line. It also appeared to him that younger firefighters were less likely to follow the masking and social-distancing rules than the veterans like him. That worried him as he realized it wouldn’t take much to spark an outbreak that could sideline crews and cripple the ability to respond to a fire.

“We’re outside, so it definitely helps with mitigation and makes it simpler to social-distance,” Paul said. “But I think if there’s a mistake made, it could happen.”

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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Namaste Noir: Yoga Co-Op Seeks to Diversify Yoga to Heal Racialized Trauma

DENVER — Beverly Grant spent years juggling many roles before yoga helped her restore her balance.

When not doting over her three children, she hosted her public affairs talk radio show, attended community meetings or handed out cups of juice at her roving Mo’ Betta Green MarketPlace farmers market, which has brought local, fresh foods and produce to this city’s food deserts for more than a decade.

Her busy schedule came to an abrupt halt on July 1, 2018, when her youngest son, Reese, 17, was fatally stabbed outside a Denver restaurant. He’d just graduated from high school and was weeks from starting at the University of Northern Colorado.

“It’s literally a shock to your system,” Grant, 58, said of the grief that flooded her. “You feel physical pain and it affects your conscious and unconscious functioning. Your ability to breathe is impaired. Focus and concentration are sporadic at best. You are not the same person that you were before.”

In the midst of debilitating loss, Grant said it was practicing yoga and meditation daily that helped provide some semblance of peace and balance. She had previously done yoga videos at home but didn’t get certified as an instructor until just before her son’s death.

Yoga then continued to be a grounding force when the coronavirus pandemic hit in March. The lockdown orders in Colorado sent her back to long days of isolation at home, where she was the sole caregiver for her special-needs daughter and father. Then, in April, her 84-year-old mother died unexpectedly of natural causes. “I’ve been doing the best that I can with facing my new reality,” said Grant.

Beverly Grant finds peace and balance through yoga and meditation in the midst of painful losses — her son’s murder in 2018, and her mother’s death earlier this year.(Rebecca Stumpf for KHN)

As a Black woman, she believes yoga can help other people of color, who she said disproportionately share the experience of debilitating trauma and grief — exacerbated today by such disparities as who’s most at risk of COVID-19 and the racialized distress from ongoing police brutality such as the killing of George Floyd in Minneapolis.

While the country still needs much work to heal itself, she wants more people of color to try yoga to help their health. She said the ancient practice, which began in India more than 5,000 years ago and has historical ties to ancient Africa, is the perfect platform to help cope with the unique stressors caused by daily microaggressions and discrimination.

“It helps you feel more empowered to deal with many situations that are beyond your control,” said Grant.

She teaches yoga with Satya Yoga Cooperative, a Denver-based group operated by people of color that was launched in June 2019, inspired partly by the Black Lives Matter and #MeToo movements. The co-op’s mission: Offer yoga to members of diverse communities to help them deal with trauma and grief before it shows up in their bodies as mental health conditions, pain and chronic disease.

“When I think about racism, I think about stress and how much stress causes illness in the body,” said Satya founder Lakshmi Nair, who grew up in a Hindu family in Aurora, Colorado. “We believe that yoga is medicine that has the power to heal.”

Satya’s efforts are part of a growing movement to diversify yoga nationwide. From the Black Yoga Teachers Alliance to new Trap Yoga classes that incorporate the popular Southern hip-hop music style to the Yoga Green Book online directory that helps Black yoga-seekers find classes, change appears to be happening. According to National Health Interview Survey data, the percentage of non-Hispanic Black adults who reported practicing yoga jumped from 2.5% in 2002 to 9.3% in 2017.

Nair seeks to plant the seeds for more: The co-op is trying to make classes more accessible and affordable for people of color. It offers many classes on a “pay what you can” model, with $10 suggested donations per session. Satya also hosts two intensive yoga instructor training sessions for people of color per year, with hopes to offer more, in an effort to diversify the pool of yoga providers.

A Unique, Healing Experience

Blacks and Latinos consistently top national health disparities lists, with elevated risks for obesity and chronic conditions such as heart disease, diabetes and some forms of cancer, which has made them more susceptible to contracting and dying of COVID-19. They also face an elevated risk for depression and other mental health conditions.

And a growing body of research asserts that racism and discrimination may be playing a larger factor than previously thought. For example, an Auburn University study published in January concluded that Blacks experience higher levels of stress due to racism, resulting in accelerated aging and premature death. Another study, from the American Heart Association, showed a link between Black people experiencing discrimination and developing increased risk for hypertension.

Yoga is obviously not a panacea for racism, but it has shown positive results in helping people manage stress, and as a complement to therapeutic work on trauma.

Satya co-op member Taliah Abdullah, 48, said stress brought on by a toxic work environment and family problems inspired her to finally attend classes. The effect was so life-changing that she enrolled in Satya’s teacher training.

“I didn’t know I needed this, but it’s really changed my life for the better,” she said. “I feel like now I have the tools and the toolbox that I need to better navigate the world as a woman of color.”

At a Saturday morning class Grant led before the pandemic hit, five Latina and Black women and a lone Black man sat atop colorful yoga mats in a half-circle around Grant with smoke billowing around them from a copal-scented incense stick.

Beverly Grant teaches a yoga class at the Dahlia Campus of the Mental Health Center of Denver in February. She believes yoga can help people of color heal from the psychological and physical dangers of racism.(Rebecca Stumpf for KHN)

Grant spoke in hushed tones during the hourlong session, leading them through cat-cow, downward dog and boat poses. The theme was more spiritual than physical, more relaxing than vigorous, as illustrated by the mantra she used to begin the class: “We are resilient, we are grounded, we are complete. And the spirit of love is in me.”

First-time attendee Ramon Gabrielof-Parish, 42, a Black professor at Naropa University in Boulder, became so relaxed that at one point he began snoring. He said that after an exhausting week he appreciated the serene vibe.

Sarah Naomi Jones, 37, who graduated from Satya’s training, said the co-op provides a safe space to bond, vent and heal — a very different vibe from predominately white yoga spaces where many people of color often feel unwelcome. She said she felt that icy reception when, as a Black yoga newbie, she attended an intensive yoga class mostly filled with white attendees.

“When I walked in, it was kind of like, ‘What are you doing here?’” recalled Jones. “The spiritual component was totally missing. It wasn’t about healing. It felt like everyone was there just to show off how much more stretchier they were than another person.”

Moving Forward in New World

Denver-based Black yogi Tyrone Beverly, 39, said the growth of yoga among people of color is a sign of yearning for more inclusivity in the practice. His nonprofit, Im’Unique, regularly hosts “Breakin’ Bread, Breakin’ Barriers” yoga sessions with a diverse mix of attendees followed by a meal and discussion on topics such as police brutality, racism and mass incarceration.

“We believe that yoga is a great unifier that brings people together,” he said.

Because of the pandemic, Beverly has moved all his events and classes online for the foreseeable future as a safety precaution. Satya took a brief hiatus of in-person classes, Grant said, but now offers some classes outdoors in parks in addition to daily online classes. Grant said that during the pandemic, even online classes could make a difference for individuals.

“That’s the beauty of yoga,” Grant said. “It can be done in a group. It can be done individually. It can be done virtually and, most importantly, it can be done at your own pace.”

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.

Where Mask-Wearing Isn’t Gospel: Colorado Churches Grapple With Reopening

COLORADO SPRINGS, Colo. — The lights dimmed. Guitars thrummed. And a nine-piece band kicked off what amounted to a rock concert inside an amphitheater of a church. “Shout for joy to the Lord,” one musician called out, quoting Scripture.

Any such shout could release the coronavirus to congregants. With some 500 people singing along, though, any concern about a deadly virus circulating was hard to find other than the spaced-out chairs in the 6,000-person hall. Although Colorado’s governor had issued a statewide order days earlier mandating masks, hardly anyone at this service at New Life Church obeyed.

“I’m finding this to be true at churches all over America: If they’re told they have to wear a mask, they’ll stay home,” said Brady Boyd, senior pastor of the 15,000-member New Life Church, a nondenominational megachurch that meets in five locations across the Pikes Peak region.

Long considered one of the country’s evangelical strongholds, Colorado Springs returned to church in ways both guarded and full of gusto after the state lifted lockdowns June 4 with limitations on how many people could gather. But as the county’s coronavirus cases and hospitalizations climb to their highest levels in months, many of the city’s largest and most well-known congregations remain undeterred — openly flouting the new statewide mask order and, in at least one instance, threatening not to stop holding in-person services again if ordered.

It all comes as church leaders across the nation navigate a growing set of political pressures: For months, President Donald Trump urged them to resume services despite pleadings from public health officials for caution and orders by some governors to stay home.

That pressure is particularly acute here at the base of Pikes Peak. Long the conservative bastion of Colorado, this city and surrounding El Paso County, home to about 720,000 people, overwhelmingly voted for Trump in 2016. (The county last voted for a Democratic candidate for president in 1964.)

The Republican sheriff has vowed not to enforce the statewide mask order that Democratic Gov. Jared Polis issued July 16. And several churches are as openly defiant.

But any indoor activities, such as worship services, pose a particularly high risk for coronavirus transmission even with masks, especially when they include singing, said Dr. Jonathan Samet, the Colorado School of Public Health’s dean. While coughing or sneezing can spread larger respiratory droplets, singing and talking release smaller infectious particles that can hang in the air and circulate in enclosed spaces.

“The circumstances of having large groups of people together without masks and doing things like singing is a setup that people talk about for superspreading events,” Samet said.

Churchgoers sit on the lawn outside Grace and St. Stephen’s Episcopal Church in Colorado Springs, Colorado, during outdoor worship services on July 19. White circles painted on the grass indicate where people can sit to remain socially distanced at 6 feet apart.(Rachel Woolf for KHN)

In Arkansas, for example, at least three people died and dozens of others tested positive in March after two people showed up at a church function with COVID symptoms. And in Washington state, dozens of choral group members were infected after a single symptomatic person attended a 2½-hour practice. Two people died.

The New Life Church, where at least 9 in 10 parishioners went without masks on the first Sunday after Colorado’s order began, was certainly not unique. Nearly all of the roughly 100 people gathered at Church for All Nations also skipped masks.

Pastor Mark Cowart kicked off his sermon there by questioning statements about masks from Dr. Anthony Fauci, the nation’s top infectious disease expert with the National Institutes of Health.

“We are not the mask police,” Cowart said, before warning state officials against trying to restrict their gatherings.

“If they come trying to tell us we can’t meet anymore, or we can’t sing, or we can’t have a Bible study anymore, that’s not going to go,” Cowart said to applause at the nondenominational church. “God does not want us to allow that to happen.”

Colorado health officials recently warned several counties that large worship services could be restricted if the rise in infections doesn’t ease. Average daily confirmed cases across the state more than doubled in July, rising from 215 a day in June to 451 as of last week, according to a state database.

The rise in COVID cases comes as residents disregard social-distancing guidelines. A recent report by the Colorado COVID-19 Modeling Group found that the share of Coloradans complying plummeted from 87% in May to 41% in late June.

Across the Pikes Peak region, dozens of pastors and parishioners described an intense and deeply spiritual desire to return to worship with their fellow believers. Meeting in person provides a unique opportunity to hug, to know they are not alone during such trying times.

“The church isn’t really a place — it’s a gathering of people,” said Brian Bone, while meeting with a dozen others at Woodmen Valley Chapel, where masks were common on a recent visit. “We get comfortable coming to a place we call church, but really it’s being with other people physically that’s important.”

Churchgoers sit on the lawn during outdoor worship services on July 19, at Grace and St. Stephen’s Episcopal Church in Colorado Springs, Colorado. The church offers socially distant, outdoor Sunday worship services.(Rachel Woolf for KHN)

(From center left) Abigail Sena leads the procession as an acolyte, followed by Gary Darress, a deacon, and Claire Elser, a curate, during worship services on July 19.(Rachel Woolf for KHN)

And some ministers fear that not meeting regularly in person could lead to apathy among parishioners, causing them to drift away.

Not all congregations in Colorado Springs have been averse to the state’s new mask order. And the myriad approaches to reopening highlight the difficulty of placing a single label on churchgoers during the pandemic.

For the Rev. Jeremiah Williamson, masking up is the Christian thing to do.

“A lot of this stuff has been caught up in partisan politics, and I’m not interested in that,” Williamson said. “I’m interested in keeping our people safe. We’re one of those churches that believes science.”

At Grace and St. Stephen’s Episcopal Church, Williamson has forsaken his pulpit for the front lawn. There, on a recent Sunday, dozens of church members sat in folding chairs spaced 6 feet apart, inside white circles painted on the grass. No congregants sang. Everyone wore masks.

Nearby on North Tejon Street, more parishioners sat in parked cars, listening with their radios as the service was broadcast via a shortwave transmitter.

And, before attending, everyone was urged to provide their names and phone numbers, in case someone tests positive and public health contact tracers need to find those who may have been exposed.

Bill and Carol Whittam (center) sit on the lawn outside Grace and St. Stephen’s Episcopal Church in Colorado Springs, Colorado, during worship services on July 19. Before attending, churchgoers are urged to sign up online and provide their names and phone numbers, in case someone tests positive and public health contact tracers need to track down people who may have been exposed.(Rachel Woolf for KHN)

“It just seems, as religious people, Christians, we would want to do our best for the common good, for the greater good,” Williamson said.

Across town, Payne Chapel AME Church also has opted not to gather indoors out of concern for its predominantly Black congregation, because Blacks have been experiencing higher rates of hospitalization and death from the coronavirus. Church members recently met in their vehicles in the church’s parking lot, waving to one another through car windows and singing hymns together on a teleconference line.

For that 300-member African Methodist Episcopal church, to have met indoors also would have been “between ridiculous and stupid,” said Pastor Leslie White, who heads the congregation.

However, Calvary Worship Center, which has a racially diverse congregation, is meeting indoors and not enforcing the mask order, even though two staff members were confirmed to have COVID-19. Instead, the church, led by a team of Black and white pastors, only recommends they be worn.

For Joshua Stephens, 29, the key to staying healthy is his faith.

The pandemic hit just as he wrapped up earning a degree from Charis Bible College, headquartered in Woodland Park. The local religious school received a cease-and-desist letter in early July from the Colorado Attorney General’s Office for hosting a conference with 300 to 500 people in violation of the state’s lockdown orders that limited gatherings to 175 people. Nevertheless, the college’s pastor had vowed to ignore the order.

Stephens, who attends Church for All Nations, said his belief in God informs his approach to the pandemic, after saying he was miraculously cured of cancer four years ago.

“My personal conviction is, I don’t get sick,” said Stephens, who was not wearing a mask.

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.

Listen: Outbreak of Trench Fever Grips Coloradans

KHN senior correspondent Markian Hawryluk joined KUNC’s Henry Zimmerman on “Colorado Edition” to discuss his recent story about an outbreak of trench fever, a rare disease carried by body lice.

Public health officials are trying to find a common thread among the four cases identified so far in Colorado. They occurred months apart, and the patients appeared to have no connection other than having been homeless in the Denver area. A scourge during World War I, the illness thrives on hardship. It causes fever, bone pain, headache, vomiting and malaise, potentially leading to life-threatening infection of heart valves.

You can listen to the conversation here.

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.

Ever Heard of a Surgical Assistant? Meet a New Boost to Your Medical Bills

Izzy Benasso was playing a casual game of tennis with her father on a summer Saturday when she felt her knee pop. She had torn a meniscus, one of the friction-reducing pads in the knee, locking it in place at a 45-degree angle.

Although she suspected she had torn something, the 21-year-old senior at the University of Colorado in Boulder had to endure an anxious weekend in July 2019 until she could get an MRI that Monday.

“It was kind of emotional for her,” said her father, Steve Benasso. “Just sitting there thinking about all the things she wasn’t going to be able to do.”

At the UCHealth Steadman Hawkins Clinic Denver, the MRI confirmed the tear, and she was scheduled for surgery on Thursday. Her father, who works in human resources, told her exactly what to ask the clinic regarding her insurance coverage.

Steve had double-checked that the hospital; the surgeon, Dr. James Genuario; and Genuario’s clinic were in her Cigna health plan’s network.

“We were pretty conscious going into it,” he said.

Isabel met with Genuario’s physician assistant on Wednesday, and the following day underwent a successful meniscus repair operation.

“I had already gotten a ski pass at that point,” she said. “So that was depressing.” But she was heartened to hear that with time and rehab she would get back to her active lifestyle.

Then the letter arrived, portending of bills to come.

The Patient: Izzy Benasso, a 21-year-old college student covered by her mother’s Cigna health plan.

College student Izzy Benasso stands outside her family’s home in Englewood, Colorado, on July 14. Benasso tore a meniscus in her knee while playing tennis with her father a year ago. The charges for her subsequent outpatient knee surgery totaled $96,377.(Rachel Woolf for KHN)

The Total Bill: $96,377 for the surgery was billed by the hospital, Sky Ridge Medical Center in Lone Tree, Colorado, part of HealthONE, a division of the for-profit hospital chain HCA. It accepted a $3,216.60 payment from the insurance company, as well as $357.40 from the Benassos, as payment in full. The surgical assistant billed separately for $1,167.

Service Provider: Eric Griffith, a surgical assistant who works as an independent contractor.

Medical Service: Outpatient arthroscopic meniscus repair surgery.

What Gives: The Benassos had stumbled into a growing trend in health care: third-party surgical assistants who aren’t part of a hospital staff or a surgeon’s practice. They tend to stay out-of-network with health plans, either accepting what a health plan will pay them or billing the patient directly. That, in turn, is leading to many surprise bills.

Even before any other medical bills showed up, Izzy received a notice from someone whose name she didn’t recognize.

“I’m writing this letter as a courtesy to remind you of my presence during your surgery,” the letter read.

It came from Eric Griffith, a Denver-based surgical assistant. He went on to write that he had submitted a claim to her health plan requesting payment for his services, but that it was too early to know whether the plan would cover his fee. It didn’t talk dollars and cents.

Steve Benasso said he was perplexed by the letter’s meaning, adding: “We had never read or heard of anything like that before.”

Surgical assistants serve as an extra set of hands for surgeons, allowing them to concentrate on the technical aspects of the surgery. Oftentimes other surgeons or physician assistants — or, in teaching hospitals, medical residents or surgical fellows — fill that role at no extra charge. But some doctors rely on certified surgical assistants, who generally have an undergraduate science degree, complete a 12- to 24-month training program, and then pass a certification exam.

Surgeons generally decide when they need surgical assistants, although the Centers for Medicare & Medicaid Services maintains lists of procedures for which a surgical assistant can and cannot bill. Meniscus repair is on the list of allowed procedures.

A Sky Ridge spokesperson said that it is the responsibility of the surgeon to preauthorize the use and payment of a surgical assistant during outpatient surgery, and that HealthOne hospitals do not hire surgical assistants. Neither the assistant nor the surgeon works directly for the hospital. UC School of Medicine, the surgeon’s employer, declined requests for comment from Genuario.

Steve Benasso says he was perplexed after receiving a letter from the surgical assistant who was in the operating room during daughter Izzy Benasso’s knee surgery. The letter, from Eric Griffith, a Denver-based surgical assistant, stated it was “a courtesy to remind you of my presence” during Izzy’s surgery. “We had never read or heard of anything like that before,” Steve says.(Rachel Woolf for KHN)

Karen Ludwig, executive director of the Association of Surgical Assistants, estimates that 75% of certified surgical assistants are employed by hospitals, while the rest are independent contractors or work for surgical assistant groups.

“We’re seeing more of the third parties,” said Dr. Karan Chhabra, a surgeon and health policy researcher at the University of Michigan Medical School. “This is an emerging area of business.”

And it can be lucrative: Some of the larger surgical assistant companies are backed by private equity investment. Private equity firms often target segments of the health care system where patients have little choice in who provides their care. Indeed, under anesthesia for surgery, patients are often unaware the assistants are in the operating room. The private equity business models include keeping such helpers out-of-network so they can bill patients for larger amounts than they could negotiate from insurance companies.

Surgical assistants counter that many insurance plans are unwilling to contract with them.

“They’re not interested,” said Luis Aragon, a Chicago-area surgical assistant and managing director of American Surgical Professionals, a private equity-backed group in Houston.

Chhabra and his colleagues at the University of Michigan recently found that 1 in 5 privately insured patients undergoing surgery by in-network doctors at in-network facilities still receive a surprise out-of-network bill. Of those, 37% are from surgical assistants, tied with anesthesiologists as the most frequent offenders. The researchers found 13% of arthroscopic meniscal repairs resulted in surprise bills, at an average of $1,591 per bill.

Colorado has surprise billing protections for consumers like the Benassos who have state-regulated health plans. But state protections don’t apply to the 61% of American workers who have self-funded employer plans. Colorado Consumer Health Initiative, which helps consumers dispute surprise bills, has seen a lot of cases involving surgical assistants, said Adam Fox, director of strategic engagement.

Izzy Benasso shows her scar from the surgery she had to repair a torn meniscus.(Rachel Woolf for KHN)

Resolution: Initially, the Benassos ignored the missive. Izzy didn’t recall meeting Griffith or being told a surgical assistant would be involved in her case.

But a month and a half later, when Steve logged on to check his daughter’s explanation of benefits, he saw that Griffith had billed the plan for $1,167. Cigna had not paid any of it.

Realizing then that the assistant was likely out-of-network, Steve sent him a letter saying “we had no intention of paying.”

Griffith declined to comment on the specifics of the Benasso case but said he sends letters to every patient so no one is surprised when he submits a claim.

“With all the different people talking to you in pre-op, and the stress of surgery, even if we do meet, they may forget who I was or that I was even there,” he said. “So the intention of the letter is just to say, ‘Hey, I was part of your surgery.’”

After KHN inquired, Cigna officials reviewed the case and Genuario’s operative report, determined that the services of an assistant surgeon were appropriate for the procedure and approved Griffith’s claim. Because Griffith was an out-of-network provider, Cigna applied his fee to Benasso’s $2,000 outpatient deductible. The Benassos have not received a bill for that fee.

Griffith says insurers often require more information before determining whether to pay for a surgical assistant’s services. If the plan pays anything, he accepts that as payment in full. If the plan pays nothing, Griffith usually bills the patient.

The Takeaway: As hospitals across the country restart elective surgeries, patients should be aware of this common pitfall.

Chhabra said he’s hearing more anecdotal reports about insurance plans simply not paying for surgical assistants, which leaves the patient stuck with the bill.

Chhabra said patients should ask their surgeons before surgery whether an assistant will be involved and whether that assistant is in-network.

“There are definitely situations where you need another set of hands to make sure the patient gets the best care possible,” he said. But “having a third party that is intentionally out-of-network or having a colleague who’s a surgeon who’s out-of-network, those are the situations that don’t really make a lot of financial or ethical sense.”

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.

Listen: Colorado Cuts Back Health Care Programs Amid Dual Crises

KHN senior correspondent Markian Hawryluk joined KUNC’s Erin O’Toole on “Colorado Edition” to discuss his recent story on how Colorado is one of the many states having to cut back on health care programs and new policy initiatives as part of the economic fallout of the pandemic.

These cuts, which in Colorado include slashing $1 million from a program designed to keep people with mental illness out of the hospital and $5 million for addiction treatment programs in underserved communities, come amid the century’s largest health crisis when people may need those services most.

You can hear the conversation here.