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Last week, after finishing inoculations of some front-line hospital staff, Jupiter Medical Center was left with 40 doses of precious covid vaccine. So, officials offered shots to the South Florida hospital’s board of directors and their spouses over age 65.
But that decision sparked outrage among workers left unvaccinated, including those at one of the hospital’s urgent care clinics, or who believe the hospital was currying favor with wealthy insiders before getting all its staffers protected, according to a hospital employee who spoke on the condition of not being named.
The move also prompted dozens of calls from donors looking to get vaccinated.
The hospital received 1,000 doses of the Moderna vaccine two days before Christmas, fewer than half of what it requested from the state to cover its workforce. Officials prioritized delivering the vaccine to front-line medical workers who requested it, performing inoculations on Christmas Eve or the holiday weekends.
Patti Patrick, a hospital vice president, said the hospital acted appropriately in its offerings of the vaccine, which has a short shelf life once vials are opened. Neither she nor other administrators who don’t work directly with patients were included in this first round of shots.
“This was a simple way to move 40 doses very quickly” before it spoiled, she said.
She added that all front-line staff from the health system, including the clinics, were given the opportunity to get the shots.
Jupiter is not the only hospital in the nation facing questions about its handling of the vaccines. The initial rollout — aimed at health care workers and nursing home residents — has been uneven at best because of a lack of a federal strategy on how it should work, with states, hospitals, nursing homes and pharmacies often making decisions on their own about who gets vaccinated and when.
In some hospitals, administrators and other personnel who have no contact with patients or face no risk at work from the virus are getting shots, while patients — and even front-line staff — who are at heightened risk for covid complications are being passed by. Some administrators who have been working remotely throughout the pandemic have been vaccinated, especially at hospitals that decided to allocate doses by age group rather than exposure risk.
Although states and federal health groups laid out broad guidelines on how to prioritize who gets the vaccine, in practice what’s mattered most was who controlled the vaccine and where the vaccine distribution was handled.
Stanford Health Care in California was forced to rework its priority list after protests from front-line doctors in training who said they had been unfairly overlooked while the vaccine was given to faculty who don’t regularly see patients. (Age was the important factor in the university’s algorithm.)
Members of Congress have called for an investigation following media reports that MorseLife Health System, a nonprofit that operates a nursing home and assisted living facility in West Palm Beach, Florida, vaccinated donors and members of a country club who donated thousands of dollars to the health company.
At least three other South Florida hospital systems — Jackson Health, Mount Sinai Medical Center and Baptist Health — have offered vaccines to donors in advance of the general public, while administering the shots to front-line employees, The Miami Herald reported.
Like Jupiter Medical, the hospitals insist that those offered shots were 65 and older, as prioritized by state officials.
Staffing Problems at Hospitals
An advisory board to the Centers for Disease Control and Prevention designated hospitals and nursing homes to get covid vaccines first because their workers and residents were considered at highest risk, and most states have followed that recommendation. But in many cases, the health institutions have found demand from staffers, some of whom are leery of the voluntary shot, is less than anticipated.
In addition, the arrival of promised shipments has been unpredictable. While the federal government approved the first covid vaccine on Dec. 14, some hospitals did not receive allotments until after Christmas.
That was the case at Hendry Regional Medical Center in Clewiston, Florida, which got 300 doses from the state. The hospital vaccinated 30 of its 285 employees between Dec. 28 and Jan. 5, said R.D. Williams, its chief executive officer. Some employees preferred to wait until after New Year’s weekend out of concern about side effects, he said.
The vaccine has been reported to commonly cause pain at the injection site and sometimes produce fever, lethargy or headache. The reactions generally last no more than a few days.
“I’m happy with how it’s going so far,” Williams said. “I know many of our employees want to be vaccinated, but I don’t see it as a panacea that they have to have it today,” he said, noting that staffers already have masks and gloves to protect themselves from the virus.
The hospital is also trying to coordinate vaccination schedules so 10 people at a time get the shot to ensure none of the medication is wasted after the multidose vials are thawed. Once vaccine is thawed, it must be used within hours to retain its effectiveness.
As of Jan. 6, Howard University Hospital in Washington, D.C., had vaccinated slightly more than 900 health workers since its first doses arrived Dec. 14. It has received 3,000 doses.
Success has been limited by reluctance among workers to get a vaccine and a lack of personnel trained to administer it, CEO Anita Jenkins said.
“We still have a hospital to run and have patients in the hospital with heart attacks and other conditions, and we don’t have additional staff to run the vaccine clinics,” she said.
While some hospitals offer the vaccine only to front-line workers who interact with patients, Howard makes it available to everyone, including public relations staff, cafeteria workers and administrators. Jenkins defended the move because, she said, it’s the best way to protect the entire hospital.
She noted such employees as information technology personnel who don’t see patients may be around doctors and nurses who do. “Working in a hospital, almost everyone runs into patients just walking down the hallway,” she said.
At Eisenhower Health, a nonprofit hospital based in Rancho Mirage, California, 2,300 of the 5,000 employees have been vaccinated.
“Our greatest challenge has been managing the current patient surge and staffing demands in our acute and critical care areas while also trying to ensure we have adequate staffing resources to operate the vaccine clinics,” said spokesperson Lee Rice.
A Non-System of Inequitable Distribution
Arthur Caplan, a bioethicist at NYU Langone Medical Center in New York City, said hospitals should not be inoculating board members ahead of hospital workers unless those people have a crucial role in running the hospital.
“That seems, to me, jostling to the head of the line and trying to reward those who may be potential donors,” he said. But he acknowledged that the hospitals’ vaccination systems are not always rational or equitable.
Covid vaccines need to get out as quickly as possible, he added, but hospitals can give them only to people they are connected with.
Caplan noted he was vaccinated at an NYU outpatient site last week, even though his primary care doctor hadn’t yet gotten the vaccine because his clinic had not received any doses.
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In October, Mary Mayhew became the association’s CEO. Mayhew, who led the state’s Medicaid agency since 2019, has been a vocal critic of the Affordable Care Act’s Medicaid expansion adopted by 38 other states. She has argued that expansion puts states in a difficult position because the federal government is unlikely to keep its financial commitment to pay its share of the costs.
Had Medicaid been expanded in Florida, hospitals there would have gained thousands of paying patients. But the institutions have done little in recent years to persuade the Republican-led legislature and Gov. Ron DeSantis, also Republican, who oppose such a move.
Mayhew acknowledged in an interview with KHN that expanding Medicaid to cover more uninsured patients could help hospitals financially, especially at a time when facilities have seen demand for services decline as people avoid care for fear of contracting COVID-19.
With that in mind, she said, she is now open to the idea of expanding Medicaid. “We need to look at all options on the table,” she said. “Is it doable? Yes.”
Still, she was quick to point out concerns about whether Florida can afford to expand.
Under the ACA, the federal government pays 90% of the costs for newly enrolled Medicaid recipients. In the traditional Medicaid program — which covers children, people who are disabled and pregnant women — the federal government pays nearly two-thirds of Florida’s Medicaid costs.
“It will be financially challenging in our state budget as revenues have dropped,” Mayhew said, echoing comments of state officials. “That 10% cost has to come from somewhere.”
Mayhew’s hire worries advocates who have spent more than seven years lobbying lawmakers to expand Medicaid. Without strong support from the hospital industry, they fear they’re unlikely to change many votes.
“It may make it harder,” said Karen Woodall, executive director of Florida People’s Advocacy Center, a group that lobbies for policies to help low-income citizens. Marshaling hospital support is important, she said, because of the industry’s money and political clout.
In many state capitals, hospitals have led the fight for Medicaid expansion either by lobbying lawmakers or bankrolling ballot initiatives. The latest example was in Missouri, which this summer expanded Medicaid via a voter initiative. The campaign for the measure was partly funded by hospitals.
But in Florida, hospitals appear to have made a calculated decision to avoid pushing an initiative that Republican leaders have said they don’t want. Among the dozen states that have not expanded Medicaid, Florida is second only to Texas in the number of residents who could gain coverage.
Aurelio Fernandez, CEO of Memorial Healthcare System in Hollywood, Florida, who was chair of the hospital association board when it hired Mayhew, said her opposition to Medicaid expansion never came up in the process. The association hired Mayhew because of the “phenomenal job” she did guiding hospitals amid the COVID pandemic, he said.
“There is no appetite at this juncture [for the legislature] to expand the Medicaid program with Obamacare,” said Fernandez, despite his belief that expansion would help hospitals and patients.
Mayhew, sounding more like a state official than a hospital industry spokesperson, said the ultimate decision on expansion will be up to lawmakers, who must review spending priorities. When states face a financial crunch, lawmakers look to reduce spending in education and Medicaid, which are the biggest parts of the budget, she said.
“The last thing we want to see is the state budget balanced on the backs of hospitals with deep Medicaid reimbursement cuts,” Mayhew said.
Mayhew said her previous opposition to expanding Medicaid occurred when she was responsible for balancing the state budget and managing the programs in Florida and, before that, in Maine. When she ran Maine’s program, she said she opposed expanding Medicaid to allow nondisabled adults into the program while there were disabled enrollees already on waiting lists to get care.
The Florida Hospital Association, which represents more than 200 hospitals, spent years lobbying state lawmakers to expand Medicaid. But since DeSantis was elected in 2018, the group has focused on other issues because the governor and Republican lawmakers made clear they would not expand the program.
Asked what the association’s current position is on Medicaid expansion, Mayhew noted she has been in her job less than a month and “we have not had that policy decision by the board for me to answer that.”
Miriam Harmatz, executive director of the Florida Health Justice Project, an advocacy group, said Mayhew’s hire suggests that hospitals are unlikely to get behind a fledgling effort to put the expansion question to voters in 2022.
Others advocating for Medicaid expansion agree.
“It does not look like they [Florida’s hospitals] are on board with helping us expand Medicaid at the moment,” said Louisa McQueeney, program director of Florida Voices for Health, a consumer group helping with the ballot initiative.
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The Orlando, Florida, resident sought treatment in May. After a series of tests, doctors told Moen she had a rare kidney condition that would require months of treatment.
“Losing the coverage ended up being worse than losing the job,” said Moen, 36, a dancer who had worked for both Walt Disney World and Universal Studios. “It was very stressful.”
Moen rushed to find replacement coverage. With help from a social service agency, she enrolled in a plan through healthcare.gov, the federal Affordable Care Act insurance marketplace. Because she and her husband, Brett, were not working — he had been laid off by Disney, too — they qualified for federal subsidies, so the coverage cost her just $35 a month. Most of her medical expenses, which involve traveling frequently to Jacksonville for specialty treatment, are covered.
Moen’s husband recently found a job, however, and the increase in the couple’s income likely means her subsidy will fall and she’ll have to pay more for health insurance. Moen said she’ll evaluate her options and may switch plans during this year’s ACA open enrollment period, which began Nov. 1 and ends Dec. 15 for coverage starting Jan. 1.
“A priority is to continue seeing my medical team in Jacksonville,” Moen said.
Moen is one of millions of Americans who have been dropped from their jobs and their employer-provided health insurance since March, when the coronavirus first ravaged the economy. Although no official tally exists, studies indicate that at least 10 million workers lost their insurance but that about two-thirds of them found alternative coverage — through a new job, Medicaid, a spouse’s or parent’s plan, or the ACA marketplaces.
That leaves at least 3 million people without coverage, the most added in a single year since accurate record-keeping began in 1968. And experts are worried that, as the virus continues to play havoc with the economy, new rounds of business closings and layoffs could add to that number.
Navigators Want More Resources
The unprecedented situation has health insurance counselors (called navigators), ACA marketplace staff members and insurers scrambling to assist a possible surge of people looking for health insurance during open enrollment.
For the 36 states that rely on the federal ACA enrollment platform — healthcare.gov — the Trump administration awarded grants totaling $10 million for marketing and outreach this year, the same level as in 2019. In 2016, the last year of the Obama administration, navigator grants totaled $63 million.
Many navigator organizations say they don’t have the resources from the federal government to do the job as they would like.
“I’m trying not to panic,” said Jodi Ray, executive director of Florida Covering Kids & Families. “We’ve seen substantially more people needing coverage and help in recent months compared to last year, and more are new to being uninsured.”
Ray said her team is booked with appointments well into November. But she bemoans the fact that she has a third of the counselors she had a few years ago — 50, compared with 150 — and only a tiny ad budget.
Like Ray, Jeremy Smith, program director at First Choice Services in Charleston, West Virginia, said his team is expecting “tens of thousands more people” needing help compared with last year — but no bigger budget to serve them. First Choice provides telephone-based enrollment assistance in West Virginia, New Hampshire, Iowa and Montana with a federal grant of $100,000 per state.
“We are talking to a lot more people who have had job-based coverage for years,” Smith said. “This is the first time they are having to find insurance elsewhere. They don’t know what to do or who to trust.”
In Wisconsin, the governor shifted $1 million into health insurance outreach, in part to make up for a lack of federal funds, said Allison Espeseth, managing director at Covering Wisconsin, the state’s navigator agency. She said the money will go to radio and TV spots, billboards, bus ads and small grants to community organizations.
“A lot of people who lost jobs and insurance didn’t know they could enroll before open enrollment, so we are hoping to see them now,” Espeseth said.
Toula Barber, 60, is happy to be among those who got clear and useful help. “I’m not that savvy with computers and figuring all this stuff out,” said Barber, who lives in Manchester, New Hampshire. After she lost her job as a waitress in August, Barber’s health insurance lapsed at the end of September. A First Choice Services navigator helped her find a plan with coverage that started Oct. 1. She pays $200 a month after subsidies.
Because that plan has a $6,000 deductible, however, Barber said she would look for something better during open enrollment, in consultation with the same navigator.
An analysis published last summer found evidence of a shortage of enrollment assistance. It also pointed out that people who turned to insurance brokers rather than independent navigators for help sometimes were presented with the option of plans (such as short-term policies or cancer-only policies) that don’t meet ACA standards.
“The bottom line was that nearly 5 million people who sought help during the last open enrollment could not find it,” said Karen Pollitz, a senior fellow at KFF and one of the authors of the study. “I’m concerned that people will face barriers to finding help this year, too.”
Some States Are Pushing Harder
In contrast to the states that use the federal website, healthcare.gov, many of the 15 states that run their own ACA marketplaces are committing more resources to outreach and marketing this year to meet the higher demand.
“We market aggressively,” said Peter Lee, executive director of Covered California, that state’s marketplace. “We want everyone who needs coverage to get it.” Of Covered California’s $440 million budget this year, Lee said $140 million will go for marketing and outreach. In addition, California is inserting information about the marketplace and subsidized coverage in all unemployment checks.
Just short of 300,000 Californians have enrolled since the pandemic began, and about half did so because they lost employment-based coverage, said Lee.
At the same time, however, about 1 in 4 Covered California enrollees dropped out this year, higher than the normal turnover as some newly qualified for Medicaid and an unknown number could no longer afford the premiums. Still, enrollment was at an all-time high of 1.5 million as of June.
In New York, state officials and private groups have been helping people enroll in Medicaid, marketplace plans or other state-supported programs.
“We’ve been super busy since April,” said Elizabeth Benjamin, vice president of health initiatives at the Community Service Society of New York, an independent advocacy group for low-income residents. “Our governor prioritized this, so it’s going well.”
One challenge Benjamin noted are the fears that a case currently before the Supreme Court might overturn the law. “Our clients keep asking whether the ACA will still be around next year,” she said. “We reassure them it will.”
Madeline McGrath, 27, sought insurance help from the service society in May after her coverage through the Peace Corps expired. The corps laid off all its overseas staff in March. Madeline was in Moldova. She returned home to Chazy, New York. She qualified for Medicaid, and just in the nick of time: A few weeks earlier, she had been diagnosed with Crohn’s disease, a chronic digestive disorder.
“I’ll stick with Medicaid since my co-payments are very low,” said McGrath, who is pursuing a graduate degree.
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Shalala’s loss to Maria Elvira Salazar — a Republican and former television journalist who compared Democratic policy proposals to leftist oppression in countries like Cuba while campaigning in the Miami district — was a notable upset for House Democrats. While Democrats held onto control of the House, so far they have fallen short of expectations that they would secure an even stronger majority there.
Political forecasters like The Cook Political Report had projected it was “likely” Shalala would win. She lost 48.6% to 51.3%.
In the final weeks of the campaign, Shalala, 79, and Salazar, 58, traded attack ads that touched on the election’s significance for health care.
“Salazar supports Trump, who wants to eliminate the Affordable Care Act and remove coverage of preexisting health conditions,” a Shalala ad warned.
Salazar pointed to Shalala’s failure to disclose stock trades in violation of federal law. She also accused the representative, who was appointed to the federal commission overseeing the distribution of coronavirus relief to small businesses, of not doing enough for her constituents during the pandemic.
Shalala came to Congress in 2018, helping Democrats reclaim the House of Representatives on promises to defend the Affordable Care Act and popular consumer protections for those with preexisting conditions.
But 2020 is proving a much different election year. A political rematch after Shalala defeated Salazar two years ago, this election appeared to hinge on issues beyond health care coverage and affordability.
Early reports signal Shalala was not the only casualty of a strong showing by Republicans in the Miami-Dade area of South Florida. Another first-term Democratic member of Congress representing part of Miami-Dade County, Rep. Debbie Mucarsel-Powell, also lost. Former Vice President Joe Biden trailed Hillary Clinton’s showing there in 2016, when she won the district by almost 20 points.
Shalala first won the seat after it was vacated by Ileana Ros-Lehtinen, a retiring Republican who had held it for 30 years, including when her district went for Clinton in 2016.
At the time, it was seen as a vulnerability that Shalala did not speak Spanish while seeking to represent a heavily Latino district. Salazar, who worked for the Spanish-language news channel Univision, often campaigned in Spanish.
During her two years in Congress, Shalala served on the House Committee on Education and Labor and its subcommittee that addressed health issues, as well as the House Rules Committee — a sign of her favor with Democratic leaders.
After the Rules Committee held a hearing on a “Medicare for All” proposal in 2019, Shalala referred to it as “the first step in exchanging ideas on how we move toward universal health coverage.” But she also expressed concerns that Medicare is “not as good” as many private insurance plans and that some constituents would prefer to keep their plans.
“Why should we spend money when people have good private health insurance?” she told C-SPAN. “We need to cover those that don’t have coverage now.”
When President Bill Clinton appointed Shalala as the nation’s top health and human services official in 1993, she was seen as a controversial pick, too liberal for some. As chancellor of the University of Wisconsin in Madison, she had encouraged the school to adopt a speech code intended to restrict hate speech, a move later ruled unconstitutional in federal court.
Shalala served as health secretary until 2001, becoming president of the University of Miami until 2015 and then head of the Clinton Foundation until 2017.
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No private firms bid on Florida’s $30 million contract to set up and operate a drug importation program. Bids were due at the end of September.
The setback is likely to delay by at least several months Florida’s effort to become the first state to import drugs.
A spokesperson for the Florida Agency for Health Care Administration said the state is exploring its options. “The agency remains confident it will find a qualified vendor soon,” the spokesperson said. The state had planned to award a contract to a private vendor in December.
The disclosure of no bidders comes less than a month after the Trump administration cleared the way for states to apply for federal permission to set up an importation program — reversing nearly two decades of U.S. policy.
A 2003 law allows drug importation from Canada, but only if the head of the federal Department of Health and Human Services deems it safe and cost-effective. HHS Secretary Alex Azar made that declaration Sept. 24 and approved final rules for such initiatives.
Jane Horvath, a health consultant in College Park, Maryland, said potential bidders on the Florida contract were likely put off because the final federal rules were not set until late September. And private firms didn’t want to bid on a contract that would have to change if the Florida rules conflicted with those from Washington, she said.
Several inconsistencies are apparent between the Florida plan and what is allowed under the HHS final rules, she said. For example, Florida aims to give bonus-scoring points to contractors that repackage and relabel drugs in Florida, which is not allowed under the federal rules.
Another problem is that the private contractor has to determine which prescription drugs will produce the most savings for Florida’s Medicaid program, which is difficult since Medicaid rebates and other discount pricing are confidential.
“It could be that the $30 million contract is not enough either,” Horvath said.
Drug prices are lower in Canada because the country limits how much drugmakers can charge for medicines. The United States lets drugmakers and their distributors dictate prices.
Trump, who made lowering prescription drug prices a key campaign issue in 2016, has promoted importation, especially in messages geared to seniors during his reelection bid.
Critics say importing drugs from Canada would threaten the drug supply with counterfeit products. Because high-cost biologic drugs, including insulin, and intravenously injected medicines are not allowed to be imported under current law, the strategy could have limited impact.
Even with HHS backing, drug importation faces several challenges. Most notably, Canada has vowed to stop any effort that would exacerbate drug shortages there, which could make it challenging to identify a Canadian exporter. And the pharmaceutical industry opposes the program and is likely to sue to stop it.
Florida plans to set up an importation program to help lower drug prices for people covered by state programs such as Medicaid and the Corrections Department. The state has projected savings of up to $150 million a year.
The federal rules take effect Nov. 30, which is when states can formally apply to HHS to set up their program.
A chief architect of Florida’s importation plan, Mary Mayhew, who was secretary of the Florida Agency for Health Care Administration, resigned in September to become CEO of the Florida Hospital Association.
Mayhew refused to comment for this story.
Vermont, Colorado, Maine, New Hampshire and New Mexico are also devising programs to import drugs from Canada.
Colorado officials plan to seek out private contractors for that state’s program in 2021, and they hope to get final federal approval by summer 2022, officials said during a recent call with stakeholder groups.
Colorado plans to allow consumers to get drugs from Canada at their U.S. pharmacy or through mail order. It estimates residents could save an average of 61% off the price of medicines in Colorado today.
It’s unclear what impact the outcome of the presidential election will have on drug importation. Democratic nominee Joe Biden said he supports importing drugs from Canada. But, if elected, he is also likely to review many of the Trump administration’s actions.
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KHN senior correspondent Sarah Jane Tribble appeared on Newsy’s “Morning Rush” on Thursday to discuss rural hospital closures and KHN’s brand-new “Where It Hurts” podcast.
- Click here to watch Tribble on Newsy
- Tribble hosts “No Mercy,” the first season of “Where It Hurts.” Click here to listen to Chapter One.
KHN chief Washington correspondent Julie Rovner appeared on Newsy’s “Newsy Tonight” program on Wednesday to fact-check the health claims made by President Donald Trump and former Vice President Joe Biden during Tuesday’s debate.
- Click here to watch Rovner on Newsy
- Listen to the latest episode of KHN’s ‘What the Health?’ podcast, hosted by Rovner: “Election Preview: What’s Next for Health?“
Rovner also appeared on WGN’s “Midday News” on Sept. 25 to discuss the impact of the death of Justice Ruth Bader Ginsburg on the Affordable Care Act.
- Click here to watch Rovner on WGN
- Read Rovner’s “Without Ginsburg, Judicial Threats to the ACA, Reproductive Rights Heighten”
KHN senior correspondent Phil Galewitz discussed Pinellas County’s important role in the presidential election in the swing state of Florida with WUSF’s “Florida Matters” on Tuesday.
- Click here to hear Galewitz on WUSF
- Read “Trump-Biden Race Could Hinge on How Florida’s Pinellas County Swings,” written by Galewitz and Margo Snipe of the Tampa Bay Times
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JACKSONVILLE, Fla. — On a sweltering July morning, Rose Wilson struggled to breathe as she sat in her bed, the light from her computer illuminating her face and the oxygen tubes in her nose.
Wilson, a retiree who worked as a public health department nurse supervisor in Duval County for 35 years, had just been diagnosed with COVID-19-induced pneumonia. She had a telemedicine appointment with her doctor.
Staring back from her screen was Dr. Rogers Cain, who runs a tidy little family medical clinic a couple of blocks from the Trout River in north Jacksonville, a predominantly Black area where the coronavirus is running roughshod. Wilson, 81, was one of Cain’s patients who’d tested positive — he had seven other COVID patients that morning before noon. Three of her grown children had contracted the virus, too.
“It started as a drip, drip, drip in May,” said Cain, his voice muffled by his mask. “Now it’s more like a faucet running.”
Cain and Wilson are nervous. Over the past two decades, both watched as the county health department was gutted of money and people, hampering Duval’s ability to respond to outbreaks, including a small cluster of tuberculosis cases in 2012. And now they face the menace of COVID-19 in a city once slated to host this week’s Republican National Convention, in one of the states leading the latest U.S. surge.
Florida is both a microcosm and a cautionary tale for America. As the nation starved the public health system intended to protect communities against disease, staffing and funding fell faster and further in the Sunshine State, leaving it especially unprepared for the worst health crisis in a century.
Although Florida’s population grew by 2.4 million since 2010 to make it the nation’s third-most-populous state, a joint investigation by KHN and The Associated Press has found, the state slashed its local health departments’ staffing — from 12,422 full-time equivalent workers to 9,125 in 2019, the latest data available.
According to an analysis of state data, the state-run local health departments spent 41% less per resident in 2019 than in 2010, dropping from $57 to $34 after adjusting for inflation. Departments nationwide have also cut spending, but by less than half as much ― an average of 18%, according to data from the National Association of County and City Health Officials.
Even before the pandemic hit, that meant fewer investigators to track, trace and contain diseases such as hepatitis. It meant fewer public health nurses to teach people how to protect themselves from HIV/AIDS or the flu. When the wave of COVID-19 inundated Florida, the state was caught flat-footed when it mattered most, its main lines of defense eviscerated.
Now, confirmed cases have soared past 588,000 and deaths have risen to more than 10,000. Concerns over the virus prompted Republicans to cancel plans for an in-person convention in Jacksonville, opting for a pared-down version in North Carolina.
Health experts blame the funding cuts on the Great Recession and choices by a series of governors who wanted to move publicly funded state services to for-profit companies.
And when the pandemic took hold, they say, residents got mixed messages about prevention strategies like wearing masks from Republican Gov. Ron DeSantis and other political leaders. Voices within the health departments were muzzled.
“The reality, unfortunately, is people are going to die because of the irresponsibility of the decisions being made by the people crafting the budgets,” said Ron Bialek, president of the Public Health Foundation, a nonprofit in Washington, D.C., offering tools and training. “Public health can’t help us get out of this situation without our elected officials giving us the resources.”
State officials neither answered specific, repeated questions from KHN and The Associated Press about changes in public health funding, nor made staffers available for deeper explanations.
Dr. Leslie Beitsch, a former deputy secretary of Florida’s state health department, said failing to prepare for a foreseeable disaster “is governmental malpractice.” The nation’s pandemic response is only as good as the weakest link, he said. Since the virus respects no borders, other states feel the ripples of Florida’s failings.
Those failings are clear in Duval County, which had employed the equivalent of 852 full-time workers and spent $91 per person in 2008 but in 2019 had only 422 workers and spent just $34 per resident, according to the KHN-AP analysis of state data. That’s less than the typical list price of a single COVID test. Former county health director Dr. Jeff Goldhagen said the county’s team has been “dismantled to the extent that it could not really manage an outbreak.”
Yet it must.
Cain’s private north Jacksonville medical clinic alone has had about 60 confirmed COVID cases and eight deaths. “We are all on fire right now,” he said. “You have to have a fire department that is adequately equipped to put out the fire. ”
Florida faced similar shortcomings around the time of the last great pandemic, the 1918 flu. Back then, according to a 1924 state report, public health workers faced too many demands and their efforts were “to some extent scattered and transitory.” The state could have used at least three more district health officers, the report said: “It is a source of regret and a matter of grave concern to public health workers that the funds available are not sufficient.”
County-based health departments began in 1930, providing more robust services closer to home. About 50 years later, legislation created state-administered primary care programs in which county health departments provided low-income Floridians with the type of basic health care and treatment most people now get at private doctors’ offices.
The 1990s saw a move toward privatization, particularly as Medicaid managed care took hold, said a 2004 paper in the Florida Public Health Review. Still, per-person spending on local public health rose until the late 1990s, when adjusted for inflation to 2019 dollars, peaking at $59.
Wilson, the retired public health nurse stricken with COVID-19, recalled how Duval County’s department started feeling the financial pain during former Republican Gov. Jeb Bush’s administration in the early 2000s and kept losing nurses and other staff until they were “very, very short.”
Beitsch, who worked for the state health department in the 1990s, said the downward trend continued under former Republican governors Charlie Crist and Rick Scott, fueled by a growing belief in shrinking government that flourished in many states. Florida’s leaders exerted more control over public health, Beitsch said, and “the amount of local autonomy has been diminishing with successive administrations.”
The recession that began in late 2007 sparked public health reductions across the nation that were especially harsh in Florida. By 2011, budget cuts and lack of money were the most frequently cited challenges in a Florida public health workforce survey, which pointed to growing needs. In the following years, the state had some of the nation’s highest rates of heart disease and diabetes.
Squeezed departments struggled and sometimes stumbled. A report from the state health department’s inspector general for the 2018-19 fiscal year, for example, found a series of lost and inconsistent shipments of lab specimens from county health departments to the state lab — not long before the pandemic would make labs more important than ever.
As governor, Scott presided over the state from 2011 to 2019, when funding and staffing dropped most. Now a U.S. senator, he said through a spokesperson that he was unapologetic for health department cuts, which he characterized as a move toward “making government more efficient” without endangering public health.
“I’m sure that he had no problem with the cuts that were being made,” said Patrick Bernet, an associate professor in health administration at Florida Atlantic University. “To put it all on him is not fair because a bunch of little henchmen from the counties had to vote that way. … We keep voting in people who undervalue public health.”
Democratic state Sen. Janet Cruz, a legislator who has represented the Tampa region for a dozen years and sat on health care committees, said she watched lawmakers systematically cut money for health departments. When she questioned it, she said, some colleagues claimed the need wasn’t as great because the state was moving toward private family health care centers. “Public health in Florida has been wholly underfunded,” she said.
Some places have suffered more than others. Departments serving at least half a million residents spent $29 per person in 2019 on average, compared with $90 per person in departments serving 50,000 or fewer — a difference starker than the typical gap between larger and smaller departments nationally, according to an KHN-AP analysis. Experts can’t say exactly why the gap is wider in Florida, which has a state-run system, but point to politics and historical decisions about budgets.
Duval County’s health department spending was the equivalent of $34 per person, down 63% since 2008. Typically, about 22 workers, or 5% of the total staff, have been dedicated to preparing for and tracking disease outbreaks.
But when the pandemic hit, many there and elsewhere were diverted to fight the coronavirus, leaving little time for their typical duties such as mosquito abatement and tracking sexually transmitted infections such as syphilis.
“Current events demonstrate how bad a decision” the deep cuts to public health were, said Dr. Marissa Levine, a professor of public health and family medicine at the University of South Florida. “It’s really come back to haunt us.”
Mixed and Muzzled Messages
The pandemic caught fire in Florida this summer as the state’s rapid reopening allowed people to flock to beaches, Disney World, movie theaters and bars.
The state has had more than half a million confirmed cases ― among them, players and workers for baseball’s Miami Marlins ― and 35,000 hospitalizations, yet DeSantis still hasn’t issued a mask mandate. Some local governments have. Jacksonville adopted one in late June, and about a week later Republican Mayor Lenny Curry announced he and his family were self-quarantining because he’d been exposed to someone who tested positive for the virus.
Chad Neilsen, director of infection prevention at the University of Florida-Jacksonville, lauded the mayor for the mask requirement, saying, “We know that masking works.” But he pointed out that other counties have different rules and that the inconsistent messaging breeds confusion.
St. Johns County began requiring masks in late July but only in county facilities. And DeSantis has appeared in public without a mask numerous times, including at an Aug. 13 coronavirus update briefing during which some other speakers wore them.
“One voice is so critical during a pandemic,” said Dr. Jonathan Kantor, a Jacksonville epidemiologist and dermatologist. “We have to have one voice, and consistent leadership that is modeling behavior if we want to get people to change their behaviors.”
Instead, experts in Florida said, public health workers have been silenced or told by top state officials what to say. For example, The Palm Beach Post reported that state leaders told school boards they needed health department approval to keep schools closed, then instructed health directors not to give it.
“All the communication is directed by the state, and localities are very limited in what they can do,” said Levine, the University of South Florida professor. “Anything to do with a mandate, there’s resistance to do at a state level. This includes the hot debate on masks. The locals have to extend the state messaging.” Local health officials “are being told bluntly: ‘Shut up,’” Bernet said. “They literally cannot speak.”
Beitsch, who now chairs the department of behavioral sciences and social medicine at Florida State University, said such limitations ― and similar mixed messages and silencing of medical experts at the national level ― fuels the politicization of public health and undermining of science.
“People think they should be listening to politicians and state legislative leaders about their health care. They’re not listening to health experts and the epidemiologists who say if you just wear a mask and if you just wash your hands, we can really, really reduce the spread of the virus,” said Cruz, the state senator. “People are confused, and they think this is a hoax and it’s nothing more than the flu.”
Meanwhile, the COVID caseload continues to rise, surpassing 25,000 in Duval County, with minorities stricken disproportionately, as elsewhere in the nation. In a county that’s 29% Black and 60% white, Black residents with COVID have been hospitalized at more than double the rate of white residents. Rates are also high for Floridians grouped together as “other,” including Native American, Asian and multiracial residents.
Duval County’s overall caseload is rising so fast that Goldhagen, the former health department director, said the agency has given up on contact tracing, which means trying to curb the virus by identifying and warning people who have been exposed.
“It’s impossible,” Goldhagen said. “Dismantling the system was a complete disregard for the health and well-being of the citizens of Florida.”
With an unequipped public health system, Wilson, the retired public health nurse, said it falls to everyone to lead Jacksonville, and Florida, out of the coronavirus crisis.
“My hope is that everybody begins to take this virus seriously, and wear their mask and stay social distancing. It can work if we do that,” said Wilson, whose condition has improved. “So, that’s my hope. Eventually there will be a vaccine that will curtail this virus. But until then, it’s up to us to help do that. And if we’re not serious about it, then we’re doomed.”
This story is a collaboration between KHN and The Associated Press.
Spending and staffing data for Florida’s local health departments is from the Florida Department of Health. Florida Atlantic University professor Patrick Bernet provided additional state data on staffing by program area. KHN-AP adjusted spending data for inflation using the Bureau of Economic Analysis’ state and local government deflator.
COVID-19 data by race is from the Florida Department of Health. KHN-AP calculated rates per 10,000 people using data on race, regardless of ethnicity, from the U.S. Census Bureau’s 2018 American Community Survey. Statewide COVID-19 cases per day are from Johns Hopkins University.
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Even as his state is a hotbed for COVID-19, Florida Gov. Ron DeSantis has been pushing schools to reopen so parents have the choice of sending children back to the classroom or keeping them home to learn virtually.
The Republican governor has said children without any underlying health conditions would benefit from in-person learning and the stimulation and companionship of being among other young people. He has also made clear that he thinks these benefits far outweigh what he considers to be minimal risks.
“The fact is, in terms of the risk to schoolkids, this is lower risk than seasonal influenza,” DeSantis said, during an Aug. 10 televised roundtable discussion on education.
DeSantis’ assertion got us wondering, so we asked the governor’s office what evidence it had to back up the claim.
Looking at the Numbers
A spokesperson responded with data from the Florida Department of Health showing the state’s COVID-19 mortality rate is 0.02% for people 24 and younger. That’s the same as the influenza mortality rate for this age group.
But for children 14 and younger, the spokesperson said, Florida’s COVID-19 mortality rate is 0.009%, far below the 0.01% for flu for that age group.
And the risk of death is not the only concern children face if infected by the COVID-19 virus. They can develop complications that require hospitalization.
“The risk of complications for healthy children is higher for flu compared to COVID-19,” according to the Centers for Disease Control and Prevention. “However, infants and children with underlying medical conditions are at increased risk for both flu and COVID-19.”
The CDC estimates there were 480 deaths among U.S. children due to flu in the 2018-19 season, including 136 cases in which the virus was confirmed by laboratory testing.
As of mid-August, 90 children died of COVID-19 in the United States, according to the American Academy of Pediatrics.
More than 46,000 children were hospitalized for flu in that 2018-19 period. The hospitalization rate among children 5 to 17 was 39.2 children per 100,000 children.
The hospitalization rate for COVID-19 is six per 100,000 children for those ages 5 to 17, according to the CDC.
The number and rate of COVID cases in children in the United States steadily increased from March to July. “The true incidence of SARS-CoV-2 infection in children is not known due to lack of widespread testing and the prioritization of testing for adults and those with severe illness,” the CDC wrote recently.
While children have lower rates of using a ventilator than adults, 1 in 3 children hospitalized with COVID-19 in the United States were admitted to the intensive care unit, the same rate as for adults, the CDC said.
Dr. Chad Vercio, chair of pediatrics at Riverside University Health System in California, said DeSantis’ statement is partly true, with many caveats. Children’s risk from COVID-19 “entirely depends on how widespread COVID is in any area,” he said.
Data Reflects a Snapshot in Time
U.S. hospitalization rates for children with COVID are lower than for those with flu, Vercio said. But that could be due to parents keeping children home and schools being closed since March, he added. “It is unknown if these COVID hospitalization rates would rise when we open schools,” he said.
About two-thirds of Florida school districts have opened in the past two weeks with the rest planning to resume by Aug. 31. Most districts are offering in-person classes while giving parents the option to keep students home for virtual learning. In South Florida, where the pandemic has hit hardest, districts are planning, at least initially, to offer only virtual teaching.
Hillsborough County, which includes Tampa, had initially planned to reopen classrooms but reversed itself after doctors warned that school closures were likely to ensue. The county revised its plan to limit classes to online-only instruction, but the state’s education commissioner rejected that approach, saying it denies parents the option of sending their children back to school. Fearing the loss of millions of dollars in state funding, the district now plans to begin virtual learning for all students on Aug. 24, and, on Aug. 31, begin offering students the option to return to the classroom.
“The direct impact of COVID-19 on children is currently small in comparison with other risks and … the main reason we are keeping children at home is to protect adults,” concluded a report in the British Medical Journal published in June. Still, health authorities say parents should make sure children practice good hygiene and limit playtime with other children.
Based on data from February through mid-May, the report found 44 deaths from COVID-19 for people 19 and younger in France, Germany, Italy, Korea, Spain, England and the United States. In a typical three-month period, there would be 308 deaths from lower respiratory tract infections, including flu, in those countries.
“At this stage of the pandemic, COVID appears to be less dangerous for children than influenza,” said Sunil Bhopal, a co-author of the report and an academic clinical lecturer at Newcastle University in England.
“We don’t need to wait for a whole season because, even at its peak in most countries, COVID killed a smaller number of children than estimated influenza deaths averaged from across a year,” Bhopal said.
“While flu is likely to have caused more deaths than COVID, this may change as the pandemic progresses and major caution is necessary to ensure this doesn’t change,” said Bhopal, an honorary assistant professor at the London School of Hygiene and Tropical Medicine.
Dr. Sean O’Leary, professor of pediatrics at the University of Colorado Anschutz Medical Campus, said the growing number of U.S. deaths could be another reason to think about COVID-19 and children.
“We do know for sure that schoolchildren are major drivers of influenza epidemics in the community and, though that is not as much the case with COVID, it doesn’t mean they can’t spread it,” he said.
DeSantis also maintained that kids are less likely to spread COVID-19 than they are the influenza virus. However, experts cautioned that there’s still a lot that is unknown about children’s ability to transmit the virus to the people they interact with — parents, grandparents and even teachers. The perceived risk for teachers, for instance, is at the root of a lawsuit between the state’s largest teachers union and the DeSantis administration. The Florida Education Association wants a Leon County judge to stop the state’s order forcing school districts to open classrooms for in-person learning by the end of August.
Dr. Gabriela Andujar Vazquez, an infectious disease specialist at Tufts Medical Center in Boston, said children are more likely to have zero or mild symptoms from COVID-19 compared with adults.
“The bottom line is kids can get infected and they tend to have less severe disease,” she said. But the concern over reopening school is that children could spread the disease to others, including adults who are more likely to develop complications.
“Because schools are tied to the community — they are not in a bubble — and if community spread is not controlled in the community, it’s likely the school will reflect that,” she said. One factor that can determine if the disease is out of control is if positivity rates for people getting tested for COVID are over 5%. Many Florida counties have been well above that mark since June, although the rates have been dropping this month.
Back-to-school risks will be handicapped based on the ability of the school to adopt physical distancing measures and enforce wearing of face masks, said Dr. Andrew Pavia, a pediatric infectious disease specialist at the University of Utah Health and Intermountain Primary Children’s Hospital.
“This fall, we may see a lot of kids get infected as schools reopen, and those could be just the tip of the iceberg,” he said. “Even though most kids have mild or asymptomatic cases, what I worry about is just how big is the tip of the iceberg,” Pavia said.
He also noted there is a vaccine for flu — which about 50% to 70% of children receive. “The vaccine is not perfect but does reduce the impact of the disease, and with COVID everyone is at risk and susceptible,” Pavia said.
Dr. Vidya Mony, an infectious disease expert with Santa Clara Valley Medical Center in San Jose, California, said data suggests COVID-19 is not as bad for children as flu and that children are not the main driver of the pandemic. But, she said, there isn’t enough data yet to say indisputably that the COVID-19 risk is lower. “We are learning something every day with this.”
DeSantis said that COVID-19 is a lower risk for schoolchildren than is seasonal influenza.
Studies show the numbers of COVID-related deaths and hospitalizations among children are lower than the average rates for flu. Still, it’s uncertain if these lower rates among children were partly because schools were closed since March and whether those rates will rise as classrooms reopen this fall. It’s also unclear whether opening schools — particularly in communities with a high number of people testing positive — will lead to more spread of the disease.
We rate the claim as Mostly True.
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KNOXVILLE, Tennessee.- Es una época de mucho trabajo para las granjas productoras de tomate en esta parte del estado. Estas plantaciones cuentan con cientos de trabajadores, la mayoría latinos. Algunos viven allí. Otros son migrantes que viajan de granja en granja, para recoger las cosechas de verano. Otros vienen de México o Centroamérica con visas agrícolas temporales.
Pero este año, la temporada se desarrolla con enormes preocupaciones por el coronavirus que afecta directamente a estos trabajadores agrícolas.
“Casi todas las fases del proceso de recolección de tomates deben ser consideradas a la luz de COVID-19”, dijo Ken Silver, profesor asociado de salud ambiental en la Universidad Estatal del Este de Tennessee, que estudia la salud de los trabajadores migrantes en las plantaciones de tomates del estado.
Los trabajadores viven en alojamientos cerrados, durmiendo en literas y compartiendo baños y cocinas. Viajan a los campos en autobuses abarrotados y a menudo trabajan en grupos. Y aunque los empleados de las granjas son considerados trabajadores esenciales, suelen no tener seguro médico o licencia paga por enfermedad.
Las granjas ya han informado de brotes entre cientos de trabajadores en estados como California, Washington, Florida y Michigan. Sin embargo, el gobierno federal no ha establecido ninguna normativa para proteger a los trabajadores agrícolas del coronavirus o para instruir a los empleadores sobre lo que deben hacer cuando sus se enferman.
Mientras que organizaciones de defensa de los trabajadores migrantes dicen que esto permite a las granjas aprovecharse de sus trabajadores y aumentar su riesgo de exposición al coronavirus, las granjas aseguran que están haciendo lo que pueden para proteger a los trabajadores con los recursos limitados que tienen, mientras no se deja de hacer el trabajo.
Lo cierto es que la situación no está clara, expresó Alexis Guild, director de políticas y programas de salud de Farmworker Justice.
La responsabilidad de las granjas
En junio, 10 de los 80 trabajadores temporales de Jones & Church Farms en el condado de Unicoi, Tennessee, dieron positivo para el coronavirus. Otra granja en ese condado tenía 38 trabajadores que también dieron positivo alrededor de la misma época.
“Esto fue lo más aterrador que pudo pasarnos”, dijo Renea Jones Rogers, directora de seguridad alimentaria de la granja.
A nivel nacional, ha habido al menos 3,600 casos de trabajadores agrícolas que han dado positivo para COVID-19, según los informes de los medios de comunicación reunidos por el Centro Nacional para la Salud de los Trabajadores Agrícolas.
A esto hay que añadir que tanto los empleadores como los trabajadores agrícolas reconocen que incluso las intervenciones más básicas para frenar la transmisión —el distanciamiento social y el uso de máscaras— a menudo no son factibles, al trabajar en altas temperaturas.
Saúl, de 52 años, es un trabajador agrícola temporal que ha viajado de México a Virginia todos los años desde 1996 para cosechar tabaco. En una entrevista por WhatsApp, dijo que las máscaras son incómodas en el trabajo porque estás al aire libre: “Es incómodo porque trabajamos a la intemperie”. (Kaiser Health News no publica el apellido de Saúl para que no sea identificado por su empleador).
Saúl dijo que le preocupa el coronavirus, pero como vive en su lugar de trabajo, en la granja, se siente seguro.
Cuando llegó a los Estados Unidos en abril, la granja le proporcionó información sobre la pandemia, máscaras y desinfectante de manos, explicó. Nadie le toma la temperatura, pero trabaja en un grupo de ocho personas, vive con tres trabajadores más y nadie en la granja ha sido diagnosticado con COVID-19.
En Tennessee, Jones & Church Farms puso en marcha su propio protocolo de seguridad para los trabajadores al comienzo de la temporada. Esto incluyó el aumento de la desinfección, la toma de lecturas diarias de temperatura y el mantenimiento de los trabajadores en grupos para que vivan y trabajen con las mismas personas.
Después que los 10 trabajadores dieron positivo para COVID-19, la granja los mantuvo a todos en la misma vivienda y lejos de los demás. Los que eran asintomáticos también siguieron trabajando en los campos, aunque alejados de los otros, señaló Jones Rogers.
Si bien el Departamento de Trabajo no ha ofrecido normas federales de seguridad ejecutables para COVID-19, sí colaboró con los Centros para el Control y Prevención de Enfermedades (CDC) para elaborar un conjunto de pautas voluntarias y específicas para la agricultura. Esto se publicó en junio, pocos días después que Jones & Church notificara del brote en la granja.
Mucho de lo que ya se había hecho en Jones & Church, sin embargo, seguía esas recomendaciones, que también sugerían que los trabajadores fueran examinados todos los días para detectar los síntomas de COVID-19 y que a los que se enfermaran se les diera su propio espacio para recuperarse alejados de los demás.
Otras sugerencias de los CDC y el Departamento de Trabajo, orientadas más hacia las factorías de procesamiento de alimentos, como las plantas de empaque de tomates, incluían la instalación de mamparas plásticas si no es posible que haya una distancia de 6 pies entre los trabajadores, la instalación de estaciones de lavado de manos y la provisión de equipos de protección personal o cubiertas de tela para la cara.
En junio, 10 de los 80 trabajadores temporales de Jones & Church Farms en el condado de Unicoi, en Tennessee, dieron positivo para COVID-19. Otra granja de la zona tuvo 38 trabajadores enfermos para la misma fecha. A nivel nacional, se han registrado al menos 3,400 casos positivos entre trabajadores agrícolas, según datos del National Center for Farmworker Health. (Victoria Knight/KHN)
Los activistas dicen que estas directrices son sólidas, en teoría. Su defecto más evidente es que son voluntarias.
“No creemos que la salud y la seguridad de los trabajadores deban dejarse a la buena voluntad de los empleadores”, señaló María Perales Sánchez, coordinadora de comunicaciones del Centro de Los Derechos del Migrante, una organización con oficinas en México y en los Estados Unidos.
Un vocero del Departamento de Trabajo ofreció una perspectiva diferente. “Los empleadores son y seguirán siendo responsables de proporcionar un lugar de trabajo libre de riesgos conocidos para la salud y la seguridad”, indicó, y añadió que los estándares de seguridad general preexistentes de la Administración de Seguridad y Salud Ocupacional (OSHA) y las directrices de los CDC se utilizan para determinar las violaciones a la seguridad en el lugar de trabajo. La OSHA es una agencia del Departamento de Trabajo.
La industria agrícola ha expresado su temor ante cualquier aumento de la regulación federal.
“No creo que OSHA pueda implementar un tipo de regulación obligatoria que no ponga en desventaja a algunos agricultores”, apuntó Allison Crittenden, directora de relaciones con el Congreso de la American Farm Bureau Federation.
Las granjas ya han tomado muchas medidas contra COVID-19, añadió, “y si estas acciones se están llevando a cabo de forma voluntaria, no vemos la razón de imponer un requisito obligatorio”.
Dificultades para acceder a la atención médica
Los trabajadores agrícolas migrantes, a pesar de ocupar un eslabón esencial en la cadena de suministro de alimentos del país, a menudo no reciben prestaciones en el lugar de trabajo, como seguro médico o licencia de enfermedad remunerada.
Saúl, el trabajador agrícola del tabaco de Virginia, dijo que no creía tener ningún seguro médico. Si se enfermara, tendría que decírselo a su empleador, que luego tendría que llevarlo al médico. La ciudad más cercana a la granja está a 15 millas. ¿Quién es responsable de estos costos? ¿El trabajador o la granja? Depende de las circunstancias individuales.
Muchas granjas emplean principalmente trabajadores latinos, y los datos de los CDC ilustran que es mucho más probable que los latinos se infecten, deban hospitalizarse o mueran por complicaciones de COVID que los blancos no hispanos. Los expertos también advierten que debido a que la pandemia de COVID está afectando desproporcionadamente a las personas de minorías, podría ampliar las disparidades de salud preexistentes.
Además, buscar la atención de un médico puede resultar riesgoso para los trabajadores agrícolas migrantes. Los trabajadores indocumentados pueden temer ser detenidos por autoridades de Immigración mientras que los que tienen la residencia permanente (green card) les puede preocupar la “regla de la carga pública” que la administración Trump endureció.
Esta polémica “regla” tiene en cuenta el uso de los programas públicos, incluyendo la atención sanitaria, a la hora de una solicitud de ciudadanía. Sin embargo, el gobierno federal ha dicho que buscar tratamiento por COVID-19 no aplicaría para esa regla.
Y aunque el rastreo de contactos es importante para detener la propagación de COVID-19 entre los trabajadores agrícolas, muchos departamentos de salud no cuentan con traductores que puedan hablar español o lenguas indígenas centroamericanas, ni ha habido un rastreo sistemático a nivel nacional de los brotes de los trabajadores agrícolas hasta ahora, como se ha hecho con los brotes en las instalaciones de cuidados a largo plazo.
Por lo tanto, “es muy difícil saber cuántos trabajadores agrícolas específicamente están dando positivo,” expresó Guild, de Farmworker Justice.
Eso podría ser un problema para rastrear los brotes, especialmente cuando la temporada de cosecha aumenta para ciertos cultivos y las granjas incrementan su fuerza laboral.
A fines de julio, llegaron a Jones & Church Farms casi 90 trabajadores temporales adicionales para ayudar a cosechar tomates hasta octubre, apuntó Jones Rogers. Aunque los 10 trabajadores que tenían COVID-19 se han recuperado, dijo que teme que si más personas contraen la enfermedad, no habrá suficientes viviendas para mantener a los trabajadores enfermos aislados o suficientes trabajadores sanos para la cosecha.
“Los tomates no esperan a que todos se sientan bien para que se los recoja”, añadió Jones Rogers.
La reportera Carmen Heredia Rodríguez y Katie Saviano asistieron con traducción al español para esta historia.
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KNOXVILLE, Tenn. — It’s a busy time for the tomato-producing farms in this part of the state. Farms have staffed up with hundreds of workers, most of whom are Latino. Some live locally. Others are migrant workers who travel from farm to farm, chasing the summer growing seasons. Still others come from Mexico or Central America on temporary agricultural visas to work at certain farms.
But, this year, the season is taking place under a cloud of coronavirus worries that, for these agricultural workers, hit close to home.
“Almost every part of the process for picking tomatoes needs to be considered in light of COVID-19,” said Ken Silver, an associate professor of environmental health at East Tennessee State University, who studies migrant worker health on Tennessee tomato farms.
After all, the workers live in close quarters, sleeping in bunk beds, and sharing bathrooms and kitchens. They ride crowded buses to fields and often work in groups. And even though farm employees are deemed essential workers, they often don’t have health insurance or paid sick leave.
Farms have already reported outbreaks among hundreds of workers in states that include California, Washington, Florida and Michigan. And yet, the federal government has not established any enforceable rules either to protect farmworkers from the coronavirus or to instruct employers what to do when their workers get sick. While migrant worker advocacy groups say this allows farms to take advantage of their workers and increase their risk of exposure to the coronavirus, farms say they’re doing what they can to protect workers with the limited resources they have, while also getting their crops harvested.
The situation certainly isn’t clear-cut, said Alexis Guild, director of health policy and programs at the advocacy group, Farmworker Justice.
Leaving It Up to the Farms
In June, 10 temporary workers out of about 80 at the Jones & Church Farms in Unicoi County, Tennessee, tested positive for the coronavirus. Another farm in that county had 38 workers test positive around the same time.
“This was the scariest thing that could happen,” said Renea Jones Rogers, the farm’s food safety director.
Nationally, there have been at least 3,600 cases of farmworkers testing positive for COVID-19, according to media reports gathered by the National Center for Farmworker Health.
Add to this that farm employers and workers alike acknowledge that even the most basic interventions to stop transmission — social distancing and mask-wearing — often aren’t feasible, especially in the hot temperatures.
Saul, 52, is a temporary farmworker who has traveled from Mexico to Virginia every year since 1996 to harvest tobacco. In a WhatsApp message interview, he said masks are uncomfortable on the job because he is working outdoors, writing in Spanish, “En el trabajo es incómodo porque trabajamos al intemperie.” (Kaiser Health News is not publishing Saul’s last name so that he won’t be identified by his employer.)
Saul said he does worry about the coronavirus, but because he lives at his job on the farm, he feels safe.
When he arrived in the U.S. in April, the farm provided him with information about the pandemic, masks and hand sanitizer, he said. Nobody takes his temperature, but he works in a crew of eight, lives with only three other workers and nobody on the farm has yet been diagnosed with COVID-19.
In Tennessee, the Jones & Church Farms put its own worker safety protocols in place at the beginning of the season. These included increasing sanitation, taking daily temperature readings and keeping workers in groups so they live and work with the same people.
After the 10 workers tested positive for COVID-19, the farm kept them all in the same housing unit and away from the other workers — but those who were asymptomatic also kept working in the fields, though they were able to stay away from others on the job, said Jones Rogers.
While the Department of Labor has not offered enforceable federal safety standards for COVID-19, it did collaborate with the Centers for Disease Control and Prevention to publish a set of voluntary, agriculture-specific guidelines. Those were released in June, just days after Jones & Church became aware of the farm’s outbreak.
Much of what had already been done at Jones & Church, though, tracked closely with those recommendations, which also suggested that workers be screened every day for COVID-19 symptoms and that those who become sick be given their own space to recover apart from others.
Other suggestions in the CDC and Labor Department directive, geared more toward indoor food-processing factories such as tomato-packing plants, included installing plastic shields if 6 feet of distance isn’t possible between workers, putting in hand-washing stations and providing personal protective equipment or cloth face coverings.
In June, 10 of about 80 temporary workers at Jones & Church Farms in Unicoi County, Tennessee, tested positive for COVID-19. Another farm in the county had 38 workers test positive around the same time. Nationally, at least 3,400 positive cases among farmworkers have been counted, according to media reports gathered by the National Center for Farmworker Health. (Victoria Knight/KHN)
Advocates say these guidelines are sound, in theory. Their glaring flaw is that they are voluntary.
“We don’t believe that the health and safety of workers should be left to the goodwill of employers,” said María Perales Sanchez, communications coordinator for Centro de Los Derechos del Migrante, an advocacy group with offices in both Mexico and the U.S.
A Department of Labor spokesperson offered a different take. “Employers are and will continue to be responsible for providing a workplace free of known health and safety hazards,” the spokesperson said, adding that the Occupational Safety and Health Administration’s preexisting general-safety standards and CDC guidelines are used to determine workplace safety violations. OSHA is an agency within the Labor Department.
Farm industry groups are apprehensive of any increased federal regulation.
“I don’t think OSHA would be able to have some sort of mandatory regulation that wouldn’t disadvantage some farmers,” said Allison Crittenden, director of congressional relations for the American Farm Bureau Federation.
Farms have already put many COVID-19 protections in place, she said, “and if these actions are taking place in a voluntary way, we don’t see that we need to have a mandatory requirement.”
Difficulties in Accessing Health Care
Migrant farmworkers, despite occupying an essential link in the country’s food supply chain, often aren’t provided with workplace benefits like health insurance or paid sick leave.
Saul, the Virginia tobacco farmworker, said he didn’t believe he has any health insurance. If he gets sick, he would need to tell his farm employer, who would then have to drive him to the doctor. The closest city to the farm is 15 miles away. Who is responsible for these costs — the worker or the farm — depends on individual circumstances.
Many farms employ mostly Latino workers, and CDC data illustrates that it’s much more likely for Hispanic or Latino people to be infected, hospitalized or die from COVID complications than white people. Experts also warn that because the COVID pandemic is disproportionately affecting people of color, it could widen preexisting health disparities.
Also, seeking a doctor’s care can feel risky for migrant farmworkers. Workers who are undocumented may worry about being detained by Immigration and Customs Enforcement, while workers who have green cards may be concerned about the Trump administration’s “public charge rule.” This controversial rule weighs immigrants’ use of public programs, including health care, against their applications for citizenship. However, the federal government has said seeking treatment for COVID-19 wouldn’t fall under the rule.
And while contact tracing is important to stop the spread of COVID-19 among farmworkers, many health departments don’t have translators on staff who can speak Spanish or Indigenous Central American languages, nor has there been a systematic nationwide tracking of farmworker outbreaks thus far, as has been done with long-term care facilities outbreaks.
So “it’s really hard to get a grasp on how many farmworkers specifically are testing positive,” said Guild, with Farmworker Justice.
That could be an issue for tracing outbreaks, especially as the harvesting season ramps up for certain crops and farms bolster their workforces.
At the end of July, almost 90 additional temporary workers arrived at Jones & Church Farms to help harvest tomatoes through October, said Jones Rogers. Though the 10 workers who had COVID-19 have recovered, she said she’s scared that if more get the disease, there won’t be enough housing to keep sick workers separate from others or enough healthy workers to harvest the crops.
“Tomatoes don’t wait until everyone is feeling good to be harvested,” said Jones Rogers.
Reporter Carmen Heredia Rodriguez and Katie Saviano provided Spanish translation assistance for this story.
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HELENA, Montana — States frustrated by private laboratories’ increasingly long turnarounds for COVID-19 test results are scrambling to find ways to salvage their testing programs.
Montana said Wednesday that it is dropping Quest Diagnostics, one of the nation’s largest diagnostic testing companies. The Secaucus, New Jersey-based company had done all the state’s surveillance COVID-19 testing — drive-thru testing that moves from community to community to help track COVID’s spread. But it told state officials last week that it was at capacity and would be unable to accommodate more tests for two or three weeks.
“We don’t want to be left high and dry again in the event that the national demand for testing puts a state like ours onto the back burner,” Democratic Gov. Steve Bullock said.
Instead, he said, the state is enlisting Montana State University’s lab to process up to 500 tests a day and has finalized a contract with a new private lab, North Carolina-based Mako Medical, for an additional 1,000 tests a day.
California, Florida and other states that work with Quest have started experimenting with separate, expedited lines for people who have symptoms of the disease. Some states are contracting with other private labs. And CVS, which uses Quest for COVID tests at many of its sites nationwide, said it is looking for more lab partners to reduce wait times for results.
Quest, LabCorp and other private labs have struggled to expand quickly enough to meet demand as states expand their testing and cases soar across the nation. Officials for Quest, which handles about 130,000 tests daily in 20 laboratories, said its ability to expand has been limited by a global shortage of the machines and chemical reagents needed to perform COVID-19 testing.
On Monday, Quest announced that turnaround times had slowed to a week or more, up from three or four days in June. It also said some patients may face wait times of up to two weeks. Quest officials warned this week that could get worse as flu season starts this fall.
A wait of a week or more for results can make the tests moot, since few people, especially those without symptoms, are likely to remain quarantined that long — and if the test comes back positive, they may already be over the disease.
“We are working with a number of different organizations to provide as much testing as possible, but some of these constraints are out of our control,” Quest spokesperson Wendy Bost said. “We’ve taken the step of asking our clients to modulate the testing demand by focusing on patients who are most in need at this time.”
The Trump administration is also trying to speed up turnaround times by allowing some labs to use an approach known as pooled testing, which combines samples from multiple people and then screens the individual samples only if the batch comes back positive for the virus. But public health experts worry it may be too late to try pool testing, as the percentage of positive results has doubled or tripled in many parts of the country.
States grappling with rising caseloads amid the testing slowdown have grown exasperated. Colorado Gov. Jared Polis, a Democrat, told NBC’s “Meet the Press” on Sunday that it can take up to nine days to get test results from Quest and LabCorp.
“Almost useless from an epidemiological or even diagnostic perspective,” Polis said.
LabCorp officials say turnaround times are improving.
Those who worry they have COVID-19 are also frustrated. In San Francisco, Mark Mackler, a 71-year-old retired law librarian, went with his husband to get a free test at the Bernal Heights Recreation Center on June 28 for peace of mind. He expected results after five days, but the test, processed by Quest, took 16 days — it came back negative for COVID-19.
“I was just annoyed and concerned the taxpayers were getting taken for a ride on something expensive and useless to a lot of people,” Mackler said.
Mark Mackler. (Photo courtesy of Wendell Choo)
In California, Democratic Gov. Gavin Newsom acknowledged Quest’s slow turnaround times at a press conference Wednesday.
“It’s rather preposterous that you get a test and 13, 14 days later you get the results,” Newsom said, adding that the results in those cases are “utterly meaningless.”
But, he added, “We’re not going to abandon Quest. We need them as one of our partners.”
California is partnering with other private and university labs to expedite test results, ramping up from 2,000 tests a day early in the pandemic to an average of more than 125,000 a day, Newsom said. Test results now average between five and seven days, and state health officials said they have told all labs to first process from high-risk groups, such as people with COVID symptoms, those in hospitals and those in long-term care facilities.
In Florida, Quest has performed more than 600,000 COVID tests, the most of any lab. After reports of labs taking seven to 10 days to turn around test results, health officials created special lanes at four testing sites for symptomatic people that will allow them to receive their results faster. If that program goes well, Florida officials said, it will be expanded to all 50 state-run sites.
Pennsylvania health officials plan to cut the number of drive-thru testing sites it runs with Quest and Walmart from 19 to 13. They also are relocating some site locations that have seen low testing numbers to more populated areas with higher positivity rates.
Weeklong waits for COVID tests are not the norm everywhere. In Texas, state-run mobile test sites are providing results within two to three days because the state has “spread the load” of testing among many lab companies, said Seth Christensen, spokesperson for the Texas Division of Emergency Management. The state does not use Quest but instead uses more than 10 other lab companies, including LabCorp, another of the nation’s largest lab chains.
Return times vary widely by company. LabCorp said turnaround time for outpatient test results improved to three to five days this week from four to six last week. BioReference Laboratories, another big lab chain, said it has improved turnaround time from about six days in June to three or fewer this month. Walmart, which has used Quest and eTrueNorth for more than 150,000 COVID tests, said on its website that Quest results take a week, compared with three to five days with eTrueNorth.
In Montana, the Quest delays forced the state to pause its community testing program, which aims to serve as an alert system for how the virus is spreading. Officials plan to resume next week once it has Montana State and the North Carolina lab in place, Bullock said.
Montana, with 2,813 confirmed cases as of Tuesday, has one of the lowest per-capita rates in the nation. But the average daily caseload in the state has risen 112% in the past two weeks — the country’s third-highest rate increase, according to an analysis by NPR.
Quest started running the state’s mass-testing events in the spring, with promised turnaround times of two or three days. But that started to stretch into a week or longer, Bullock said.
Bost, the Quest spokesperson, described the delay in community testing as a temporary agreement with state officials.
“We mutually agreed to postpone some community events for the general population in order to ensure testing is available for the patients who are most in need, such as those who are symptomatic and ill in the hospital,” she said.
Montana hasn’t canceled its contract with Quest, but state officials said they are unsure whether the state will resume using the company.
“We can meet the need that we have in Montana with these two solutions,” Bullock said, referring to the Montana State University and North Carolina laboratories. “But that doesn’t mean that we won’t be returning to Quest at some point.”
KHN correspondent Rachel Bluth contributed to this report.