Are Public Health Ads Worth the Price? Not if They’re All About Fear

ST. LOUIS — The public service announcement showed a mother finding her teenage son lifeless, juxtaposed with the sound of a ukulele and a woman singing, “That’s how, how you OD’d on heroin.”

It aired locally during the 2015 Super Bowl but attracted national attention and has been viewed more than 500,000 times on YouTube.

“You want to tap into a nerve, an emotional nerve, and controversy and anger,” said Mark Schupp, whose consulting firm created the ad pro bono. “The spot was designed to do that, so we were happy with it.”

But like other ads and PSAs seeking to move the needle on public health, it went only so far.

Marketing experts say public health advertising often falls short because it incites people’s worst fears rather than providing clear steps viewers can take to save lives. They say lessons from opioid messaging can inform campaigns seeking to influence behavior that could help curb the coronavirus pandemic, such as wearing masks, not gathering in big groups and getting a covid-19 vaccine.

The Super Bowl ad was produced and aired by the St. Louis chapter of the National Council on Alcohol and Drug Abuse using $100,000 from an anonymous donor. Then-director Howard Weissman said a top priority for his group was for Missouri to start a prescription drug monitoring program.

Five years later, Missouri remains the only state without a statewide program. And the number of opioid deaths has steadily increased in that time, state data shows, up from 672 in all of 2015 to 716 deaths in just the first six months of 2020.

The national council, now called PreventEd, is one of many nonprofits and government agencies that invest millions in messaging aimed at curbing the opioid epidemic. People who study such advertisements said it’s difficult to measure their impact, but if the metric is the number of overdose deaths, they have not yet succeeded. The country set a record for overdose deaths in 2019 that it was on pace to break in 2020.

“You have to give them a solution, especially in a health context, like with opioids, because similar to with cigarette smoking, if you increase fear and don’t give a solution, they are just going to abuse more because that’s their coping mechanism,” said Punam Anand Keller, a Dartmouth College professor who studies health marketing.

To address public health issues, marketers often use images of diseased lungs to discourage smokers or the bloody aftermath of car crashes to prevent drunken driving. But these can provoke “defensive responses” that may be avoided by giving people ways to take action, said a 2014 International Journal of Psychology review of campaigns that use fear to persuade people.

Missouri’s state health and mental health departments, with the help of federal funds, spent at least $800,000 on advertising in 2019 to curb the opioid epidemic through their Time 2 Act and NoMODeaths campaigns, according to data from advertising agencies and partner organizations.

Mac Curran, a 34-year-old social media influencer, described his struggles with opioid addiction in a number of videos for Time 2 Act, one of which was viewed more than 100,000 times on Facebook. In another recent video, Curran used storytelling to highlight the benefits of getting treatment for his addiction. He talked about strangers cheering for him when he returned to a friend’s streetwear store after getting out of the recovery program, and discussed how he learned coping skills he could use throughout life.

Jay Winsten, a Harvard University scientist who spearheaded the U.S. designated-driver campaign to combat drunken driving, described Curran’s videos as “really excellent because he comes across as genuine and well spoken. People remember stories more than they do someone simply lecturing at them.”

Still, Winsten emphasized the importance of including actionable steps and would like to see Missouri and other groups focus on teaching friends of users “how to intervene and what language to use and not to use.”

Others, including the libertarian Cato Institute, argue that PSAs on drug use just don’t work and point to the history of failed campaigns to discourage teen marijuana use.

Yet agencies keep trying. Missouri’s mental health department and the Missouri Institute of Mental Health at the University of Missouri-St. Louis convened focus groups in 2019 with drug users and their families and captured their words on billboards for the NoMODeaths campaign. One said, “Don’t give up on treatment. It’s worth the work,” and gave a number to text for help with heroin, fentanyl or pill misuse.

In addition to giving information, the goal was “to let people who use drugs know that other people care if they live or die,” said Rachel Winograd, a psychologist who leads the NoMODeaths group aimed at reducing harm from opioid misuse.

She said she understands the argument that PSAs are a waste of money, given that organizations like hers have limited funds and also try to provide housing for those in recovery and naloxone, used to revive people after overdoses.

But, Winograd said, some of the advertisements appeared to work. The organization saw a big increase after the ads ran in the number of people who visited its website or texted a number for information on treatment or obtaining naloxone.

Although federal funding rose for fiscal years 2021 and 2022, Winograd’s team and state officials decided to cut NoMODeaths’ advertising budget in half and instead spend the money on direct services like naloxone, treatment and housing.

Now health agencies are consumed by the coronavirus pandemic and are trying to craft messages that cut through politically charged discourse and get the public to adopt safety measures such as wearing masks, staying physically distanced and getting vaccinated.

Convincing people to wear masks has been difficult because messages have been mixed. Missouri’s health department has tried to depoliticize mask-wearing and get people to view it as a public health solution, said spokesperson Lisa Cox.

But Missouri Gov. Mike Parson has appeared without a mask at public events and has declined to enact a statewide mask mandate. He also said at a Missouri Cattlemen’s Association event in July, “If you want to wear a dang mask, wear a mask.”

Cox would not comment on whether Parson’s approach undermined the state’s public health efforts, but Keller said it did.

Missouri’s messaging about vaccines has been much more straightforward and clear. A website provides facts and answers to common questions as it encourages people to “make an informed choice” on whether to get the shots.

Keller praised the “unemotional, not-fear-arousing” approach to the vaccine messaging issued so far.

“It needs the right messengers: well-known individuals who have high credibility within specific population groups that currently are hesitant about taking the vaccine,” Winsten said.

This time, Parson has been one of those messengers. When he announced the launch of the vaccine website in November, he said in a news release: “Safety is not being sacrificed, and it’s important for Missourians to understand this.”

In spite of the politicization of the virus crisis, Winsten, who serves on the board of advisers of the Ad Council’s $50 million covid vaccine campaign, has “guarded optimism” that enough people will get vaccinated to curb the pandemic.

And he remains hopeful that PSAs could eventually help reduce the number of people who die from opioids.

“Look at the whole anti-smoking movement. That took over two decades,” he said. “These are tough problems. Otherwise, they would be solved already.”

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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Mientras los vulnerables esperan, cónyuges de polٌíticos reciben la vacuna contra covid

Los suministros de vacunas contra covid-19 son escasos, por eso un panel asesor federal recomienda primero administrarlas a los trabajadores de salud, que mantienen en funcionamiento el sistema médico del país, y a los adultos mayores en hogares, que tienen más probabilidades de morir a causa del coronavirus.

En ninguna parte de la lista de personas prioritarias están los cónyuges de los funcionarios públicos.

Sin embargo, las primeras damas de Kentucky y West Virginia; Karen Pence, la esposa del vicepresidente Mike Pence; Jill Biden, la esposa del presidente electo Joe Biden; y Doug Emhoff, el esposo de la vicepresidenta electa Kamala Harris, estuvieron entre los primeros estadounidenses en recibir las vacunas que podrían salvar vidas.

Kentucky también vacunó a seis ex gobernadores y cuatro ex primeras damas, incluidos los padres de Andy Beshear, el actual gobernador demócrata.

Las primeras vacunas a los cónyuges provocaron indignación en las redes sociales, y varios usuarios de Twitter dijeron que no deberían poder “saltar la fila” antes que los médicos, enfermeras y personas mayores.

En la mayoría de los 29 estados que respondieron a las consultas de KHN (que llamó a las 50 oficinas de gobierno estatales), los principales funcionarios electos dijeron que ellos, y sus cónyuges, serán vacunados, pero han optado por esperar su turno detrás de electores más vulnerables.

Algunos miembros del Congreso de ambos partidos dijeron lo mismo cuando rechazaron las primeras dosis ofrecidas, en nombre de mantener al gobierno en funcionamiento.

Los gobernadores que recibieron las vacunas junto con sus cónyuges, y la oficina del vicepresidente, dijeron que querían dar el ejemplo a los residentes, generar confianza, salvar las divisiones ideológicas y demostrar que la vacuna es segura y eficaz.

Pero algunos cuestionan esta razón.

“Se parece más a hacer trampa. Los políticos pueden conseguir que los hospitales los vacunen bajo esta ilusión de generar confianza. Pero es una fachada”, dijo Arthur Caplan, profesor de bioética y director fundador de la división de ética médica de la Escuela de Medicina Grossman de la Universidad de Nueva York. “La gente podría decir: ‘Típica gente rica. No se puede confiar en ellos’. Esto socava la meta original”.

Caplan agregó que, de todos modos, el público no confía demasiado en los políticos, por lo que la vacunación de celebridades, líderes religiosos o figuras deportivas probablemente ayudaría más a aumentar la confianza en la vacuna.

Elvis Presley recibió la famosa vacuna contra la polio en 1956 para ganar la confianza de los escépticos; las acciones de las esposas de los gobernadores de ese período se recuerdan menos.

El doctor José Romero, presidente del Comité Asesor de Prácticas de Inmunización de los Centros para el Control y Prevención de Enfermedades (CDC), dijo en un correo electrónico a KHN que si bien su grupo proporciona un esquema para distribuir dosis limitadas de vacunas, “las jurisdicciones tienen la flexibilidad de hacer lo que sea apropiado para su población”.

Los funcionarios de Kentucky y Texas señalaron que el doctor Robert Redfield, director de los CDC, alentó a los gobernadores a vacunarse públicamente.

Nadie mencionó razones médicas para que sus cónyuges se vacunaran; los hospitales generalmente no están vacunando a los cónyuges de los profesionales médicos que han recibido la vacuna.

La oficina del gobernador de West Virginia, el republicano Jim Justice, publicó fotografías de él, su esposa, Cathy Justice, y otros funcionarios recibiendo las dosis. También posteó su propia vacunación en YouTube.

La oficina de Beshear en Kentucky también publicó fotos del gobernador recibiendo la vacuna en diciembre, el mismo día que su esposa, Britainy Beshear, y otros funcionarios estatales.

“Es cierto que hay dudas sobre las vacunas”, dijo Beshear en una reunión informativa sobre el coronavirus, el día en el que los ex gobernadores de Kentucky y sus cónyuges fueron vacunados. Aludió a un programa futuro que involucra a líderes religiosos y a otras personas influyentes.

Su padre, el ex gobernador demócrata Steve Beshear, publicó fotos de su vacunación en su página de Facebook, diciendo que él y su esposa, Jane Beshear, junto con otros ex gobernadores de Kentucky de ambos partidos y sus cónyuges, intervinieron en parte para alentar a los residentes a vacunarse.

Kentucky se encuentra actualmente en la primera etapa de distribución de vacunas, dirigida a trabajadores de salud y a residentes de centros de vida asistida. Se habían distribuido menos de 15,000 de las 58,500 dosis para estas residencias cuando los ex gobernadores y sus cónyuges fueron vacunados.

Tres Watson, ex director de comunicaciones del Partido Republicano de Kentucky, que fundó una firma de consultoría política, se mostró escéptico sobre las intenciones detrás del evento. Dijo que parecía ser un esfuerzo de relaciones públicas creado para que el gobernador pudiera vacunar a sus padres.

“Entiendo la continuidad del gobierno, pero las primeras damas no tienen parte en la continuidad del gobierno”, dijo. “Tienes que ajustarte a las prioridades. Una vez que empiezas a hacer excepciones, es cuando tienes problemas”.

Los funcionarios que representan al equipo de transición de Biden-Harris y otros tres estados donde se vacunaron los gobernadores (West Virginia y Texas liderados por republicanos, y Kansas liderado por un demócrata) no respondieron a KHN. El gobernador republicano de Alabama, Kay Ivey, recibió la vacuna y está divorciado.

Políticos de otros estados han hecho lo opuesto.

En Arkansas, el gobernador republicano Asa Hutchinson se centra en garantizar que los grupos de alta prioridad, como los trabajadores de salud, y el personal y residentes de centros de vida asistida, se vacunen, dijo la vocera LaConda Watson. “Él y su esposa recibirán la vacuna cuando sea su turno”, informó.

En Missouri, Kelli Jones, directora de comunicaciones del gobernador republicano Mike Parson, dijo en un correo electrónico que él y la primera dama tienen la intención de vacunarse. Al igual que los gobernadores de Colorado, Nevada y otros lugares, ambos se han recuperado de covid-19, dijo Jones, y “esperarán hasta que su grupo de edad sea elegible” según el plan estatal. Los médicos recomiendan las vacunas incluso para personas que ya han tenido covid.

Cissy Sanders, de 52 años, directora de eventos que vive en Austin, Texas, dijo que entiende por qué los legisladores deberían vacunarse. Su propio gobernador, el republicano Greg Abbott, se vacunó por televisión en vivo para infundir confianza, dijo su secretaria de prensa, Renae Eze, quien no quiso comentar si la esposa de Abbott se había vacunado.

Pero Sanders dijo que los cónyuges de los políticos no deben vacunarse antes que los residentes de un asilo, como su propia madre de 71 años. La madre de Sanders recibió la vacuna a fines de diciembre pero dijo que todavía hay demasiados residentes de hogares esperando en todo el país.

“¿Por qué un grupo que no es de alto riesgo, es decir, estos cónyuges, va a vacunarse antes que el grupo de mayor riesgo? ¿Quién toma estas decisiones?, se preguntó. “Los cónyuges de los políticos no han estado en la zona cero del virus. Los residentes de hogares sí”.

La corresponsal de Montana, Katheryn Houghton, la corresponsal de California Healthline, Angela Hart y los corresponsales Markian Hawlyruk y JoNel Aleccia 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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As the Vulnerable Wait, Some Political Leaders’ Spouses Get Covid Vaccines

With supplies of covid-19 vaccines scarce, a federal advisory panel recommends first putting shots into the arms of health care workers, who keep the nation’s medical system running, and long-term care residents most likely to die from the coronavirus.

Nowhere on the list of prioritized recipients are public officials’ spouses.

Yet the first ladies of Kentucky and West Virginia; Republican Vice President Mike Pence’s wife, Karen Pence; Democratic President-elect Joe Biden’s wife, Jill Biden; and Vice President-elect Kamala Harris’ husband, Doug Emhoff, were among the first Americans to get the potentially lifesaving shots.

Kentucky also vaccinated six former governors and four former first ladies, including current Democratic Gov. Andy Beshear’s parents.

The early vaccinations of political spouses spurred outrage on social media, with several Twitter users saying they should not be able to “jump the line” ahead of doctors, nurses and older people.

In most of the 29 states that responded to KHN inquiries of all 50 governors’ offices, top elected officials said they — and their spouses — will be vaccinated but have chosen to wait their turn behind more vulnerable constituents. Some Congress members from both parties said much the same when they refused early doses offered in the name of keeping the government running. Those weren’t offered to their spouses.

Governors who got the shots along with their spouses, and the vice president’s office, said they wanted to set an example for residents, build trust, bridge ideological divides and show that the vaccine is safe and effective.

But that’s a rationale some critics don’t buy.

“It looks more like cutting in line than it does securing trust. The politicians can get the hospitals to give it to them under this illusion of building trust. But it’s a façade,” said Arthur Caplan, a bioethics professor and founding head of the medical ethics division at New York University Grossman School of Medicine. “People might say: ‘Yup, typical rich people. They can’t be trusted.’ This undermines what they set out to do.”

Besides, Caplan said, the public doesn’t trust politicians all that much anyway, so inoculating celebrities, religious leaders or sports figures would likely do more to boost confidence in the vaccine. Rock ’n’ roll king Elvis Presley famously got the polio vaccine in 1956 to help win over those who were skeptical; the actions of governors’ wives from that period are less remembered.

Dr. José Romero, chairperson of the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices, said in an email to KHN that while his group provides an outline for distributing limited vaccine doses, “jurisdictions have the flexibility to do what’s appropriate for their population.” Kentucky and Texas officials pointed out that CDC Director Dr. Robert Redfield encouraged governors to publicly get the vaccine.

No one mentioned medical reasons for their spouses to get vaccines; hospitals are generally not vaccinating the spouses of medical professionals who have gotten the shot. (It’s unclear whether vaccinated people can still spread the virus, so it’s possible that a vaccinated person could pass the virus to their spouse or have to quarantine if an unvaccinated spouse were to get covid.)

The office of West Virginia’s governor, Republican Jim Justice, released pictures of him, his wife, Cathy Justice, and other officials receiving shots. He also showed his own vaccination on YouTube.

Beshear’s office in Kentucky also released photos of him getting the vaccine in December on the same day as his wife, Britainy Beshear, and other state officials.

“There is no question that there is vaccine hesitancy out there,” Beshear said at a coronavirus briefing on Monday, the day former Kentucky governors and their spouses were vaccinated. He alluded to a future program involving faith leaders and others. “Validators are incredibly important to building that confidence.”

His father, Democratic former Gov. Steve Beshear, posted photos of his vaccination on his Facebook page, saying that he and his wife, Jane Beshear, along with other former Kentucky governors of both parties and their spouses, stepped up partly to show residents the vaccine is safe and encourage them to get it when it’s available to them.

Kentucky is currently in the first stage of vaccine distribution, which targets health care workers and residents of long-term care and assisted living facilities. Fewer than 15,000 of the 58,500 doses received for long-term care had been given out when the former governors and their spouses were vaccinated.

Tres Watson, a former communications director for the Republican Party of Kentucky who founded a political consulting firm, was skeptical about the intentions behind the event. He said it seemed to be a public relations effort created so the governor could vaccinate his parents.

“I understand the continuity of government, but first ladies have no part in the continuity of government,” he said. “You need to stick with the priorities. Once you start making exceptions, that’s when you run into problems.”

Officials representing the Biden-Harris transition team and three other states where governors got vaccinated — Republican-led West Virginia and Texas, and Democratic-led Kansas — either didn’t respond to KHN or didn’t answer questions about spouses. Alabama’s Republican governor, Kay Ivey, got the vaccine and is divorced.

Politicians in other states have taken the opposite tack.

In Arkansas, Republican Gov. Asa Hutchinson is focused on ensuring high-priority groups such as health care workers, long-term care staffers and residents are vaccinated, said spokesperson LaConda Watson. “He and his wife will receive the vaccination when it’s their turn,” she said.

In Missouri, Kelli Jones, communications director for Republican Gov. Mike Parson, said in an email that he and the first lady fully intend to get the vaccine. Like governors from Colorado, Nevada and elsewhere, they’ve both recovered from covid-19, Jones said, and will “wait until their age group is eligible” under the state plan. Doctors recommend vaccinations even for people who have already had covid.

Cissy Sanders, 52, an events manager who lives in Austin, Texas, said she understands why lawmakers would need to get the vaccine. Her own governor, Republican Greg Abbott, received it on live television to instill confidence, said his press secretary, Renae Eze, who wouldn’t address whether Abbott’s wife was vaccinated.

But Sanders said politicians’ spouses should not be vaccinated before nursing home residents like her 71-year-old mom. Sanders’ mother received the vaccine in late December — after some public officials’ spouses — but she said far too many nursing home residents across America are still waiting.

“Why is a non-high-risk group — i.e., these spouses — going before the most high-risk group? Who makes these decisions? Who thinks this is a good, responsible, safe decision to make?” she said. “Political spouses have not been at ground zero for the virus. Nursing home residents have been.”

KHN Montana correspondent Katheryn Houghton, California Healthline correspondent Angela Hart and KHN senior correspondents Markian Hawryluk and JoNel Aleccia contributed to this report.

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

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KHN’s ‘What the Health?’: 2020 in Review — It Wasn’t All COVID

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COVID-19 was the dominant — but not the only — health policy story of 2020. In this special year-in-review episode of KHN’s “What the Health?” podcast, panelists look back at some of the biggest non-coronavirus stories. Those included Supreme Court cases on the Affordable Care Act, Medicaid work requirements and abortion, as well as a year-end surprise ending to the “surprise bill” saga.

This week’s panelists are Julie Rovner of KHN, Joanne Kenen of Politico, Anna Edney of Bloomberg News and Sarah Karlin-Smith of Pink Sheet.

Among the takeaways from this week’s podcast:

  • The coronavirus pandemic strengthened the hand of ACA supporters, even as the Trump administration sought to get the Supreme Court to overturn the federal health law. Many people felt it was an inopportune time to get rid of that safety valve while so many Americans were losing their jobs — and their health insurance — due to the economic chaos from the virus.
  • Preliminary enrollment numbers released by federal officials last week suggest that more people were taking advantage of the option to buy coverage for 2021 through the ACA marketplaces than for 2020, even in the absence of enrollment encouragement from the federal government.
  • The ACA’s Medicaid expansion had a bit of a roller-coaster ride this year. Voters in two more states — Oklahoma and Missouri — approved the expansion in ballot measures, but the Trump administration continued its support of state plans that require many adults to prove they are working in order to continue their coverage. The Supreme Court has agreed to hear a challenge to that policy. Although lower courts have ruled that the Medicaid law does not allow such restrictions, it’s not clear how the new conservative majority on the court will view this issue.
  • Concerns are beginning to grow in Washington about the near-term prospect of the Medicare trust fund going insolvent. That can likely be fixed only with a remedy adopted by Congress, and that may not happen unless lawmakers feel a crisis is very near.
  • The Trump administration has sought to bring down drug out-of-pocket expenses for Medicare beneficiaries. Among those initiatives is a demonstration project to lower the cost of insulin. About a third of Medicare beneficiaries will be enrolled in plans that offer reduced prices in 2021. But the effort could have a hidden consequence: higher insurance premiums.
  • Many members of Congress began this session two years ago with grand promises of working to lower drug prices — but they never reached an agreement on how to do it.
  • President Donald Trump, however, was strongly motivated by the issue and late this year issued an order to set many Medicare drug prices based on what is paid in other industrialized nations. Drugmakers detest the idea and have vowed to fight it in court. Although some Democrats endorse the concept, it seems unlikely that President-elect Joe Biden would want to spend much capital in a legal battle for a plan that hasn’t been carefully vetted.
  • The gigantic spending and COVID relief bill that Congress finally approved Monday includes a provision to protect consumers from surprise medical bills when they are unknowingly treated by doctors or hospitals outside their insurance network. The law sets up a mediation process to resolve the charges, but the process favors the doctors. Insurers are likely to pass along any extra costs to consumers through higher premiums.

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

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A Child’s Death in the Heartland Changes Community Views About COVID

WASHINGTON, Mo. — In August, local officials in this small city an hour west of St. Louis voted against requiring residents to wear masks to prevent the spread of the coronavirus.

On Nov. 23, with COVID cases surging and the local hospital overflowing, the City Council brought a mask order back for another vote. As protesters marched outside, Councilman Nick Obermark, an electrician, was the sole member of the nonpartisan council to change his vote, causing the mandate to pass.

One of his many reasons? He has a child the same age as Washington Middle School student Peyton Baumgarth, 13, who on Halloween became the youngest person in Missouri to die of COVID complications.

“That hit pretty hard,” Obermark said later. Though the councilman doesn’t like wearing a mask, he said it’s worth it if we can keep one or two people from getting COVID-19.

Washington became the latest community to flip its stance on masks and other restrictions while the coronavirus ravages the country.

As America enters a dark winter without national directives to curb the pandemic, numerous cities, counties and states must decide: enact more restrictions now or leave people to their own will? Some in this tightknit city of 14,000 have discovered that the answer — and the key to changing hearts and minds — lies in how close and real the danger seems.

After a spate of nursing home fatalities early on in Franklin County, where Washington is located, two months this summer passed without a death from COVID. Some residents saw the virus as a big-city problem and rejected preventive measures.

Families attended weddings with hundreds of guests. Downtown merchants held “Thirsty Thursday,” with participants mingling over drinks. Even as officials at the city’s hospital urged COVID restrictions, 356 people signed a letter to the local paper vowing their opposition to being “forced to cover our mouths in public.”

Republican Missouri Gov. Mike Parson has declined to enact a statewide mask mandate. Franklin County Presiding County Commissioner Tim Brinker posted on Twitter July 29: “Franklin County MO. No mandates, low case counts, low to no hospitalizations. Logic! Keep hands clean, and if you don’t have the space, cover your face. We love Freedom and respect human life. Come to Franklin County and raise your children in God’s Country! #COVID.”

Embracing freedom and tradition is as expected here as following deer hunting season or attending the Washington Town & Country Fair. The city’s downtown, within view of the swirling brown Missouri River, is lined with historical red-brick buildings and quaint shops. The Missouri Meerschaum Co. still produces corn cob pipes on Front Street. Its motto: “Over 150 Years & Still Smokin’.”

In the months before the election, yards sprouted signs for President Donald Trump, who has downplayed the threat of COVID-19 since the start of the pandemic.

But the virus crept closer in September when 74-year-old Ralph Struckhoff died of the disease. The Missourian newspaper published a story describing him as a healthy man who had just done a day of construction work at his church before he fell ill. “Please wear a mask in memory of Ralph,” his widow, Jayne Struckhoff, wrote in a letter to the editor. “If this virus can take Ralph, it can take down anyone.”

Some locals began asking: What would it take for this town to change? University of Missouri health communication assistant professor Yerina Ranjit said many factors influence health decisions. For instance, she said, people usually follow health advice if they believe an illness is serious and that they are susceptible to it.

“That’s true with COVID as well,” she said. Older people are more likely to wear masks and social distance. But others might not wear masks if they think the virus wouldn’t make them very ill.

Symbolic threats, or things that people feel threaten their values, can also affect behavior. In a survey of U.S. adults yet to be published, Ranjit and her colleagues studied media viewing and found that the kind of information people are exposed to makes a real difference. Regardless of political affiliation, they found, Fox News viewers were more likely to think the pandemic threatens the American way of life, which made them less likely to wear masks. They were “buying into the idea that masks are against our identity,” she said. On the other hand, people watching MSNBC felt more afraid of the virus, which caused them to wear masks.

But in November, Mayor Sandy Lucy noticed that attitudes were evolving. That’s when residents heard about Peyton, the middle schooler, who declined rapidly and died days after being admitted to the hospital, his mother told KMOV. According to his obituary, he was known for his love of Pokémon Go, flag football and the St. Louis Blues. “He loved his puppies Yadi and Louie who be lost without their buddy,” it said. “He loved listening to music and singing in the school choir.”

“Suddenly there was a death of a 13-year-old,” Lucy said, “and you think, maybe this virus is more vicious than I give it credit for being.”

Peyton’s mother, Stephanie Franek, pleaded in a TV interview: “Wear a mask when you’re in public, wash your hands and know that COVID is real.”

Meanwhile, cases skyrocketed. Between the first and second mask votes, the total COVID count in Franklin County, with a population around 104,000, climbed from 728 to 4,594, and deaths rose from 19 to 75. In the week ending Nov. 23, 25% of COVID tests returned positive results.

Mercy Hospital Washington was running out of space. Hospital President Eric Eoloff tied rising hospitalizations and deaths to the absence of safety measures. “As a hospital administrator, I knew we would be on the receiving end of the choices not to wear the masks and not social distancing,” he said.

In a surprise move Nov. 19, the Franklin County Board of Commissioners enacted a mandatory mask order. Presiding Commissioner Brinker told The Missourian that he had spoken to local doctors and the St. Louis regional pandemic task force, and the numbers “speak for themselves.” Brinker did not respond to requests for comment for this story.

Although the order already applied to the city, the Washington City Council went further and approved its own mask rule four days later. Unlike the county order, which expires Dec. 20, the city’s mandate will stay in force based on metrics related to the new COVID case rate, hospital admissions and deaths.

Dozens of protesters wielded flags and signs against mandatory masking outside City Hall the evening of the vote. Ali and Duncan Whittington came with their 4-year-old daughter. “I’m here because I feel my freedom is being violated,” Ali Whittington said.

Councilman Obermark later said that he had lost a lot of sleep over his decision. “It wasn’t one thing,” he said. “It was several things that made me change my mind.”

The high positivity rate, the lack of capacity at the hospital. Knowing healthy people whom COVID “knocked down” for days. His wife having to quarantine. And Peyton’s death.

He said he knows masks aren’t a cure-all, but they could help reduce the spread until vaccines arrive.

“We tried nothing and it isn’t working,” he said, “so we have to try something.”

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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Where Does the Arsenic in Rice, Mushrooms, and Wine Come From?

What happens when our crops are grown in soil contaminated with arsenic-based pesticides and arsenic drug-laced chicken manure?

When arsenic-containing drugs are fed to chickens, not only does the arsenic grow out into their feathers, which are then fed back to them as a slaughterhouse byproduct, but the arsenic can also get into their tissues and then into our tissues when we eat eggs or meat, a cycle depicted at the start of my video Where Does the Arsenic in Rice, Mushrooms, and Wine Come From?. This explains why national studies have found that those who eat more poultry have tended to have more arsenic flowing through their bodies. Why would the industry do that? In modern poultry farms, often called CAFOs for concentrated animal feeding operations, there can be 200,000 birds under one roof and the floors of these buildings become covered with feces. While this so-called factory farming decreases costs, it also increases the risk of disease. That’s where arsenic-containing drugs and other antibiotic feed additives can come in: to try to cut down the spread of disease in such an unnatural environment. If you’re feeling a little smug because you don’t eat chicken, what do you think happens to the poop?

As depicted at 1:17 in my video, from chicken manure, the arsenic from the drugs in the animal feed can get into our crops, into the air, and into the groundwater, and find its way into our bodies whether we eat meat or not. Yes, but how much arsenic are we really talking about? Well, we raise billions of chickens a year, and, if, historically, the vast majority were fed arsenic, then, if you do the math, we’re talking about dumping a half million pounds of arsenic into the environment every year—much of it onto our crops or shoveled directly into the mouths of other farm animals.

Most of the arsenic in chicken waste is water soluble, so, there are certainly concerns about it seeping into the groundwater. But, if it’s used as a fertilizer, what about our food? Studies on the levels of arsenic in the U.S. food supply dating back to the 1970s identified two foods, fish aside, with the highest levels—chicken and rice—both of which can accumulate arsenic in the same way. Deliver an arsenic-containing drug like roxarsone to chickens, and it ends up in their manure, which ends up in the soil, which ends up in our pilaf. “Rice is [now] the primary source of As [arsenic] exposure in a non seafood diet.”

I was surprised to learn that mushrooms are in the top-five food sources of arsenic, but then it made sense after I found out that poultry litter is commonly used as a starting material to grow mushrooms in the United States. As you can see at 2:58 in my video, over the years, the arsenic content in mushrooms has rivaled arsenic concentration in rice, though people tend to eat more rice than mushrooms on a daily basis. Arsenic levels in mushrooms seemed to be dipping starting about a decade ago, which was confirmed in a 2016 paper that looked at a dozen different types of mushrooms: plain white button mushrooms, cremini, portobello, shiitake, trumpet, oyster, nameko, maitake, alba clamshell, brown clamshell, and chanterelle. Now, mushrooms are only averaging about half the arsenic content as rice, as you can see at 3:37 in my video.

Just like some mushrooms have less arsenic than others, some rice has less. Rice grown in California has 40 percent less arsenic than rice grown in Arkansas, Louisiana, Mississippi, Missouri, and Texas. Why? Well, arsenic-based pesticides had been used for more than a century on millions of acres of cotton fields, a practice noted to be “dangerous” back in 1927. Arsenic pesticides are now effectively banned, so it’s not simply a matter of buying organic versus conventional rice because millions of pounds of arsenic had been laid down in the soil well before the rice was even planted.

The rice industry is well aware of this. There’s an arsenic-toxicity disorder in rice called “straighthead,” where rice planted in soil too heavily contaminated with arsenic doesn’t grow right. So, instead of choosing cleaner cropland, they just developed arsenic-resistant strains of rice. Now, lots of arsenic can build up in rice without the plant getting hurt. Can the same be said, however, for the rice consumer?

It’s the same story with wine. Arsenic pesticides were used, decade after decade, and even though they’ve since been banned, arsenic can still be sucked up from the soil, leading to “the pervasive presence of arsenic in [American] wine [that] can pose a potential health risk.” Curiously, the researchers sum up their article by saying that “chronic arsenic exposure is known to lower IQ in children,” but if kids are drinking that much wine, arsenic toxicity is probably the least of their worries.

Hold on. Chickens are being fed arsenic-based drugs? See Where Does the Arsenic in Chicken Come From? to find out more.


 I expect the arsenic-in-rice issue brought up a lot of questions, and giving you answers is exactly why I’m here! Check out:

In health,

Michael Greger, M.D.

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Rural Areas Send Their Sickest Patients to Cities, Straining Hospitals

Registered nurse Pascaline Muhindura has spent the past eight months treating COVID patients at Research Medical Center in Kansas City, Missouri.

But when she returns home to her small town of Spring Hill, Kansas, she’s often stunned by what she sees, like on a recent stop for carryout food.

“No one in the entire restaurant was wearing a mask,” Muhindura said. “And there’s no social distancing. I had to get out, because I almost had a panic attack. I was like, ‘What is going on with people? Why are we still doing this?’”

Many rural communities across the U.S. have resisted masks and calls for social distancing during the coronavirus pandemic, but now rural counties are experiencing record-high infection and death rates.

Critically ill rural patients are often sent to city hospitals for high-level treatment and, as their numbers grow, some urban hospitals are buckling under the added strain.

Kansas City has a mask mandate, but in many smaller communities nearby, masks aren’t required — or masking orders are routinely ignored. In the past few months, rural counties in both Kansas and Missouri have seen some of the highest rates of COVID-19 in the country.

At the same time, according to an analysis by KHN, about 3 in 4 counties in Kansas and Missouri don’t have a single intensive care unit bed, so when people from these places get critically ill, they’re sent to city hospitals.

A recent patient count at St. Luke’s Health System in Kansas City showed a quarter of COVID patients had come from outside the metro area.

Two-thirds of the patients coming from rural areas need intensive care and stay in the hospital for an average of two weeks, said Dr. Marc Larsen, who leads COVID-19 treatment at St. Luke’s.

“Not only are we seeing an uptick in those patients in our hospital from the rural community, they are sicker when we get them because [doctors in smaller communities] are able to handle the less sick patients,” said Larsen. “We get the sickest of the sick.”

Dr. Rex Archer, head of Kansas City’s health department, warns that capacity at the city’s 33 hospitals is being put at risk by the influx of rural patients.

“We’ve had this huge swing that’s occurred because they’re not wearing masks, and yes, that’s putting pressure on our hospitals, which is unfair to our residents that might be denied an ICU bed,” Archer said.

study newly released by the Centers for Disease Control and Prevention showed that Kansas counties that mandated masks in early July saw decreases in new COVID cases, while counties without mask mandates recorded increases.

Hospital leaders have continued to plead with Missouri Republican Gov. Mike Parson, and with Kansas’ conservative legislature, to implement stringent, statewide mask requirements but without success.

Parson won the Missouri gubernatorial election on Nov. 3 by nearly 17 percentage points. Two days later at a COVID briefing, he accused critics of “making the mask a political issue.” He said county leaders should decide whether to close businesses or mandate masks.

“We’re going to encourage them to take some sort of action,” Parson said Thursday. “The holidays are coming and I, as governor of the state of Missouri, am not going to mandate who goes in your front door.”

In an email, Dave Dillon, a spokesperson for the Missouri Hospital Association, agreed that rural patients might be contributing to hospital crowding in cities but argued that the strain on hospitals is a statewide problem.

The reasons for the rural COVID crisis involve far more than the refusal to mandate or wear masks, according to health care experts.

Both Kansas and Missouri have seen rural hospitals close year after year, and public health spending in both states, as in many largely rural states, is far below national averages.

Rural populations also tend to be older and to suffer from higher rates of chronic health conditions, including heart disease, obesity and diabetes. Those conditions can make them more susceptible to severe illness when they contract COVID-19.

Rural areas have been grappling with health problems for a long time, but the coronavirus has been a sort of tipping point, and those rural health issues are now spilling over into cities, explained Shannon Monnat, a rural health researcher at Syracuse University.

“It’s not just the rural health care infrastructure that becomes overwhelmed when there aren’t enough hospital beds, it’s also the surrounding neighborhoods, the suburbs, the urban hospital infrastructure starts to become overwhelmed as well,” Monnat said.

Unlike many parts of the U.S., where COVID trend lines have risen and fallen over the course of the year, Kansas, Missouri and several other Midwestern states never significantly bent their statewide curve.

Individual cities, such as Kansas City and St. Louis, have managed to slow cases, but the continual emergence of rural hot spots across Missouri has driven a slow and steady increase in overall new case numbers — and put an unrelenting strain on the states’ hospital systems.

The months of slow but continuous growth in cases created a high baseline of cases as autumn began, which then set the stage for the sudden escalation of numbers in the recent surge.

“It’s sort of the nature of epidemics that things often look like they’re relatively under control, and then very quickly ramp up to seem that they are out of hand,” said Justin Lessler, an epidemiologist at Johns Hopkins Bloomberg School of Public Health.

Now, a recent local case spike in the Kansas City metro area is adding to the statewide surge in Missouri, with an average of 190 COVID patients per day being admitted to the metro region’s hospitals. The number of people hospitalized throughout Missouri increased by more than 50% in the past two weeks.

Some Kansas City hospitals have had to divert patients for periods of time, and some are now delaying elective procedures, according to the University of Kansas Health system’s chief medical officer, Dr. Steven Stites.

But bed space isn’t the only hospital resource that’s running out. Half of the hospitals in the Kansas City area are now reporting “critical” staffing shortages. Pascaline Muhindura, the nurse who works in Kansas City, said that hospital workers are struggling with anxiety and depression.

“The hospitals are not fine, because people taking care of patients are on the brink,” Muhindura said. “We are tired.”

This story is from a reporting partnership that includes KCUR, NPR and KHN.

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

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Despite Pandemic Threat, Gubernatorial Hopefuls Avoid COVID Nitty-Gritty

Just 15 days ahead of the election, Montana Lt. Gov. Mike Cooney laid out his ideas on how he’d handle the COVID-19 pandemic if elected governor. Details were few, but the Democrat’s plan became one of only a handful being offered by candidates in the 11 U.S. governor’s races about how they’ll approach what’s certain to be the dominant issue of their terms, should they win.

While much of the nation’s focus is on who will be president come January, voters who are deciding the next occupant of their governor’s mansion are also effectively choosing the next leader of their state’s COVID-19 response. The virus has made governors’ power highly visible to voters. As the states’ top executives, they decide whether to issue mask mandates, close businesses and order people to stay home.

All but two races for governor feature incumbents running for reelection: Montana’s Democratic Gov. Steve Bullock can’t run again because of term limits and Utah’s Republican Gov. Gary Herbert decided not to run for another term. In several other competitive races for governor this year, such as those in North Carolina and Missouri, opponents clash on the role of state mandates in slowing the virus. Still, COVID-19 often fades into the backdrop of many long-standing platforms or primarily comes up as candidates talk about the need to revive the economy.

Cooney’s proposal, released Monday, suggested using the National Guard to transport patients in extreme weather and subsidizing heating bills to help those quarantining at home. But other parts vaguely described how he would “develop a robust plan” to come.

His opponent, Republican U.S. Rep. Greg Gianforte, has acknowledged the health crisis but has focused primarily on the economy, saying the state has to “cure the economic pandemic” the virus caused.

Bryce Ward, a health economist with the University of Montana, said Cooney’s list was one of the first times he’s seen long-term planning for COVID-19 come up in what appears to be the nation’s tightest governor’s race. But, he added, neither Montana candidate has offered a concrete plan to deal with the dual crises that risk public health when people gather and businesses’ bottom lines when they don’t. Meanwhile, the state’s number of COVID-19 cases climbs and its economy suffers.

“Whoever wins, this is going to be the bulk of their term,” Ward said. “How are the candidates going to keep people afloat as long as they can? What are we doing in terms of planning for what we think our post-COVID world is going to look like?”

An October KFF poll found 29% of registered voters said the economy was the most important issue in choosing a president, while 18% said the coronavirus outbreak was their top issue. Republican voters were more likely to pick the economy, the survey found, and Democrats were more likely to pick the coronavirus. (KHN is an editorially independent program of KFF.)

“There are voters that feel that the government needs to lead, and there are voters that feel that the government is utilizing a pandemic to become too invasive,” said Capri Cafaro, a former Democratic Ohio state senator now teaching in American University’s public administration and policy department. “People are not necessarily making their decisions on ‘Did you do contact tracing? Are you going to slow the spread?’”

Among the incumbent governors seeking reelection this year, most of their campaigns’ focus on COVID-19 has been on how well they’ve responded to the crisis. Several pledge more of what they’ve been doing. “We’ll continue to follow the science and wear masks,” Delaware Democratic Gov. John Carney said in a recent debate.

Meanwhile, their challengers generally seek to cast the incumbents as mismanaging their states’ response and promising to undo what’s been done. Those who have put out actual plans to handle the pandemic are Democratic challengers to Republican governors, and their plans are similar to what Cooney released — some specific ideas and promises to fill in the gaps later.

In Missouri, Democratic challenger Nicole Galloway, who is the state auditor, made health care the center of her campaign and released a plan to respond to the virus with a statewide mask mandate and a limit on when public school classes can meet in person based on the community’s rate of infection.

Republican Gov. Mike Parson is the apparent front-runner in that state’s race. He has pledged to lead “the greatest economic comeback that we’ve ever seen in Missouri history.” The former Polk County sheriff also has focused on supporting law enforcement amid backlash against police brutality and racial injustice.

Curbing the coronavirus has taken a back seat to boosting the economy in Parson’s campaign. And, as governor, Parson has refused to issue a statewide mask mandate, despite a White House recommendation to do so. In late September, the governor and his wife tested positive for COVID-19. Parson has returned to work, which includes traveling across the state.

One of the more heated races is in North Carolina, where Democratic Gov. Roy Cooper is defending his seat against a challenge by his lieutenant governor, Republican Dan Forest. Forest sued Cooper this year to challenge the governor’s authority to impose COVID-related restrictions by executive order.

Forest dropped the lawsuit in August after a judge made a preliminary ruling against his case, then said on Twitter, “I did my part. If y’all want your freedoms back you’ll have to make your voices heard in November.”

Cooper’s campaign called the lawsuit “a desperate tactic to garner attention” for Forest’s political campaign. Since then, the governor has slowly eased COVID restrictions, updating an executive order to allow a limited number of people in bars, sporting events, movie theaters and amusement parks. Cooper is leading the race in recent polls.

Back in Montana, the pandemic surfaced in the gubernatorial campaign after health officials announced on Oct. 16 that a Helena concert, which Gianforte attended, was linked to several COVID-19 cases. More than 100 health professionals blasted him in an open letter for flouting local health restrictions, going maskless and making light of safety precautions at campaign events. Cooney called on him to suspend his campaign events until tested. Gianforte’s campaign has said he’s taking proper precautions and accused Cooney of politicizing a public health issue.

Cooney has said he’ll keep Montana’s COVID-19 response on the track he is helping set as lieutenant governor, with science guiding that work. Gianforte, who built a tech startup in Bozeman, has touted his business experience as proof he can lead Montana’s comeback. Both have said more needs to be learned about this virus and have pitched themselves as the one to steer the state’s economy through the crisis.

Ward, the University of Montana health economist, said the details are missing, such as how the winner will support businesses through the winter without federal aid. Or what the new governor would cut from the state budget if the economic crisis hits its coffers.

The state has a public mask mandate and a plan for reopening the economy with no apparent thresholds or timelines. The option for stricter rules has been left to county governments as the state sees its largest COVID surge yet.

Jeremy Johnson, a political scientist at Carroll College in Helena, said the initial lack of detailed pandemic policy in the state’s race could be attributed to both candidates trying to win over swing voters with safe themes. President Donald Trump won Montana in 2016 by 20 points, but the state has also had a Democratic governor for 16 years. While polls show Gianforte leading Cooney slightly, election handicappers Real Clear Politics and the Cook Political Report still consider the race a toss-up.

Yet as Election Day nears, the question of how to address the pandemic only looms larger. Montana’s case count is rising, adding to its total of more than 23,000 cases in the state of roughly 1 million.

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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Swab, Spit, Stay Home? College Coronavirus Testing Plans Are All Over the Map

Yousuf El-Jayyousi, a junior engineering student at the University of Missouri, wanted guidance and reassurance that it would be safe to go back to school for the fall semester. He tuned into a pair of online town halls organized by the university hoping to find that.

He did not.

What he got instead from those town halls last month was encouragement to return to class at the institution affectionately known as Mizzou. The university, in Columbia, would be testing only people with symptoms, and at that point, the university said people who test positive off campus were under no obligation to inform the school.

“It feels like the university doesn’t really care whether we get sick or not,” said El-Jayyousi, who is scheduled for two in-person classes, and lives at home with his parents and 90-year-old grandmother.

He’s seen the studies from researchers at Yale and Harvard that suggest testing needs to be much more widespread. He asked his instructors if he could join lectures remotely once classes begin Monday. One was considering it; the other rejected it.

“It was kind of very dismissive, like ‘so what?’” El-Jayyousi said.

But it’s an enormous “so what?” packed with fear and unknowns for Jayyousi and some 20 million other students enrolled in some level of postsecondary education in America, if they are not already online only.

As with the uncoordinated and chaotic national response to the COVID-19 pandemic, higher education has no clear guidance or set of standards to adhere to from the federal government or anywhere else. Policies for reentry onto campuses that were abruptly shut in March are all over the map.

Hundreds Undecided

According to the College Crisis Initiative, or C2i, a project of Davidson College that monitors how higher ed is responding to the pandemic, there is nothing resembling a common approach. Of 2,958 institutions it follows, 151 were planning to open fully online, 729 were mostly online and 433 were taking a hybrid approach. Just 75 schools were insisting on students attending fully in person, and 614 were aiming to be primarily in-person. Some 800 others were still deciding, just weeks before instruction was to start.

The decisions often have little correlation with the public health advisories in the region. Mizzou, which is in an area with recent COVID spikes, is holding some in-person instruction and has nearly 7,000 students signed up to live in dorms and other university-owned housing. Harvard, in a region with extremely low rates of viral spread, has opted to go all online and allowed students to defer a year.

The specific circumstances colleges and universities face are as much determined by local fiscal and political dictates as by medicine and epidemiology. It is often unclear who is making the call. So it’s every-student-for-herself to chart these unknown waters, even as students (or their families) have written tuition checks for tens of thousands of dollars and signed leases for campus and off-campus housing.

And the risks — health, educational and financial — boomerang back on individual students: Two weeks after University of North Carolina students, as instructed, returned to the flagship campus in Chapel Hill with the promise of at least some in-person learning, all classes went online. Early outbreaks surged from a few students to more than 130 in a matter of days. Most undergrads have about a week to clear out of their dorms.

“It’s really tough,” said neuroscience major Luke Lawless, 20. “Chapel Hill is an amazing place, and as a senior it’s tough to know that my time’s running out — and the virus only adds to that.”

Location, Location, Location

C2i’s creator, Davidson education Assistant Professor Chris Marsicano, said the extreme diversity of approaches comes from the sheer diversity of schools, the penchant of many to follow the leads of more prestigious peers, and local politics.

“Some states have very strong and stringent mask requirements. Some have stronger stay-at-home orders. Others are sort of leaving it up to localities. So the confluence of politics, institutional isomorphism — that imitation — and different needs that the institutions have are driving the differences,” Marsicano said.

Location matters a lot, too, Marsicano said, pointing to schools like George Washington University and Boston University in urban settings where the environment is beyond the control of the school, versus a place like the University of the South in remote, rural Sewanee, Tennessee, where 90% of students will return to campus.

“It’s a lot easier to control an outbreak if you are a fairly isolated college campus than if you are in the middle of a city,” Marsicano said.

Student behavior is another wild card, Marsicano said, since even the best plans will fail if college kids “do something stupid, like have a massive frat party without masks.”

“You’ve got student affairs professionals across the country who are screaming at the top of their lungs, ‘We can’t control student behavior when they go off campus’” Marsicano said.

Another factor is a vacuum at the federal level. Although the Department of Education says Secretary Betsy DeVos has held dozens of calls with governors and state education superintendents, there’s no sign of an attempt to offer unified guidance to colleges beyond a webpage that links to relaxed regulatory requirements and anodyne fact sheets from the Centers for Disease Control and Prevention on preventing viral spread.

Even the money that the department notes it has dispensed — $30 billion from Congress’ CARES Act — is weighted toward K-12 schools, with about $13 billion for higher education, including student aid.

The U.S. Senate adjourned last week until Sept. 8, having never taken up a House-passed relief package that included some $30 billion for higher education. A trio of Democratic senators, including Sen. Elizabeth Warren, is calling for national reporting standards on college campuses.

No Benchmarks

Campus communities with very different levels of contagion are making opposite calls about in-person learning. Mizzou’s Boone County has seen more than 1,400 confirmed COVID cases after a spike in mid-July. According to the Harvard Global Health Institute’s COVID risk map, Boone has accelerated spread, with 14 infections per day per 100,000 people. The institute advises stay-at-home orders or rigorous testing and tracing at such rates of infection. Two neighboring counties were in the red zone recently, with more than 25 cases per day per 100,000 people. Mizzou has left it up to deans whether classes will meet in person, making a strong argument for face-to-face instruction.

Meanwhile, Columbia University in New York City opted for all online instruction, even though the rate of infection there is a comparatively low 3.8 cases per day per 100,000 people.

Administrators at Mizzou considered and rejected mandatory testing. “All that does is provide one a snapshot of the situation,” University of Missouri system President Mun Choi said in one of the town halls.

Mizzou has an in-house team that will carry out case investigation and contact tracing with the local health department. This week, following questions from the press and pressure from the public, the university announced students will be required to report any positive COVID test to the school.

Who Do You Test? When?

CDC guidance for higher education suggests there’s not enough data to know whether testing everyone is effective, but some influential researchers, such as those at Harvard and Yale, disagree.

“This virus is subject to silent spreading and asymptomatic spreading, and it’s very hard to play catch-up,” said Yale professor David Paltiel, who studies public health policy. “And so thinking that you can keep your campus safe by simply waiting until students develop symptoms before acting, I think, is a very dangerous game.”

Simulation models conducted by Paltiel and his colleagues show that, of all the factors university administrators can control — including the sensitivity and specificity of COVID-19 tests — the frequency of testing is most important.

He’s “painfully aware” that testing everyone on campus every few days sets a very high bar — logistically, financially, behaviorally — that may be beyond what most schools can reach. But he says the consequences of reopening campuses without those measures are severe, not just for students, but for vulnerable populations among school workers and in the surrounding community.

“You really have to ask yourself whether you have any business reopening if you’re not going to commit to an aggressive program of high-frequency testing,” he said.

The Fighting — And Testing — Illini

Some institutions that desperately want students to return to campus are backing the goal with a maximal approach to safety and testing.

About a four-hour drive east along the interstates from Mizzou is the University of Illinois at Urbana-Champaign, whose sports teams are known as the Fighting Illini.

Weeks ago, large white tents with signs reading “Walk-Up COVID-19 Testing” have popped up across campus; there students take a simple saliva test.

“This seems to be a lot easier than sticking a cotton swab up your nose,” graduate student Kristen Muñoz said after collecting a bit of her saliva in a plastic tube and sealing it in a bag labeled “Biohazard.”

In just a few hours, she got back her result: negative.

The school plans to offer free tests to the 50,000 students expected to return this month, as well as some 11,000 faculty and staff members.

“The exciting thing is, because we can test up to 10,000 per day, it allows the scientist to do what’s really the best for trying to protect the community as opposed to having to cut corners, because of the limitations of the testing,” said University of Illinois chemist Martin Burke, who helped develop the campus’s saliva test, which received emergency use authorization from the federal Food and Drug Administration this week.

The test is similar to one designed by Yale and funded by the NBA that cleared the FDA hurdle just before the Illinois test. Both Yale and Illinois hope aggressive testing will allow most undergraduate students to live on campus, even though most classes will be online.

University of Illinois epidemiologist Becky Smith said they are following data that suggest campuses need to test everyone every few days because the virus is not detectable in infected people for three or four days.

“But about two days after that, your infectiousness peaks,” she said. “So, we have a very small window of time in which to catch people before they have done most of the infection that they’re going to be doing.”

Campus officials accepted Smith’s recommendation that all faculty, staffers and students participating in any on-campus activities be required to get tested twice a week.

Illinois can do that because its test is convenient and not invasive, which spares the campus from using as much personal protective equipment as the more invasive tests require, Burke said. And on-site analysis avoids backlogs at public health and commercial labs.

Muddled in the Middle

Most other colleges fall somewhere between the approaches of Mizzou and the University of Illinois, and many of their students still are uncertain how their fall semester will go.

At the University of Southern California, a private campus of about 48,500 students in Los Angeles, officials had hoped to have about 20% of classes in person — but the county government scaled that back, insisting on tougher rules for reopening than the statewide standards.

If students eventually are allowed back, they will have to show a recent coronavirus test result that they obtained on their own, said Dr. Sarah Van Orman, chief health officer of USC Student Health.

They will be asked to do daily health assessments, such as fever checks, and those who have been exposed to the virus or show symptoms will receive a rapid test, with about a 24-hour turnaround through the university medical center’s lab. “We believe it is really important to have very rapid access to those results,” Van Orman said.

At California State University — the nation’s largest four-year system, with 23 campuses and nearly a half-million students — officials decided back in May to move nearly all its fall courses online.

“The first priority was really the health and safety of all of the campus community,” said Mike Uhlenkamp, spokesperson for the CSU Chancellor’s Office. About 10% of CSU students are expected to attend some in-person classes, such as nursing lab courses, fine art and dance classes, and some graduate classes.

Uhlenkamp said testing protocols are being left up to each campus, though all are required to follow local safety guidelines. And without a medical campus in the system, CSU campuses do not have the same capacity to take charge of their own testing, as the University of Illinois is doing.

For students who know they won’t be on campus this fall, there is regret at lost social experiences, networking and hands-on learning so important to college.

But the certainty also brings relief.

“I don’t think I would want to be indoors with a group of, you know, even just a handful of people, even if we have masks on,” said Haley Gray, a 28-year-old graduate student at the University of California-Berkeley starting the second year of her journalism program.

She knows she won’t have access to Berkeley’s advanced media labs or the collaborative sessions students experience there. And she said she realized the other day she probably won’t just sit around the student lounge and strike up unexpected friendships.

“That’s a pretty big bummer but, you know, I think overall we’re all just doing our best, and given the circumstances, I feel pretty OK about it,” she said.

This story is part of a partnership that includes KBIA, Illinois Public Media, Side Effects Public Media, NPR and Kaiser Health News.

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

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In Rural Missouri, Latinos Learn to Contain and Cope With the Coronavirus

Francisco Bonilla is a pastor in Carthage, Missouri, tending to the spiritual needs of the town’s growing Latino community. He’s also a media personality, broadcasting his voice far beyond the walls of Casa de Sanidad. Bonilla runs a low-power, Spanish-language radio station from the church.

He mainly uses the station to broadcast sermons and religious music. But these days he is also focused on COVID-19: explaining the illness and its symptoms, updating his listeners with the newest case counts and bringing on guests. He has broadcast interviews with a local nurse and with investigators from the Centers for Disease Control and Prevention.

Bonilla and some fellow pastors have closed their churches amid the pandemic. But there are some 30 churches serving the town’s Latino community, and he said other pastors haven’t acted as responsibly. Bonilla said some church leaders may believe that not holding services means they don’t have faith and that they want to show God is in control.

Starting in June, the southwestern corner of Missouri experienced a surge of coronavirus cases, including an outbreak among workers at the Butterball poultry-processing plant in Carthage. Coronavirus infections have been a problem at food-processing plants in many states. The impact has been particularly hard on nearby Latino communities, which often provide the bulk of the workforce at the plants.

Hispanics have been disproportionately affected by COVID-19. Nationwide, Hispanic patients are hospitalized for COVID-19 at four times the rate of non-Hispanic whites. (Hispanics can be of any race or combination of races.)

In Missouri, Hispanics and Latinos make up 4% of the state’s population but 14% of cases in which race or ethnicity is known. In Jasper County, where Carthage is located, they account for almost 40% of the confirmed cases but only 8.5% of the population, according to the Missouri Department of Health and Senior Services.

Many Latin American immigrants came to Carthage to work at the Butterball plant, which employs roughly 800 people in the town of about 15,000. The first to arrive in Carthage were predominantly from Mexico. But those who moved to the area over the past two decades came primarily from Guatemala and El Salvador.

The Butterball plant is half a mile from Carthage’s town square, a straight shot north along Main Street. Along the stretch are small shops and restaurants, many with Spanish-language flyers in the windows. They advertise money transfer services, self-help books and the availability of regional ingredients from Guatemala and El Salvador.

The Butterball plant has always been a sort of anchor for Carthage Councilman Juan Topete. His Mexican American parents worked there in the 1990s, after moving the family to Carthage from Los Angeles. When he was younger, Topete also worked for Butterball.

“My family came from having nothing, whatever we had in our U-Haul and that was it, to owning a restaurant and selling it later and being well established in the community,” Topete explained.

It’s a common story for many of the Latin American immigrants to Carthage, who can find well-paying jobs at the plant without having to speak English.

“When I first moved down here, if you were Hispanic you knew each other,” Topete said. “It was a very tight group and it has expanded tremendously these last few years.”

Shops like the Supermercado Coatepeque line a half-mile stretch of Main Street that runs from the town square to the Butterball plant in Carthage, Missouri.(Sebastián Martínez Valdivia/KBIA)

These days, a third of the people in Carthage are Hispanic, according to the U.S. Census Bureau. In 2016, Topete won a seat on the City Council, the first Latino resident to do so.

Topete said the Latino residents at Butterball and in other essential jobs face pressure on several fronts. Some who test positive for the coronavirus feel they have to keep going to work. They’re afraid of being laid off, or they need the money for their families.

“I do know people that have tested positive,” Topete said. “I try to stay in contact by calling them, following up on them, making sure they’re doing OK.”

A CDC team visited Carthage to investigate the outbreak. They reported the virus made its way into the Butterball plant, infecting workers and spreading through their families. In a statement, Butterball confirmed workers have tested positive but declined to say how many.

Topete said some residents still don’t know much about the disease, so the city is ramping up its outreach.

A Spanish-language public service announcement produced by the Carthage Police Department explains that the Missouri governor’s lifting of the statewide stay-at-home order doesn’t mean the virus is gone. The police department is part of the town’s COVID-19 task force and has helped Topete post Spanish-language flyers.

Such rural health departments face hurdles connecting to immigrant communities, said Lori Freeman, CEO of the National Association of County and City Health Officials. They typically have fewer language resources than their larger, urban counterparts, she said.

“In larger or even medium health departments, there are community health workers that are often bilingual or lingual enough to serve the communities that exist in the demographic area that they serve,” Freeman said.

At La Tiendita Mexican Market, a grocery store and restaurant, owner Jose Alvarado has taken steps to help keep his workers and customers safe. He’s concerned about children being exposed to the virus when their parents bring them in to shop, so he has posted a sign on the door asking that only one member of a family enter at a time. Next to the industrial tortilla maker, he has marked the floor with large X’s, as a visual guide and reminder for customers to stay socially distant from one another.

Topete fears the town’s Latino community could become a scapegoat for the virus. He said many people have the impression that the virus has affected only workers at the Butterball plant, when in reality it has spread throughout town.

Topete said Carthage officials need to keep up their outreach efforts but he sees the educational efforts working: On a recent trip to the store, he noticed more Latino shoppers than before wearing masks — and more of them were wearing masks than were the non-Hispanic shoppers.

This story is part of a partnership that includes KBIA, NPR and Kaiser Health News.

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

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KHN’s ‘What the Health?’: Still Waiting for That Trump Health Plan

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President Donald Trump keeps promising to unveil a comprehensive plan to replace the Affordable Care Act, but it keeps not appearing. However, this week he did order an expansion of telehealth for Medicare beneficiaries and a program to help struggling rural hospitals.

Meanwhile, the administration still lacks a comprehensive plan to fight the COVID-19 pandemic in the U.S., and Congress remains unable to agree on another round of COVID relief funding, despite broad agreement on the need.

Outside Washington, Missouri this week became the sixth state where voters approved an expansion of Medicaid under the Affordable Care Act over the objections of Republican governors and/or Republican-controlled legislatures.

This week’s panelists are Julie Rovner of Kaiser Health News, Alice Miranda Ollstein of Politico, Tami Luhby of CNN and Kimberly Leonard of Business Insider.

Among the takeaways from this week’s podcast:

  • If a compromise over a federal relief package is not reached, Trump said he will issue executive orders to provide enhanced unemployment benefits and protections for people facing eviction. Even if he can do that, other parts of the stimulus plan — including money for states and local governments facing major deficits, schools, and testing and tracing programs — will likely be out of luck.
  • Six states announced this week they are banding together to purchase quick-turnaround coronavirus tests as they try to increase the number of tests they can offer.
  • States that have been using National Guard troops during the coronavirus emergency to help provide services are facing the prospect of having to pick up part of the cost for those service members. The mobilization was set to expire soon, but this week the administration announced it would extend the use of the National Guard, if states helped pay for it.
  • No new health plan was offered by Trump despite his comments in an interview with Fox News anchor Chris Wallace two weeks ago that a plan would be unveiled by Aug. 2. Instead, the administration has rolled out a number of smaller initiatives, including proposals to lower prescription drug prices and extending telemedicine.
  • The loosening of Medicare’s rules for telehealth during the pandemic has proved popular and may be hard to roll back. It has helped overcome shortages of medical professionals in rural areas and in mental health services. Nonetheless, federal officials and some health policy analysts suggest that increased use of digital medical appointments could expand the nation’s overall health bill. For example, if a patient has a virtual visit with the doctor who then says the patient needs to be seen in person, the doctor can collect fees for two visits.
  • Among the big supporters of the Missouri measure to expand Medicaid was the health care industry, which spent heavily on the campaign.
  • It’s second-quarter earnings season, and most health care companies are reporting good profits, despite the upheaval caused by the coronavirus. Still, they warn that they could take a hit in the third quarter.

Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read too:

Julie Rovner: Vanity Fair’s “How Jared Kushner’s Secret Testing Plan ‘Went Poof Into Thin Air’,” by Katherine Eban

Alice Miranda Ollstein: The Atlantic’s “How the Pandemic Defeated America,” by Ed Yong

Kimberly Leonard: The New York Times’ “’The Biggest Monster’ Is Spreading. And It’s Not the Coronavirus,” by Apoorva Mandavilli

Tami Luhby: The Washington Post’s “Trump Keeps Promising an Overhaul of the Nation’s Health-Care System That Never Arrives,” by Anne Gearan, Amy Goldstein and Seung Min Kim

To hear all our podcasts, click here.

And subscribe to What the Health? on iTunesStitcherGoogle PlaySpotify, or Pocket Casts.

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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Missouri Voters Approve Medicaid Expansion Despite GOP Resistance

Despite strong opposition from Republicans and rural voters, Missouri on Tuesday joined 37 states and the District of Columbia in expanding its Medicaid program. Voters in Missouri approved creating a state constitutional amendment that will open Medicaid eligibility to include healthy adults starting July 1, 2021.

Voters approved expansion by a margin of 6.5 percentage points.

Missouri joins five other mostly conservative states that have passed Medicaid expansion via ballot initiatives — most recently, Oklahoma, on June 30. Most of the remaining 12 states that have not expanded Medicaid are Republican-leaning states in the South.

Nika Cotton, owner of Soulcentricitea, a new tea shop in Kansas City, Missouri, woke to the news on Wednesday morning. Cotton, whose children are 8 and 10, said she will qualify for health care coverage under the expansion.

“It takes a lot of stress off of my shoulders with having to think about how I’m going to take care of myself, how I’m going to be able to go and see a doctor and get the health care I need while I’m starting my business,” Cotton said.

Medicaid expansion, which states have the option of adopting as part of the Affordable Care Act, extends eligibility in the program to individuals and families with incomes up to 138% of the federal poverty level. A family of three, like Cotton’s, could make up to $29,974 to qualify.

The federal government pays for 90% of expansion costs.

As of 2018, 9.3% of Missourians were uninsured. And in 2019, researchers from Washington University in St. Louis estimated that around 230,000 people in Missouri would enroll for Medicaid if it were expanded. The study also showed expansion would save the state an estimated $39 million a year, largely by eliminating the need for other state health spending.

Missouri’s adoption of expansion follows a trend of increasing support in largely Republican states, according to health policy expert Rachel Nuzum of the Commonwealth Fund.

“What we’ve seen in our surveys over the years is when you take the labels off of the policies, when you take the Affordable Care Act label off, when you take Medicaid expansion off, and just start asking people whether or not you think low-income families should have access to Medicaid coverage, the support is overwhelming,” Nuzum said.

Support for expansion came largely from voters in and around Missouri’s urban centers such as Kansas City, St. Louis, Springfield and Columbia. In Kansas City for example, 87.6% of voters backed the measure.

Amendment 2 was rejected overwhelmingly by conservative voters in the mostly rural parts of the state that have the highest uninsured and poverty rates. Voters in McDonald, Morgan and Scotland counties, which have the three highest uninsured rates in the state, rejected the measure by margins of nearly 2-to-1 or greater.

Expansion opponents warned that high enrollment in the program could lead to the state’s 10% share of the costs becoming a significant burden for Missouri, especially when state revenues are down.

“When state revenues fall, it begs the question, how are you going to pay for this?” said Ryan Johnson, in late July. He is a senior adviser for United for Missouri, a conservative policy advocacy organization.

“We’re concerned that they are going to have to raid public education,” he said, “and that’s a disservice to the kiddos who hope to go back to school this fall, the teachers, the administrators and everyone involved in the public education system.”

Responding to declining revenue related to the coronavirus, Missouri’s Republican governor, Mike Parson, recently reduced the 2021 budget by nearly $449 million, with education taking the hardest hit.

Health care experts have said that the economic effects of the pandemic, including high unemployment and lower state revenue, could strain the capacity of state Medicaid programs. However, health care advocates argue that expansion benefits individuals and families struggling as a result of the pandemic, and the influx of federal dollars and the jobs that result from expansion could help the economy.

“If we’re worried about the economy and we’re worried about people working, Medicaid expansion is actually a way to encourage people to work and not have that worry they’re going to lose health insurance for themselves or their families,” said Ryan Barker, vice president of strategic initiatives for Missouri Foundation for Health.

Republican state lawmakers have fiercely resisted Medicaid expansion. The expansion question was placed on the ballot after a petition.

Expansion advocates enlisted the Fairness Project, a Washington, D.C.-based campaigning organization, in developing and executing their campaign strategy. The Fairness Project has been involved in successful Medicaid expansion campaigns in other mostly conservative states, including Maine, Utah, Idaho, Nebraska and Oklahoma.

The “YES on 2” campaign was supported by a wide range of groups, including the Missouri Chamber of Commerce and Industry, the Missouri Hospital Association, the NAACP, the AFL-CIO and the AARP, among others. And, the coalition forged unlikely alliances, including Planned Parenthood supporters and Catholic Charities of St. Louis, which is operated by the Archdiocese of St. Louis.

YES on 2 campaign material made almost no mention of the Affordable Care Act, which has been unpopular in Missouri, and some of its flyers didn’t use the words “Medicaid expansion.”

Although support for the measure was much lower in conservative rural areas, Fairness Project executive director Jonathan Schleifer said Missouri’s expansion success relied on both activating progressive urban voters and engaging rural voters — though conservative resistance remained a significant obstacle to reforming health care policy.

“I think there’s still a lot of work to do to push back against the hundreds of millions of dollars, the public messages coming from as high as the White House, that there’s something wrong with the Affordable Care Act,” Schleifer said.

Opponents to expansion included Gov. Parson and other Republican lawmakers, Missouri Right to Life, Missouri Farm Bureau and Americans for Prosperity.

In the days leading up to the election, the “No on 2 in August” campaign sent a mailer suggesting that expansion would lead to an influx of undocumented immigrants seeking health care, but undocumented immigrants are not eligible for Medicaid and would not be under expansion, either.

The flyer, which featured a man in a medical mask emblazoned with the Mexican flag, read “Amendment 2 Means Illegal Immigrants Flooding Missouri Hospitals … While We Pay for It!”

The “No On 2 in August” campaign did not respond to requests for comment about the flyer.

Between serving customers on a busy morning on Wednesday, shop owner Cotton said her excitement about expansion was only slightly diminished by having to wait almost a year for it to take effect.

“It’s better late than never,” said Cotton. “The fact that it’s coming is better than nothing.”

This story is part of a partnership that includes KCUR, NPR and Kaiser Health News.

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

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Missourians to Vote on Medicaid Expansion as Crisis Leaves Millions Without Insurance

ST. LOUIS — Haley Organ thought she had everything figured out. After graduating from a small private college just outside Boston, she earned her master’s degree, entered the workforce and eventually landed a corporate job here as a data analyst.

Life seemed to be going as planned until the national retailer that Organ worked for announced furloughs during the coronavirus pandemic. After nine weeks of mandatory leave, the 35-year-old was laid off. The company gave her a severance package and put an expiration date on her health insurance plan.

“I haven’t slept the whole night since about March,” Organ said earlier this summer. “I can’t turn my brain off, just worrying about everything.”

Organ filed for unemployment, adding her claim to more than 40 million others nationwide since the pandemic took hold in mid-March, according to the Department of Labor. That’s about 1 in 4 U.S. workers. As a result of the unemployment crisis, millions of people lost access to their private health insurance plans at a time when they might need it most.

Medicaid, the federal and state health insurance program for people with low incomes or disabilities, could have served as a safety net for Organ if she lived in one of the 38 states that have opted to expand under provisions of the Affordable Care Act. But in Missouri, Republicans who control both the governor’s office and the legislature have said the state cannot afford its share of the cost of expansion and have been adamant foes of the ACA, helping lead a lawsuit now before the U.S. Supreme Court that may nullify the law.

That opposition by state leaders has meant adults like Organ who don’t have dependent children or specific disabilities cannot qualify for Missouri’s Medicaid program — even if their incomes are well below the poverty line.

“This is literally the first time in my life I’ve had to worry about health care coverage,” Organ said. “It’s kind of been a rude awakening for me.”

Voters in Missouri will decide Tuesday whether to expand eligibility for MO HealthNet program (Missouri’s Medicaid program) to provide insurance to more than 230,000 additional people in the state, including many who find themselves newly struggling for health coverage amid a national health crisis. More than 700,000 initial unemployment claims were reported in Missouri from mid-March through the first week of July.

If Medicaid expansion passes in Missouri, coverage for those newly eligible people would begin in 2021. Advocates for the measure say Medicaid expansion would also create jobs, protect hospitals from budget cuts and bring billions of federal taxpayer dollars back to the state.

Missouri is the latest red state to try expanding Medicaid with a ballot measure to circumvent recalcitrant legislatures. Oklahoma approved a measure June 30.

But Missouri’s Republican Gov. Mike Parson, who has said he opposes expanding Medicaid, moved the ballot measure from the general election in November to the primary election on Tuesday. Democrats criticized the shift, noting that fewer voters traditionally turn out for the primary and suggesting it could be easier to defeat in August. The ongoing threat of COVID-19 could also keep some voters away from the polls.

In a statement, Parson said changing the election date will allow the state to prepare for the potential cost of expansion. But an analysis from Washington University in St. Louis suggests that expanding the program could save the state money by lowering the amount it must pay for uncompensated care and bolstering efforts to prevent certain diseases, thereby reducing treatment costs to the state. Under the terms of the Affordable Care Act, the federal government picks up 90% of the coverage costs for newly eligible enrollees, as compared with the 65% it pays for people who qualify under regular Medicaid rules.

Backers of expansion are cautiously optimistic that Missouri voters will approve the measure Tuesday, heartened by Oklahoma’s win last month and positive polling.

For people who qualify for the current Medicaid program, enrollment is open year-round, which means people can apply when needed.

“That’s why we call them safety-net programs,” said Jen Bersdale, executive director of Missouri Health Care for All, a group that has advocated for Medicaid expansion since 2012. “When you get dropped from a job, dropped from insurance, they are there to catch you until you’re back on your feet.”

Amid the pandemic, Medicaid already appears to be helping people newly out of work. In 22 states, Medicaid enrollment increased by an average 5% from February to May, according to Georgetown University Health Policy Institute data. Newer data for May in those same states suggests enrollment growth is accelerating.

Even without expanding the program, Missouri leads the group with an 8.8% increase since February in total Medicaid enrollment. While economic recessions often contribute to increasing Medicaid enrollment, the early spike in Missouri could signify reenrollment of a large number of people, mostly children, who had been dropped from the program two years in a row. A federal rule blocks disenrollment during the pandemic.

Even some Missourians already on Medicaid are worried about the ballot measure not passing. Without expansion of the program, Sally Terranova fears that her 16-year-old son, Colin, will be ineligible for Medicaid when he ages out of the kids’ coverage at age 19. He was diagnosed with Type 1 diabetes in 2016.

Terranova is concerned that her son wouldn’t be able to afford the insulin he needs without insurance. She worries even more when she hears stories about diabetics rationing their insulin.

“It’s bad enough he has this illness hanging over him,” Terranova said. “But he can live a good life and be healthy if he has access to health care.”

That’s one reason Terranova, 39, hopes to land a job with good benefits when she finishes graduate school in a year and half. She has studied social work for the past four years, so she understands the challenges low-income families face.

Terranova had moved from New York to Missouri to give her son a better life. They’ve called St. Louis home for 10 years, but the single mom is contemplating another big move for her son’s health. She’s thinking of going this time to a state that has already expanded the program.

Organ, whose health insurance expired in July, is now one of the lucky ones. She just got a new job and will get new health insurance when she starts next week. Still, she’s hoping the Medicaid measure will pass, as she now appreciates more than ever how much it could mean for others who have lost their jobs and lack coverage amid the COVID-19 pandemic. Instead of heading to a polling place Tuesday, though, Organ is planning to vote by mail.

“I’m trying to do everything I can to keep me and others safe,” Organ said. “But I want to make sure my voice is still heard.”

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.

Trump Administration’s Sudden Shift on COVID Data Leaves States in the Lurch

Just as the number of people hospitalized for COVID-19 approaches new highs in some parts of the country, hospital data in Kansas and Missouri is suddenly incomplete or missing.

The Missouri Hospital Association reports that it no longer has access to the data it uses to guide state coronavirus mitigation efforts, and Kansas officials say their hospital data may be delayed.

The Trump administration this week directed hospitals to change how they report data to the federal government and how that data will be made available.

In an email, Missouri Hospital Association spokesperson Dave Dillon called the move “a major disruption.”

“All evidence suggests that Missouri’s numbers are headed in the wrong direction,” Dillon said. “And, for now, we will have very limited situational awareness. That’s all very bad news.”

The absence of the data will make it harder for health and public officials, as well as the general public, to understand how the virus is spreading.

“It’s hugely problematic,” said Dr. Karen Maddox, a public health researcher at Washington University in St. Louis. “The only way that we know where things are going up and where things are going down and where we need to be putting resources and where we need to be planning is because of those data.”

The White House instructed hospitals to report data to the Department of Health and Human Services through a new system created by a Pennsylvania-based company, TeleTracking, instead of to the Centers for Disease Control and Prevention.

The directive came as a surprise to hospitals, according to Kansas Hospital Association spokesperson Cindy Samuelson.

“From our perspective, these changes are big,” Samuelson said. “We only found out Tuesday, and we had to update the data by Wednesday night — so, less than 48 hours.”

The Missouri Hospital Association currently does not have access to the new HHS system, according to Dillon. He said the new system is also significantly different from the CDC system.

“The new datasets for reporting are not identical and in several cases are ill-defined,” Dillon said. “That has complicated hospitals’ efforts.”

In the wake of the announcement, the Missouri Department of Health and Senior Services posted a notice on its website this week that the daily and weekly updates on hospitals, including the numbers of people hospitalized and the availability of standard hospital beds, ICU beds and ventilators, would be temporarily halted.

“Missouri Hospital Association (MHA) and the State of Missouri will be unable to access critical hospitalization data during the transition. While we are working to collect interim data, situational awareness will be limited,” the notice on the department’s website says.

Dillon said the hospital association hopes to have “within a few days or weeks” hospital and coronavirus data that had been available through the CDC.

“However, in the short term, we’ll be very much in the dark,” Dillon said.

The hospital association will create an alternative reporting system for hospitals, according to Dillon, and plans to continue producing weekly reports, despite the uncertainty about data.

The Missouri Department of Health and Senior Services did not respond to inquiries regarding the data.

Kansas health officials are still able to access hospital and coronavirus data through the CDC and TeleTracking, according to Kansas Department of Health and Environment spokesperson Kristi Zears.

However, Kansas Hospital Association spokesperson Samuelson said the Kansas hospital data may be delayed if it is incomplete.

“If we’re not able to get a bulk of our members converted and uploading, I’m not sure we want to show it because then it will look like things have gotten a lot better,” Samuelson said.

The most recent data shows that as of July 12, 875 Missourians were hospitalized with COVID-19, among the highest reported numbers since an early May peak of 984. Kansas’ most recent data shows 1,393 people have been hospitalized with the disease.

The Trump administration said the reporting change was needed due to reporting delays and other problems with the CDC.

But the move has been widely criticized for being disruptive, especially as COVID-19 infection numbers reach new highs and hospitals in some areas of the country are reaching capacity.

“By now, we should have a foolproof, streamlined reporting system for COVID,” Maddox said. “And this change — midstream — is not going to do anything to help our ability to fight the disease.”

This story is part of a reporting partnership that includes KCUR, NPR and Kaiser Health News.