KHN’s ‘What the Health?’: The Biden Health Agenda

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President Joe Biden wasted no time getting down to work. Among the raft of executive orders he signed on Inauguration Day were several aimed at curtailing the covid crisis, including one requiring mask-wearing by federal employees and anyone on federal property for the next 100 days.

Meanwhile, with the inauguration of Vice President Kamala Harris and the swearing-in of two new Democratic senators from Georgia, Democrats took over the majority in the Senate, albeit with a 50-50 tie. That leaves Democrats in charge of both the legislative and executive branches for the first time since 2010, but with such narrow majorities it could be difficult to advance many of Biden’s top health agenda items, starting with an expansion of the Affordable Care Act.

This week’s panelists are Julie Rovner of KHN, Alice Miranda Ollstein of Politico, Tami Luhby of CNN and Sarah Karlin-Smith of the Pink Sheet.

Among the takeaways from this week’s podcast:

  • Although Biden can make certain changes to the federal policies in the fight against covid-19, much of what he has detailed in his plan will require congressional action, and Senate Republicans do not appear willing to support a major legislative package just yet.
  • Many of the efforts against covid that Biden has said he wants to put in place are initiatives that have been recommended by public health officials over the past year and not acted upon. But the discovery of new, more contagious variants of the coronavirus may necessitate faster efforts to distribute vaccine and other actions.
  • Wearing masks and other simple public health practices can have a big impact on slowing the spread of covid, but much of the public is looking to a vaccine for help. Those supplies remain limited and it’s not clear whether Biden’s interest in using the Defense Production Act to force industry to help will increase vaccine production.
  • Vaccination success is hampered by unreliable estimates of the amount of supplies states can expect to receive and a patchwork of sign-up methods and eligibility criteria.
  • Among the actions Biden and a Democratic Congress could take to reverse policies instituted by the Trump administration are ramping up workplace enforcement of covid rules to help keep employees from spreading the disease, restoring a penalty for not having insurance so that the lawsuit threatening the Affordable Care Act would become moot, and overturning rules requiring reviews of federal scientists.
  • The Senate has not yet scheduled a confirmation hearing for Xavier Becerra, Biden’s choice for Health and Human Services secretary. Before a mob stormed the U.S. Capitol this month, it was thought that establishing a new federal health team would be the president’s priority, but national security took precedence after the violence.
  • Controlling drug prices is an issue with huge popular support, but Congress is divided over how to do it. The broad measure that passed the House in 2019 is again unlikely to fly in the Senate, but senators may try to produce a more modest proposal along the lines of a bipartisan measure offered previously by Sens. Chuck Grassley (R-Iowa) and Ron Wyden (D-Ore).
  • Drugmakers have generally fought most efforts to implement price controls, but there may be growing interest within the industry to work out a bipartisan deal that they have a hand in, rather than waiting to see what Democrats can push through.

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

Julie Rovner: The Atlantic’s “Pramila Jayapal Is ‘Next-Level’ Angry,” by Elaine Godfrey

Alice Miranda Ollstein: The New York Times’ “Emerging Coronavirus Variants May Pose Challenges to Vaccines,” by Apoorva Mandavilli

Sarah Karlin-Smith: Vanity Fair’s “A Tsunami of Randoms”: How Trump’s COVID Chaos Drowned the FDA in Junk Science,” by Katherine Eban

Tami Luhby: KHN’s “Black Americans Are Getting Vaccinated at Lower Rates Than White Americans,” by Hannah Recht and Lauren Weber

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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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‘An Arm and a Leg’: Host Dan Weissmann Talks Price Transparency on ‘Axios Today’

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As we settle into the new year, we have two small doses of good news.

First, a new federal rule could help cut through one health care issue. Host Dan Weissmann talked about the rule — which requires hospitals to make public the prices they negotiate with insurers — in a short conversation with his former public-radio colleague, Niala Boodhoo, for the daily-news podcast “Axios Today.”

You’ll find more detail on that rule in this story from reporter Celia Llopis-Jepsen, whose reporting about a $50,000 “air ambulance” ride formed the core of a recent episode about how consumers get squeezed by insurers on one side and providers on the other.

Later in the episode, a listener describes how he used what he learned from “An Arm and a Leg” to head off an insurance nightmare.

Here’s a transcript for this episode.

“An Arm and a Leg” is a co-production of Kaiser Health News and Public Road Productions.

To keep in touch with “An Arm and a Leg,” subscribe to the newsletter. You can also follow the show on Facebook and Twitter. And if you’ve got stories to tell about the health care system, the producers would love to hear from you.

To hear all Kaiser Health News podcasts, click here.

And subscribe to “An Arm and a Leg” on iTunesPocket CastsGoogle Play or Spotify.

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?’: On Capitol Hill, Actions Have Consequences

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The reverberations from the Jan. 6 storming of the U.S. Capitol by supporters of President Donald Trump continue. A broad array of business groups, including many from the health industry, are halting contributions to Republicans in the House and Senate who voted against certifying the victory of President-elect Joe Biden. Meanwhile, Republicans in the House who have refused to wear masks or insisted on carrying weapons are being subjected to greater enforcement, including significant fines.

Away from the Capitol, the Trump administration has granted a first-in-the-nation waiver to Tennessee to turn its Medicaid program into a block grant, which would give the state potentially less federal money but more flexibility to structure the federal-state health program for those with low incomes. And in its waning days, the administration is moving to make its last-minute policies harder for Biden to undo.

This week’s panelists are Julie Rovner of KHN, Joanne Kenen of Politico, Margot Sanger-Katz of The New York Times and Kimberly Leonard of Business Insider.

Among the takeaways from this week’s podcast:

  • The decision by industry groups to cut their political contributions to some Republican lawmakers could reshape businesses’ relationships on Capitol Hill. But it’s still not clear if this announcement will affect the vast sums of political contributions that come through PACs and other unnamed sources, as well as individual contributions from corporate officials.
  • The slow start of the covid vaccination campaign points to the tension between the need to steer the vaccine to people at high risk of contracting the disease and the concerns about wasting the precious medicine. Because the vaccines that have been approved for emergency use have a relatively short shelf life, some doses may go to waste if they are reserved for specific populations.
  • The response to the vaccine among health care workers varies widely. In some areas, staffers are eager to get the shots, while in other places, some workers have been hesitant and the shots are going unused. And the federal government has not provided a strong public messaging campaign about the vaccines.
  • The Trump administration’s announcement last week that it would move to convert Tennessee’s Medicaid program to a block grant program is raising concerns among advocates for the poor, who fear that the flexibility the state is gaining could lead to enrollees getting less care, especially since the state will get a hefty portion of any savings it finds in running the program.
  • It may not be easy for the Biden administration to change this decision. Federal officials in recent weeks have been sending states, including Tennessee, letters to sign that could protect the Medicaid waivers they have received from the Trump administration and could serve as a legal guarantee that would require a long, difficult process to unwind.
  • Mental health care may be a casualty of the coronavirus pandemic. As states look to balance their budgets after a year in which revenues were slashed, they may turn to cutting mental health care services provided through Medicaid and other programs.

Also this week, Rovner interviews KHN’s Victoria Knight, who wrote the latest KHN-NPR “Bill of the Month” feature — about an unusually large bill for in-network care. If you have an outrageous medical bill you’d like to share with us, you can do that here.

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

Julie Rovner: The Washington Post’s “Young ER doctors Risk Their Lives on the Pandemic’s Front Line. But They Struggle to Find Jobs,” by Ben Guarino

Margot Sanger-Katz: The New York Times’ “Why You’re Probably Not So Great at Risk Assessment,” by AC Shilton

Joanne Kenen: The Atlantic’s “Why Aren’t We Wearing Better Masks?” by Zeynep Tufekci and Jeremy Howard

Kimberly Leonard: Business Insider’s “I Was Offered a Covid Vaccine Even Though I’m Young and Healthy. Here’s How I Did It,” by Kimberly Leonard

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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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‘An Arm And a Leg’: How a Former Health Care Executive Became a Health Care Whistleblower

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Former health care executive Wendell Potter spent part of 2020 publishing high-profile apologies for the work he used to do — the lies he said he told the American people for his old employers. These days, he said, he’s also trying to debunk myths he once sold.

“What I used to do for a living was mislead people into thinking that we had the best health care system in the world,” Potter said.

In this episode, Potter talks about his transformation from health care executive to health care whistleblower. His is also a story about the long, messy process of change — whether that’s changing your own life or trying to change a bigger system.

Here’s a transcript of the episode.

“An Arm and a Leg” is a co-production of Kaiser Health News and Public Road Productions.

To keep in touch with “An Arm and a Leg,” subscribe to the newsletter. You can also follow the show on Facebook and Twitter. And if you’ve got stories to tell about the health care system, the producers would love to hear from you.

To hear all Kaiser Health News podcasts, click here.

And subscribe to “An Arm and a Leg” on iTunesPocket CastsGoogle Play or Spotify.

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?’: Georgia Turns the Senate Blue

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Surprise Democratic victories in Georgia’s two runoff elections this week will give Democrats control of the Senate, which means they will be in charge of both houses of Congress and the White House for the first time since 2010. Although the narrow majorities in the House and Senate will likely not allow Democrats to pass major expansions to health programs, it will make it easier to do things such as pass fixes for the Affordable Care Act.

Meanwhile, the speedy development and approval of vaccines to protect against covid-19 is being squandered by the lack of a national strategy to get those vaccines into people’s arms. Straightening out and speeding up vaccinations will be a major priority for the incoming administration of President-elect Joe Biden.

This week’s panelists are Julie Rovner of Kaiser Health News, Anna Edney of Bloomberg News, Alice Miranda Ollstein of Politico and Mary Ellen McIntire of CQ Roll Call.

Among the takeaways from this week’s podcast:

  • The Georgia election results will make it easier for some of Biden’s Cabinet picks to be confirmed, including Xavier Becerra, his choice to head the Department of Health and Human Services.
  • Among the ACA fixes that congressional Democrats may seek is a restoration of a small penalty for people who do not have health coverage. That could negate the case before the Supreme Court now that was brought by Republican state officials.
  • One strategic error in the covid vaccine distribution efforts was that the release of the vaccine was not coupled with a major messaging campaign to explain what the vaccine does and dispel fears about it.
  • Late last month, a federal court blocked the Trump administration from implementing a plan to tie what Medicare pays for some drugs to the prices in other countries. It’s not clear if the Biden administration will continue the legal fight to keep the program, but the president-elect has suggested he is more interested in bringing down drug prices by negotiating with manufacturers.
  • The Trump administration has sued retail giant Walmart, alleging it unlawfully dispensed opioids from its pharmacies.

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

Julie Rovner: The New York Times’ “One Hospital System Sued 2,500 Patients After Pandemic Hit,” by Brian M. Rosenthal

Alice Miranda Ollstein: Politico’s “Congress Using COVID Test That FDA Warns May Be Faulty,” by David Lim and Sarah Ferris

Mary Ellen McIntire: Bloomberg News’ “The World’s Most Loathed Industry Gave Us a Vaccine in Record Time,” by Drew Armstrong

Anna Edney: STAT News’ “How It Started: A Q&A With Helen Branswell, One Year After Covid-19 Became a Full-Time Job,” by Jason Ukman

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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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Listen: How Operation Warp Speed Became a Slow Walk

KHN Editor-in-Chief Elisabeth Rosenthal appeared on Diane Rehm’s “On My Mind” podcast on NPR to discuss the bottlenecks that have prevented doses of precious covid-19 vaccine from making it from drugmakers’ factories into patients’ arms. It didn’t have to be this way, she explains.

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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‘An Arm and a Leg’: A Look Back at 2020 — What We Learned and Where We’re Headed

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This episode turns the tables: Host Dan Weissmann gets interviewed about what he learned in 2020 and what’s ahead for the show — with T.K. Dutes, a radio host and podcast-maker who is also a former nurse, so she knows a thing or two about the health care system. She chronicled her career transition in an episode of NPR’s “Life Kit.”

During their conversation, Dutes shared stories about life before and after health insurance. She coins what could be a new tagline for “An Arm and a Leg”: “Where there’s money, there’ll be scams.”

Here’s a transcript of the episode.

For more of Dutes’ work, check out “Open World,” a podcast she published recently with Rose Eveleth. The first episode features a reading by and discussion with the writer N.K. Jemisin, who won a MacArthur “genius” award the day after the show came out. (Clearly, the MacArthur folks were listening.)

“An Arm and a Leg” is a co-production of Kaiser Health News and Public Road Productions.

To keep in touch with “An Arm and a Leg,” subscribe to the newsletter. You can also follow the show on Facebook and Twitter. And if you’ve got stories to tell about the health care system, the producers would love to hear from you.

To hear all Kaiser Health News podcasts, click here.

And subscribe to “An Arm and a Leg” on iTunesPocket CastsGoogle Play or Spotify.

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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Video: The Healthy Nurse Who Died at 40 on the COVID Frontline: ‘She Was the Best Mom I Ever Had’

Yolanda Coar was 40 when she died of COVID-19 in August 2020 in Augusta, Georgia. She was also a nurse manager, and one of nearly 3,000 frontline workers who have died in the U.S. fighting this virus, according to an exclusive investigation by The Guardian and KHN.

Read more of the health workers’ stories behind the statistics — their personalities, passions and quirks. “Lost on the Frontline” examines: Did they have to die?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

But not anymore.

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

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

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

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

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

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

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

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

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

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

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

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

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KHN’s ‘What the Health?’: All I Want for Christmas Is a COVID Relief Bill

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Congress appears to be inching ever closer to agreement on a long-delayed COVID-19 relief bill, which would extend unemployment insurance and other emergency programs set to expire in the next several days. That bill, however, apparently will not include the top-priority items for both political parties: business liability protections supported by Republicans and aid to states and localities sought by Democrats.

The bill is likely to be part of a giant spending bill to keep the federal government funded for the rest of the fiscal year. And it might include a last-minute surprise: legislation to put an end to “surprise” medical bills sent to patients who inadvertently obtain care outside their insurance network.

This week’s panelists are Julie Rovner of Kaiser Health News, Alice Miranda Ollstein of Politico, Rebecca Adams of CQ Roll Call and Mary Agnes Carey of KHN.

Among the takeaways from this week’s podcast:

  • Congress has essentially agreed on a federal spending bill for the rest of the fiscal year — which began in October. But it will likely wait as lawmakers continue squabbling over the COVID relief package, with negotiations now centering on small details.
  • Republicans for months have been hesitant to move forward on a bill that would provide more relief for consumers affected by the pandemic because party leaders did not like Democrats’ insistence that it include more state and local aid. But that provision has been jettisoned, so Republicans are less opposed to the measure. Plus, they see a political downside to holding up the bill: Their two Georgia candidates for Senate — facing Democratic opponents in a special runoff election — are being hammered on the issue.
  • The compromise on surprise medical bills came after supporters secured agreement among Democrats who had favored varying remedies and all the committees in the House and Senate on the bill, a consensus that was forged with major concessions by progressives.
  • But doctors’ groups and other industry critics are still attacking the surprise billing proposal — even though many observers see the bill as tilted in their favor over insurers — so its passage is not guaranteed. Supporters are banking on the looming end of the congressional session to move the measure over the finish line.
  • Vice President Mike Pence announced he will get vaccinated against COVID-19 in public this week in hopes of convincing anyone skeptical about the shots that they are safe. President-elect Joe Biden is planning to do the same soon. But this is a difficult stance for politicians. They don’t want to look as if they are pushing themselves ahead in line, but they also want to normalize the use of the vaccine.
  • About 200 state and local public health leaders have quit or been fired because of public opposition to measures to curb the coronavirus. Although President Donald Trump has reined in his criticism of some of these officials and their efforts, the opposition is still strong. Those critics may be buttressed by fears that new restrictions imposed to control the surging virus will hurt the economy.

Also this week, Rovner interviews Elizabeth Mitchell, president and CEO of the Pacific Business Group on Health, about the future of employer-provided health insurance.

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

Julie Rovner: The Texas Monthly’s “Texas Wedding Photographers Have Seen Some $#!+,” by Emily McCullar

Alice Miranda Ollstein: The New York Times’ “‘Like a Hand Grasping’: Trump Appointees Describe the Crushing of the C.D.C.,” by Noah Weiland

Mary Agnes Carey: NPR’s “How Do We Grieve 300,000 Lives Lost?” by Will Stone

Rebecca Adams: Bloomberg News’ “White House Official Recovers From Severe Covid-19, Friend Says,” by Jennifer Jacobs

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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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‘An Arm and a Leg’: Shopping for Health Insurance? Here’s How One Family Tried to Pick a Plan

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When host Dan Weissmann and his wife set out to pick a health insurance plan for next year, they realized that keeping the plan they have means paying $200 a month more. But would a “cheaper” plan cost them more in the long run?  It depends. And the COVID pandemic makes their choice a lot more complicated.

After trying to puzzle it out, Weissmann debriefs with Karen Pollitz, a health insurance expert at KFF, who knows about the angst of medical bills from personal experience.

Health insurance can be painful, but the alternative ― not having health insurance ― is so much worse. If you want to go deeper on health insurance, you might want to check out these episodes from the first season of the podcast:

  • In “Why You (and I) Will Likely Pick the Wrong Health Insurance,” we learn: Smart economists have proved it’s actually super hard — even they aren’t sure they’ll pick correctly.
  • In an episode inspired by KHN reporter Jenny Gold, we learn about insurance companies’ price-gouging. And often we end up paying the price.
  • In the first-ever episode of this show, Weissmann’s family confronts the big puzzle: Can we even get insurance that’ll work for us?
  • In “A ‘Deal’ on Health Insurance Comes With Troubling Strings,” we go on a journey with a kinda-famous “financial therapist” who says she gets rattled when it comes to picking health insurance. And she’s pretty uncomfortable — morally, personally — with some of the choices she’s made. (Also, Weissmann’s family makes another cameo.)

And here are some other helpful big-picture takes:

Want to go a lot deeper? Especially if you’re actually looking at buying health insurance, maybe on the Obamacare exchange?

Weissmann found healthcare.gov to be super usable this year, way better than the last time he checked.

“I punched in the answers to a few questions, and got to quickly tell it which doctors our family sees (and what meds we take) … and it provided a clear list that showed which plans cover our docs, how much they would cost us, etc.,” he said.

  • Subsidies are available for Affordable Care Act plans. KFF has this explanation of how they work. It’s a slog, but thorough. Print it out, grab a snack and settle in. This bit of research explains that a lot of people qualify for a plan with no premium. (KHN, which co-produces “An Arm and a Leg,” is an editorially independent program of KFF.)
  • KFF has a whole database of frequently asked questions about the ACA. Hundreds of Q’s and A’s, including 180-plus in Spanish.
  • Also great, also very thorough: The Georgetown University Center on Health Insurance Reforms has a whole site full of resources for navigating the ACA. (It’s actually for “navigators” — folks who help civilians understand the sign-up process.)

That’s a lot, right? Picking a plan can be overwhelming. But don’t let it get you down.

“An Arm and a Leg” is a co-production of Kaiser Health News and Public Road Productions.

To keep in touch with “An Arm and a Leg,” subscribe to the newsletter. You can also follow the show on Facebook and Twitter. And if you’ve got stories to tell about the health care system, the producers would love to hear from you.

To hear all Kaiser Health News podcasts, click here.

And subscribe to “An Arm and a Leg” on iTunesPocket CastsGoogle Play or Spotify.

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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Ataques a la salud pública generan éxodo de funcionarios en medio de la pandemia

Tisha Coleman ha vivido en el muy unido condado de Linn, Kansas, por 42 años. Y nunca se ha sentido tan sola.

Como administradora de salud pública, ha luchado cada día de la pandemia para mantener a salvo a su condado rural, ubicado a lo largo de la frontera con Missouri. A cambio, ha sido acosada, demandada, vilipendiada y le han gritado “cumple-órdenes”.

Los meses de peleas por máscaras y cuarentenas ya la estaban desgastando. Luego contrajo COVID-19, probablemente de su esposo, quien se ha negado a exigir el uso de máscaras en la ferretería familiar. Su madre también lo contrajo y murió el domingo 13 de diciembre.

En todo Estados Unidos, funcionarios de salud pública estatales y locales se han encontrado en el centro de una tormenta política.

Algunos han sido el blanco de activistas de extrema derecha, grupos conservadores y extremistas antivacunas, que se han unido en torno a objetivos comunes: luchar contra los mandatos de uso de máscaras, las cuarentenas y el rastreo de contactos, con protestas, amenazas y ataques personales.

El poder de la salud pública también se está socavando en los tribunales. Legisladores, en al menos 24 estados, han diseñado leyes para debilitar poderes que la salud pública ha mantenido por mucho tiempo.

En medio de este retroceso, desde el 1 de abril, al menos 181 líderes de salud pública estatales y locales, en 38 estados, han renunciado, se han jubilado o han sido despedidos, según una investigación en curso de The Associated Press y KHN. Expertos dicen que se trata del éxodo más grande de líderes de salud pública en la historia de los Estados Unidos.

Uno de cada 8 estadounidenses, 40 millones de personas, vive en una comunidad que perdió a su líder de salud pública local durante la pandemia. En 20 estados, los principales funcionarios de salud pública han dejado sus puestos, y también se ha ido un número incalculable de empleados de niveles inferiores.

Muchos de los líderes se retiraron debido al retroceso político o la presión de la pandemia. Algunos se fueron para ocupar puestos de más alto perfil o por problemas de salud. Otros fueron despedidos por mal desempeño. Docenas se jubilaron.

“No tenemos gente haciendo fila afuera para cubrir estos puestos”, dijo el doctor Gianfranco Pezzino, oficial de salud en el condado de Shawnee, Kansas, quien se está retirando anticipadamente de su trabajo. “Es una gran pérdida que es probable que impacte en las  generaciones futuras”.

Estas partidas son una erosión adicional a la ya frágil infraestructura de salud pública del país, antes de la campaña de vacunación más grande en la historia de los Estados Unidos.

AP y KHN informaron anteriormente que, desde 2010, el gasto per cápita de los departamentos de salud pública estatales se había reducido en un 16%, y en los departamentos de salud locales, un 18%. Al menos 38,000 empleos de salud pública estatales y locales han desaparecido desde la recesión de 2008.

Desde que comenzó la pandemia, la fuerza laboral de salud pública en Kansas se ha visto muy afectada: 17 de los 100 departamentos de salud del estado han estado perdiendo a sus líderes desde finales de marzo.

La gobernadora demócrata Laura Kelly emitió un mandato de uso de máscaras en julio, pero la legislatura estatal permitió que los condados optaran por no participar. Un informe reciente de los Centros para el Control y Prevención de Enfermedades (CDC) mostró que los 24 condados de Kansas que habían cumplido con este mandato registraron una disminución del 6% en los casos de COVID-19, mientras que los 81 condados que optaron por no participar por completo vieron un aumento del 100%.

Coleman presionó para que el condado de Linn mantuviera la regla, pero los comisionados escribieron que las máscaras “no son necesarias para proteger la salud pública y la seguridad del condado”.

Coleman se sintió decepcionada, pero no sorprendida. “Al menos sé que he hecho todo lo posible para intentar proteger a la gente”, dijo.

En Boise, Idaho, el 8 de diciembre, cientos de manifestantes, algunos armados, invadieron las oficinas de salud del distrito y las casas de los miembros de la junta de salud, gritando y haciendo sonar las bocinas. Entre ellos había miembros del grupo anti-vacunas Health Freedom Idaho.

Según expertos, el movimiento contra las vacunas se ha vinculado con extremistas políticos de derecha, y ha asumido un papel más amplio en contra de la ciencia, rechazando otras medidas de salud pública.

Ahora, los opositores están recurriendo a las legislaturas estatales, e incluso a la Corte Suprema, para despojar a los funcionarios públicos del poder legal que han tenido durante décadas para detener las enfermedades transmitidas por alimentos y las enfermedades infecciosas mediante el cierre de negocios y las cuarentenas, entre otras medidas.

Legisladores de Missouri, Louisiana, Ohio, Virginia y al menos otros 20 estados han elaborado proyectos de ley para limitar los poderes de la salud pública. En algunos estados, estos esfuerzos han fracasado; en otros, los han acogido con entusiasmo.

Mientras tanto, los gobernadores de varios estados, incluidos Wisconsin, Kansas y Michigan, han sido demandados por sus propios legisladores, u otros, por utilizar sus poderes ejecutivos para restringir las operaciones comerciales y exigir máscaras.

En Ohio, un grupo de legisladores busca procesar al gobernador republicano Mike DeWine por sus reglas sobre la pandemia.

Un fallo de 5-4 el mes pasado indicó que la Corte Suprema también está dispuesta a imponer nuevas restricciones a los poderes de la salud pública. Lawrence Gostin, experto en derecho de salud pública de la Universidad Georgetown, en Washington, DC, dijo que la decisión podría animar a legisladores estatales y a gobernadores a buscar limitaciones adicionales.

Junto con la reacción política, muchos funcionarios de salud se han enfrentado a amenazas violentas. En California, un hombre con vínculos con el movimiento de derecha Boogaloo, que está asociado con múltiples asesinatos, fue acusado de acechar y amenazar al funcionario de salud de Santa Clara. Fue arrestado y se declaró inocente.

Linda Vail, funcionaria de salud del condado de Ingham, en Michigan, recibió correos electrónicos y cartas en su casa diciendo que sería “derrocada como la gobernadora”, lo que interpretó como una referencia al intento frustrado de secuestrar a la gobernadora demócrata Gretchen Whitmer.

“Puedo entender completamente por qué algunas personas simplemente se fueron”, dijo. “Hay otros lugares para ir a trabajar”.

A medida que los funcionarios de salud pública a lo largo del país parten, la cuestión de quién ocupa sus lugares preocupa a la doctora Oxiris Barbot, quien dejó su trabajo como comisionada del departamento de salud de la ciudad de Nueva York en agosto en medio de un enfrentamiento con el alcalde demócrata Bill de Blasio.

“Me preocupa si tendrán la fortaleza necesaria para decirles a los funcionarios electos lo que necesitan escuchar en lugar de lo que quieren escuchar”, dijo Barbot.

En el condado de Linn, los casos están aumentando. Hasta el 14 de diciembre, 1 de cada 24 residentes había dado positivo para COVID.

“Por supuesto, podría rendirme y colgar la toalla, pero todavía no he llegado a ese punto”, dijo Coleman.

Ha notado que más personas usan máscaras en estos días.

Pero en la ferretería familiar, todavía no son mandatorias.

Michelle R. Smith es reportera de AP, y Anna Maria Barry-Jester, Hannah Recht y Lauren Weber son reporteras de KHN.

Esta historia es una colaboración entre The Associated Press y KHN (Kaiser Health News), un servicio de noticias sin fines de lucro que cubre temas de salud. Es un programa editorialmente independiente de KFF (Kaiser Family Foundation) que no tiene relación con Kaiser Permanente.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Methodology

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

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

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Pandemic Backlash Jeopardizes Public Health Powers, Leaders


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

Tisha Coleman has lived in close-knit Linn County, Kansas, for 42 years and never felt so alone.

As the public health administrator, she’s struggled every day of the coronavirus pandemic to keep her rural county along the Missouri border safe. In this community with no hospital, she’s failed to persuade her neighbors to wear masks and take precautions against COVID-19, even as cases rise. In return, she’s been harassed, sued, vilified — and called a Democrat, an insult in her circles.

Even her husband hasn’t listened to her, refusing to require customers to wear masks at the family’s hardware store in Mound City.

“People have shown their true colors,” Coleman said. “I’m sure that I’ve lost some friends over this situation.”

By November, the months of fighting over masks and quarantines were already wearing her down. Then she got COVID-19, likely from her husband, who she thinks picked it up at the hardware store. Her mother got it, too, and died on Sunday, 11 days after she was put on a ventilator.

Across the U.S., state and local public health officials such as Coleman have found themselves at the center of a political storm as they combat the worst pandemic in a century. Amid a fractured federal response, the usually invisible army of workers charged with preventing the spread of infectious diseases has become a public punching bag. Their expertise on how to fight the coronavirus is often disregarded.

Some have become the target of far-right activists, conservative groups and anti-vaccination extremists, who have coalesced around common goals — fighting mask orders, quarantines and contact tracing with protests, threats and personal attacks.

The backlash has moved beyond the angry fringe. In the courts, public health powers are being undermined. Lawmakers in at least 24 states have crafted legislation to weaken public health powers, which could make it more difficult for communities to respond to other health emergencies in the future.

“What we’ve taken for granted for 100 years in public health is now very much in doubt,” said Lawrence Gostin, an expert in public health law at Georgetown University in Washington, D.C.

It is a further erosion of the nation’s already fragile public health infrastructure. At least 181 state and local public health leaders in 38 states have resigned, retired or been fired since April 1, according to an ongoing investigation by The Associated Press and KHN. According to experts, this is the largest exodus of public health leaders in American history. An untold number of lower-level staffers has also left.

“I’ve never seen or studied a pandemic that has been as politicized, as vitriolic and as challenged as this one, and I’ve studied a lot of epidemics,” said Dr. Howard Markel, a medical historian at the University of Michigan. “All of that has been very demoralizing for the men and women who don’t make a great deal of money, don’t get a lot of fame, but work 24/7.”

One in 8 Americans — 40 million people — lives in a community that has lost its local public health department leader during the pandemic. Top public health officials in 20 states have left state-level departments, including in North Dakota, which has lost three state health officers since May, one after another.

Many of the state and local officials left due to political blowback or pandemic pressure. Some departed to take higher-profile positions or due to health concerns. Others were fired for poor performance. Dozens retired.

KHN and AP reached out to public health workers and experts in every state and the National Association of County and City Health Officials; examined public records and news reports; and interviewed hundreds to gather the list.

Collectively, the loss of expertise and experience has created a leadership vacuum in the profession, public health experts say. Many health departments are in flux as the nation rolls out the largest vaccination campaign in its history and faces what are expected to be the worst months of the pandemic.

“We don’t have a long line of people outside of the door who want those jobs,” said Dr. Gianfranco Pezzino, health officer in Shawnee County, Kansas, who is retiring from his job earlier than planned because, he said, he’s burned out. “It’s a huge loss that will be felt probably for generations to come.”

Existing Problems

The departures accelerate problems that had already weakened the nation’s public health system. AP and KHN reported that per capita spending for state public health departments had dropped by 16%, and for local health departments by 18%, since 2010. At least 38,000 state and local public health jobs have disappeared since the 2008 recession.

Those diminishing resources were already prompting high turnover. Before the pandemic, nearly half of public health workers said in a survey they planned to retire or leave in the next five years. The top reason given was low pay.

Such reduced staffing in departments that have the power and responsibility to manage everything from water inspections to childhood immunizations left public health workforces ill-equipped when COVID-19 arrived. Then, when pandemic shutdowns cut tax revenues, some state and local governments cut their public health workforces further.

“Now we’re at this moment where we need this knowledge and leadership the most, everything has come together to cause that brain drain,” said Chrissie Juliano, executive director of the Big Cities Health Coalition, which represents leaders of more than two dozen public health departments.

Politics as Public Health Poison

Public health experts broadly agree that masks are a simple and cost-effective way to reduce the spread of COVID-19 and save lives and livelihoods. Scientists say that physical distancing and curtailing indoor activities can also help.

But with the pandemic coinciding with a divisive presidential election, simple acts such as wearing a mask morphed into political statements, with right-wing conservatives saying such requirements stomped on individual freedom.

On the campaign trail, President Donald Trump ridiculed President-elect Joe Biden for wearing a mask and egged on armed people who stormed Michigan’s Capitol to protest coronavirus restrictions by tweeting “LIBERATE MICHIGAN!”

Coleman, a Christian and a Republican, said that’s just what happened in Linn County. “A lot of people are shamed into not wearing a mask … because you’re considered a Democrat,” she said. “I’ve been called a ‘sheep.’”

The politicization has put some local governments at odds with their own health officials. In California, near Lake Tahoe, the Placer County Board of Supervisors voted to end a local health emergency and declared support for a widely discredited “herd immunity” strategy, which would let the virus spread. The idea is endorsed by many conservatives, including former Trump adviser Dr. Scott Atlas, as a way to keep the economy running, but it has been denounced by public health experts who say millions more people will unnecessarily suffer and die. The supervisors also endorsed a false conspiracy theory claiming many COVID-19 deaths are not actually from COVID-19.

The meeting occurred just days after county Public Health Officer Dr. Aimee Sisson explained to the board the rigorous standards used for counting COVID-19 deaths. Sisson quit the next day.

In Idaho, protests against public health measures are intensifying. Hundreds of protesters, some armed, swarmed health district offices and health board members’ homes in Boise on Dec. 8, screaming and blaring air horns. They included members of the anti-vaccination group Health Freedom Idaho.

Dr. Peter Hotez, dean of the National School of Tropical Medicine at Baylor College of Medicine, has tracked the anti-vaccine movement and said it has linked up with political extremists on the right, and taken on a larger anti-science role, pushing back against other public health measures such as contact tracing and physical distancing.

Members of a group called the Freedom Angels in California, which sprung up in 2019 around a state law to tighten vaccine requirements, have been organizing protests at health departments, posing with guns and calling themselves a militia on the group’s Facebook page.

The latest Idaho protests came after a July skirmish in which Ammon Bundy shoved a public health employee who tried to stop him and his maskless supporters from entering a health meeting.

Bundy, whose family led armed standoffs against federal agents in 2014 and 2016, has become an icon for paramilitary groups and right-wing extremists, most recently forming a multistate network called People’s Rights that has organized protests against public health measures.

“We don’t believe they have a right to tell us that we have to put a manmade filter over our face to go outside,” Bundy said. “It’s not about, you know, the mandates or the mask. It’s about them not having that right to do it.”

Kelly Aberasturi, vice chair for the Southwest District Health, which covers six counties, said the worker Bundy shoved was “just trying to do his job.”

Aberasturi, a self-described “extremist” right-wing Republican, said he, too, has been subjected to the backlash. Aberasturi doesn’t support mask mandates, but he did back the board’s recommendation that people in the community wear masks. He said people who believe even a recommendation goes too far have threatened to protest at his house.

The Mask Fight in Kansas

The public health workforce in Kansas has been hit hard — 17 of the state’s 100 health departments have lost their leaders since the end of March. 

Democratic Gov. Laura Kelly issued a mask mandate in July, but the state legislature allowed counties to opt out. A recent Centers for Disease Control and Prevention report showed the 24 Kansas counties that had upheld the mandate saw a 6% decrease in COVID-19, while the 81 counties that opted out entirely saw a 100% increase.

Coleman, who pushed unsuccessfully for Linn County to uphold the rule, was sued for putting a community member into quarantine, a lawsuit she won. In late November, she spoke at a county commissioner’s meeting to discuss a new mask mandate — it was her first day back in the office after her own bout with COVID-19.

She pleaded for a plan to help stem the surge in cases. One resident referenced Thomas Jefferson, saying, “I prefer a dangerous freedom over a peaceful slavery.” Another falsely argued that masks caused elevated carbon dioxide. Few, besides Coleman, wore a mask at the meeting.

Commissioner Mike Page supported the mask order, noting that a close friend was fighting COVID-19 in the hospital and saying he was “ashamed” that members of the community had sued their public health workers while other communities supported theirs.

In the end, the commissioners encouraged community members to wear masks but opted out of a county-wide rule, writing they had determined that they are “not necessary to protect the public health and safety of the county.”

Coleman was disappointed but not surprised. “At least I know I’ve done everything I can to attempt to protect the people,” she said.

The next day, Coleman discussed Christmas decorations with her mother as she drove her to the hospital.

Stripping of Powers

The state bill that let Linn County opt out of the governor’s mask mandate is one of dozens of efforts to erode public health powers in state legislatures across the country.

For decades, government authorities have had the legal power to stop foodborne illnesses and infectious diseases by closing businesses and quarantining individuals, among other measures.

When people contract tuberculosis, for example, the local health department might isolate them, require them to wear a mask when they leave their homes, require family members to get tested, relocate them so they can isolate and make sure they take their medicine. Such measures are meant to protect everyone and avoid the shutdown of businesses and schools.

Now, opponents of those measures are turning to state legislatures and even the Supreme Court to strip public officials of those powers, defund local health departments or even dissolve them. The American Legislative Exchange Council, a corporate-backed group of conservative lawmakers, has published model legislation for states to follow.

Lawmakers in Missouri, Louisiana, Ohio, Virginia and at least 20 other states have crafted bills to limit public health powers. In some states, the efforts have failed; in others, legislative leaders have embraced them enthusiastically.

Tennessee’s Republican House leadership is backing a bill to constrain the state’s six local health departments, granting their powers to mayors instead. The bill stems from clashes between the mayor of Knox County and the local health board over mask mandates and business closures.

In Idaho, lawmakers resolved to review the authority of local health districts in the next session. The move doesn’t sit right with Aberasturi, who said it’s hypocritical coming from state lawmakers who profess to believe in local control.

Meanwhile, governors in Wisconsin, Kansas and Michigan, among others, have been sued by their own legislators, state think tanks or others for using their executive powers to restrict business operations and require masks. In Ohio, a group of lawmakers is seeking to impeach Republican Gov. Mike DeWine over his pandemic rules.

The U.S. Supreme Court in 1905 found it was constitutional for officials to issue orders to protect the public health, in a case upholding a Cambridge, Massachusetts, requirement to get a smallpox vaccine. But a 5-4 ruling last month indicated the majority of justices are willing to put new constraints on those powers.

“It is time — past time — to make plain that, while the pandemic poses many grave challenges, there is no world in which the Constitution tolerates color-coded executive edicts that reopen liquor stores and bike shops but shutter churches, synagogues, and mosques,” Justice Neil Gorsuch wrote.

Gostin, the health law professor, said the decision could embolden state legislators and governors to weaken public health authority, creating “a snowballing effect on the erosion of public health powers and, ultimately, public’s trust in public health and science.”

Who’s Left?

Many health officials who have stayed in their jobs have faced not only political backlash but also threats of personal violence. Armed paramilitary groups have put public health in their sights.

In California, a man with ties to the right-wing, anti-government Boogaloo movement was accused of stalking and threatening Santa Clara’s health officer. The suspect was arrested and has pleaded not guilty. The Boogaloo movement is associated with multiple murders, including of a Bay Area sheriff deputy and federal security officer.

Linda Vail, health officer for Michigan’s Ingham County, has received emails and letters at her home saying she’d be “taken down like the governor,” which Vail took to be a reference to the thwarted attempt to kidnap Democratic Gov. Gretchen Whitmer. Even as other health officials are leaving, Vail is choosing to stay despite the threats.

“I can completely understand why some people, they’re just done,” she said. “There are other places to go work.”

In mid-November, Danielle Swanson, public health administrator in Republic County, Kansas, said she was planning to resign as soon as she and enough of her COVID-19-positive staff emerged from isolation. Someone threatened to go to her department with a gun because of a quarantine, and she’s received hand-delivered hate mail and calls from screaming residents.

“It’s very stressful. It’s hard on me; it’s hard on my family that I do not see,” she said. “For the longest time, I held through it thinking there’s got to be an end in sight.”

Swanson said some of her employees have told her once she goes, they probably will not stay.

As public health officials depart across the country, the question of who takes their places has plagued Dr. Oxiris Barbot, who left her job as commissioner of New York City’s health department in August amid a clash with Democratic Mayor Bill de Blasio. During the height of the pandemic, the mayor empowered the city’s hospital system to lead the fight against COVID-19, passing over her highly regarded department.

“I’m concerned about the degree to which they will have the fortitude to tell elected officials what they need to hear instead of what they want to hear,” Barbot said.

In Kentucky, 189 employees, about 1 in 10, left local health departments from March through Nov. 21, according to Sara Jo Best, public health director of the Lincoln Trail District Health Department. That comes after a decade of decline: Staff numbers fell 49% from 2009 to 2019. She said workers are exhausted and can’t catch up on the overwhelming number of contact tracing investigations, much less run COVID-19 testing, combat flu season and prepare for COVID-19 vaccinations.

And the remaining workforce is aging. According to the de Beaumont Foundation, which advocates for local public health, 42% of governmental public health workers are over age 50.

Back in Linn County, cases are rising. As of Dec. 14, 1 out of every 24 residents has tested positive.

The day after her mother was put on a ventilator, Coleman fought to hold back tears as she described the 71-year-old former health care worker with a strong work ethic.

“Of course, I could give up and throw in the towel, but I’m not there yet,” she said, adding that she will “continue to fight to prevent this happening to someone else.”

Coleman, whose mother died Sunday, has noticed more people are wearing masks these days.

But at the family hardware store, they are still not required.

This story is a collaboration between The Associated Press and KHN.

Methodology

KHN and AP counted how many state and local public health leaders have left their jobs since April 1, or who plan to leave by Dec. 31.

The analysis includes the exits of top department officials regardless of the reason. Some departments have more than one top position and some had multiple top officials leave from the same position over the course of the pandemic.

To compile the list, reporters reached out to public health associations and experts in every state and interviewed hundreds of public health employees. They also received information from the National Association of County and City Health Officials, and combed news reports and public records, such as meeting minutes and news releases.

The population served by each local health department is calculated using the Census Bureau 2019 Population Estimates based on each department’s jurisdiction.

The count of legislation came from reviewing bills in every state, prefiled bills for 2021 sessions, where available, and news reports. The bills include limits on quarantines, contact tracing, vaccine requirements and emergency executive powers.

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?’: Vaccines Coming Soon but COVID Relief Bill Still Stalled

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The first vaccine to protect against COVID-19 could be approved in the U.S. within days, but legislation to help fund its distribution remains mired in Congress.

And President-elect Joe Biden has tapped California Attorney General Xavier Becerra as his secretary of Health and Human Services. The choice of Becerra, who served 12 terms in the House of Representatives, is being criticized by Republicans for his support of single-payer health care.

This week’s panelists are Julie Rovner of Kaiser Health News, Joanne Kenen of Politico, Kimberly Leonard of Business Insider and Mary Ellen McIntire of CQ Roll Call.

Among the takeaways from this week’s podcast:

  • Despite indications that both Republican and Democratic lawmakers are eager to push out a new COVID relief bill, they are having trouble finding common ground on the issue of liability protections for employers whose workers or customers may get sick. And the party leaders, notably Senate Majority Leader Mitch McConnell, have not tipped their hands on whether they will go along with the effort.
  • Complicating the COVID relief bill talks is Congress’ inability thus far to come to terms on a spending bill for the government for the fiscal year that began Oct. 1.
  • Some of the delay in getting deals on spending and COVID relief is linked to the uncertainty over which party will control the Senate after the January special elections in Georgia, which will determine two Senate seats. Although many observers expect the Republicans to win at least one, if not both, of those races, McConnell can’t be sure. He likely aims to use what political muscle he has now with the majority and an ally in the White House to get deals favorable to his causes.
  • Despite the grumbling by some Republican senators over Becerra’s nomination, it is still too early to suggest that he won’t win approval. The outcome may also depend on whether McConnell remains majority leader and whether Republicans determine that this is a nomination they want to take a stand on — or whether they save the gunpowder for another nominee.
  • Dr. Vivek Murthy, chosen by Biden to be the next surgeon general, is likely to have a broader portfolio than that office typically has because of his strong relationship with Biden.
  • An advisory committee for the Food and Drug Administration is meeting to consider an application for Pfizer’s COVID vaccine. If the request is approved, consumers should still anticipate there could be glitches in distribution and some unforeseen issues with the vaccine, such as the side effects noted in Britain this week in people with strong allergies. Nevertheless, this vaccine and others can be expected to make significant progress in the battle against the coronavirus. 
  • The clinical trials for the COVID vaccine have shown it reduces the severity of the disease, but it’s not clear whether the vaccine will stop disease transmission.

Also this week, Rovner interviews Michael Mackert, director of the Center for Health Communication at the University of Texas-Austin and a professor both at the Dell Medical School and the Stan Richards School of Advertising and Public Relations.

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

Julie Rovner: Politico’s “How Biden Aims to Covid-Proof His Administration,” by Alice Miranda Ollstein and Daniel Lippman

Kimberly Leonard: Business Insider’s “Here’s How the GSA Plans to Disinfect the White House Between Trump’s Departure and Biden’s Arrival,” by Robin Bravender and Kimberly Leonard

Mary Ellen McIntire: The Atlantic’s “The Danger of Assuming That Family Time Is Dispensable,” by Julia Marcus

Joanne Kenen: The New Yorker’s “How Will We Tell the Story of the Coronavirus?” by Andrew Dickson

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

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


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

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

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

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

Staking Ground in Sacramento

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

From Defense to Offense

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

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

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

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

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

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

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

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

Legal Loopholes

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

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

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

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

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

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

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

Targeting Legislative Adversaries

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

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

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

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

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

Methodology

How California Healthline compiled data about dialysis companies’ political spending

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

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

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

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

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

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

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

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‘An Arm and a Leg’: Obamacare Alum Andy Slavitt Takes Stock of the COVID Pandemic — So Far

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Andy Slavitt has spent much of 2020 talking with almost everybody who knows anything about the COVID-19 pandemic — and sharing what he learns in real time, first on Twitter, then on his pandemic podcast, “In the Bubble.

To do our own podcast episode about what we’ve learned so far and what we might expect next, Slavitt was the person to speak with.

He is a former head of the Centers for Medicare & Medicaid Services during the final years of the Obama administration.

Slavitt shared some of the cost-side realities of vaccines and testing. Then there was an uncomfortable guest-host moment about the characterization of his role as founder of a venture capital firm — before the conversation got back on track and he shared thoughts on the role of profit and health care.

“We’ve created some of the worst excesses, and we’re not getting the basic job done. Health care is not affordable to people,” Slavitt said.

Given the choice, he said, he would pick a health system that covers everybody even if it were a little worse than the current system, versus one that is very expensive and leaves many people without health care. 

“I’d be, ‘I’m all over the socialist side,’” he said. “If you asked me, though, what do I think are the ingredients to a successful health care system? I would say it includes innovation.”

“An Arm and a Leg” is a co-production of Kaiser Health News and Public Road Productions.

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

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

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

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

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

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

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

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

‘The ‘Rona Beast Is a Very Nasty Beast’

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

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

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

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

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

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

An airport spokeswoman declined to comment about Papenfus’ experience.

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

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

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

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

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

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

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

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

‘Bank Robbers Wear Masks Out There’

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

This story is from a reporting partnership that includes Colorado Public RadioNPR and KHN.

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

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KHN’s ‘What the Health?’: Who Will Run the Biden Health Effort?

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The quadrennial guessing game about who will get what health job in a new presidential administration has taken on a new urgency in 2020 as the COVID-19 pandemic continues to rage.

Meanwhile, as two promising vaccine candidates inch closer to approval, the federal government is gearing up for the immense effort of delivering two shots to as many Americans as they can.

This week’s panelists are Julie Rovner of Kaiser Health News, Margot Sanger-Katz of The New York Times, Alice Miranda Ollstein of Politico and Paige Winfield Cunningham of The Washington Post.

Among the takeaways from this week’s podcast:

  • After naming his national security and economic teams, President-elect Joe Biden is expected to focus next on his health care officials. Those names likely will be unveiled by next week. But even without a full list of appointees, it’s clear Biden will have strong health experience in the White House with his choice of Ron Klain as chief of staff and Neera Tanden to head the Office of Management and Budget. Klain was the Ebola response coordinator for President Barack Obama, and Tanden worked on the Affordable Care Act negotiations.
  • The departure of Dr. Scott Atlas from the list of President Donald Trump’s key advisers does not mean his influence is over. His advocacy for policies that opened the economy — even if they caused wider spread of the coronavirus — and an acceptance of attempting to achieve herd immunity by letting the virus spread have gained traction in some states and among conservatives.
  • Democratic House and Senate leaders endorsed efforts by a bipartisan group of lawmakers for a $900 billion COVID relief bill. But Senate Majority Leader Mitch McConnell has not yet said he will sign on to the effort, nor has Trump.
  • Public health officials are concerned that many people will be hesitant to get a coronavirus vaccine, if one is approved by the Food and Drug Administration, because the effort has been so politicized. Trump’s hard press to get the vaccine out before the election alarmed some consumers, who fear that the usual careful procedures were rushed. But if approved, a vaccine would be highly touted by health officials and celebrities.
  • What’s not known about the rollout of the vaccine is whether private companies and schools will make inoculation mandatory for workers and children.
  • Among the news items that may have been overlooked during Thanksgiving celebrations, Canada announced it would bar the exports of drugs to the U.S. if it would cause shortages there. Trump and some states, including Florida, have been pushing for importation programs to help lower drug costs in the U.S.
  • Also last week, the 5th Circuit Court of Appeals agreed that Texas could remove Planned Parenthood from its list of Medicaid providers and said that patients in the federal-state health program do not have a right to challenge state decisions on which providers are accepted into the program. The decision is likely headed to the Supreme Court.

Also this week, Rovner interviews KHN’s Julie Appleby, who wrote the latest KHN-NPR “Bill of the Month” feature — about a boy, a bicycle accident and a really big bill. If you have an outrageous medical bill you’d like to share with us, you can do that here.

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

Julie Rovner: ProPublica’s “States With Few Coronavirus Restrictions Are Spreading the Virus Beyond Their Borders,” by David Armstrong

Margot Sanger-Katz: Science Magazine’s “Public Needs to Prep for Vaccine Side Effects,” by Meredith Wadman

Paige Winfield Cunningham: Politico’s “Biden’s Chief of Staff Has Battled Pandemics Before. Here’s How He Plans to Beat This One,” by Alice Miranda Ollstein

Alice Miranda Ollstein: The New York Times’ “Prisons Are Covid-19 Hotbeds. When Should Inmates Get the Vaccine?” by Roni Caryn Rabin

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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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‘An Arm and a Leg’: How to Avoid a Big Bill for Your COVID Test

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Tests for the coronavirus are supposed to be free. And, usually, they are. But sometimes … things happen. Here’s how to keep those things from happening to you.

New York Times reporter Sarah Kliff has been asking readers to send in their COVID-testing bills. She’s now seen hundreds of them, and she ran down for us the most common ways things can go sideways, and how to avoid them.

First off, she said: “I don’t want people to think, ‘Holy crap,  I should just not get tested for coronavirus because it’s going to cost me a ton of money.’ You absolutely should. And the odds are that you will not get a surprise bill, and it will cost zero dollars.” Still, if only 2% of people end up with a surprise bill and a million people a day are getting coronavirus tests, that’s a lot of surprise bills, she noted.

Kliff’s top tip is to avoid getting a test in an emergency room, where you might get charged a “facility fee” that your insurance doesn’t cover.

“An Arm and a Leg” is a co-production of Kaiser Health News and Public Road Productions.

To keep in touch with “An Arm and a Leg,” subscribe to the newsletter. You can also follow the show on Facebook and Twitter. And if you’ve got stories to tell about the health care system, the producers would love to hear from you.

To hear all Kaiser Health News podcasts, click here.

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

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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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Surging LA

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On a Monday afternoon in March, four days after Gov. Gavin Newsom issued the nation’s first statewide stay-at-home order to slow the spread of the coronavirus, some of Southern California’s most famous landmarks were deserted and few cars traveled the region’s notoriously congested freeways.

Eight months later, businesses are open, traffic is back — and COVID-19 cases in the state are surging. 

“This is simply the fastest increase California has seen since the beginning of this pandemic,” Newsom said in a press conference Monday, when he announced a major rollback of the state’s reopening process, saying the state’s daily case numbers had doubled in the previous 10 days.

That same day, California Healthline’s Heidi de Marco returned to the landmarks she photographed in March. This time, it took her nearly two days — Monday and Tuesday — to document them because of traffic.

The biggest change was the greater number of vehicles on the road. Foot traffic had also stepped up, but most pedestrians and shoppers were wearing masks and not gathering in large numbers.

It turns out that activities such as strolling along the beach and window-shopping are not the primary way the disease is spreading in Los Angeles County. Public health officials there blame the surge on an increase in social gatherings, such as private dinners and sports-watching parties with people from multiple households, and the virus is spreading mostly among adults ages 18 to 29. In a bid to slow the virus, county public health director Barbara Ferrer announced additional restrictions on businesses, effective Friday. Among them, outdoor dining and drinking at restaurants and breweries will be limited to 50% of capacity, and outdoor gatherings can include only 15 people from no more than three households, including the host’s household.

KHN correspondent Anna Almendrala contributed to this report.

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

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

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KHN’s ‘What the Health?’: Transition Troubles Mount as COVID Spreads

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President-elect Joe Biden is still being blocked from launching his official transition while President Donald Trump contests the outcome of the election. That could be particularly dangerous for public health as COVID-19 spreads around the country at an alarming rate.

Meanwhile, a second vaccine to prevent COVID — the one made by Moderna — is showing excellent results of its early trials. And unlike the one made by Pfizer, Moderna’s vaccine does not need to be kept ultra-cold, which could ease distribution.

There is news on prescription drug prices, as well. Amazon announced plans to get into the drug delivery market, and the Trump administration was set to announce a new rule that could base some U.S. drug prices on the price-controlled prices of other industrialized countries.

This week’s panelists are Julie Rovner of Kaiser Health News, Margot Sanger-Katz of The New York Times, Alice Miranda Ollstein of Politico and Sarah Karlin-Smith of the Pink Sheet.

Among the takeaways from this week’s podcast:

  • The dramatic resurgence of the coronavirus pandemic is prompting new urgency on public health measures from federal and state officials. Republican governors who once played down the threat are instituting new restrictions, the Centers for Disease Control and Prevention called on Americans not to travel for Thanksgiving, and the White House coronavirus task force, which hadn’t been seen in months, held a briefing this week.
  • Nonetheless, the communications still lack a consistent message. Even as health officials and the White House task force underlined the dangers this week, the White House press secretary railed against some state restrictions, calling them “Orwellian.”
  • And public health efforts often seem inconsistent, such as closing schools while allowing bars and restaurants to continue to operate, albeit often with earlier mandated closing times. Part of the reluctance to close bars and restaurants comes from concerns about the economic impact — both to the businesses and the tax revenue they generate for their states and localities.
  • Even with the crisis deepening, efforts on Capitol Hill to negotiate a new stimulus package appear mired, with little sign of serious talks.
  • The biggest issue facing hospitals overrun with COVID-19 patients is a concern about having enough trained personnel. With the entire country feeling the effects of the pandemic, it is hard to shift workers to deal with outbreaks in specific areas.
  • Many states are using National Guard troops to help support overburdened hospitals and run testing sites, but the Trump administration has not said whether it will continue funding for that effort after the end of the year.
  • As vaccine candidates move ever closer to approval, some officials worry that states are not equipped to handle the logistics of distribution. And it’s not clear whether the Trump administration, which took serious missteps on getting PPE and testing supplies out earlier, is prepared to step in adequately.
  • Biden says efforts by the Trump administration to deny him the usual access to government officials and information could impair his efforts to make vaccine distribution effective when he takes office.
  • Amazon’s announcement this week that it will start selling prescription drugs has the potential to shake up the industry — but probably not right away. And it’s not clear that the giant retailer’s entrance into the market will have any effect on lowering prices.

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

Julie Rovner: Politico’s “The Biden Adviser Focused on the Pandemic’s Stark Racial Disparities,” by Joanne Kenen

Margot Sanger-Katz: The Washington Post’s “Dolly Parton Helped Fund Moderna’s Vaccine. It Began With a Car Crash and an Unlikely Friendship,” by Timothy Bella

Sarah Karlin-Smith: Vox’s “Social Distancing Is a Luxury Many Can’t Afford. Vermont Actually Did Something About It,” by Julia Belluz

Alice Miranda Ollstein: The New York Timess “What 635 Epidemiologists Are Doing for Thanksgiving,” by Claire Cain Miller, Margot Sanger-Katz and Quoctrung Bui

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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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KHN’s ‘What the Health?’: What Would Dr. Fauci Do?

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Since the mid-1980s, whenever there’s been a public health crisis, America — and six U.S. presidents — have turned to Dr. Anthony Fauci. As director of the National Institute of Allergy and Infectious Diseases (one of the National Institutes of Health), Fauci has helped guide the U.S. and the world through the HIV/AIDS epidemic, as well as various flu epidemics and outbreaks of SARS, Ebola and Zika.

Now Fauci is facing the difficult task of navigating the turbulent waters between the outgoing Trump administration and incoming Biden administration in the midst of an escalating pandemic. As a member of the Trump administration’s COVID-19 task force, Fauci has taken heat from President Donald Trump and his supporters for delivering news and advice that does not match what the president wants to hear. And with the transition delayed because the federal government has not yet recognized Joe Biden as president-elect, Fauci is not free to meet with Biden’s team.

On this special episode of KHN’s “What the Health?” podcast, Fauci sits down for an interview with KHN Editor-in-Chief Elisabeth Rosenthal, a fellow physician. They explore the thorny political landscape and discuss how regular Americans should prepare to get through the coming months — as the pandemic surges and we wait for vaccines to become available.

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Facebook Live: Helping COVID’s Secondary Victims: Grieving Families and Friends

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The coronavirus pandemic has killed more than 246,000 people in the U.S., but it also has left hundreds of thousands of others grieving, and often feeling as if they have been robbed of the usual methods for dealing with the loss. For every person who dies of the virus, nine close family members are affected, researchers estimate. In addition to deep sadness, the ripple effects may linger for years as survivors deal with traumatic stress, anxiety, guilt and regret.

As the holidays approach, millions of people will be experiencing these losses afresh, as well as disruptions to comforting routines and beloved traditions.

Judith Graham, author of KHN’s Navigating Aging column, hosted a discussion on these unprecedented losses and dealing with the bereavement on Facebook Live on Monday. She was joined by Holly Prigerson, co-director of the Center for Research on End-of-Life Care at Weill Cornell Medicine in New York City, and Diane Snyder-Cowan, leader of the bereavement professionals steering committee of the National Council of Hospice and Palliative Professionals.

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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‘An Arm and a Leg’: For Your Next Health Insurance Fight, an Exercise in Financial Self-Defense

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A listener asked: ‘How do I remain cool when calling insurance companies?” So we called veteran self-defense teacher Lauren Taylor for advice. She leads Defend Yourself, an organization that works to empower people against violence and abuse. 

As Taylor teaches it, self-defense involves a lot more than hitting and kicking. It’s about standing up for yourself in all kinds of difficult situations. Striking that posture includes using your words, and we asked Taylor to talk us through her top strategies. This year, she used them in her own health insurance fight.

“An Arm and a Leg” is a co-production of Kaiser Health News and Public Road Productions.

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Clots, Strokes and Rashes: Is COVID a Disease of the Blood Vessels?

Whether it’s strange rashes on the toes or blood clots in the brain, the widespread ravages of COVID-19 have increasingly led researchers to focus on how the novel coronavirus sabotages blood vessels.

As scientists have come to know the disease better, they have homed in on the vascular system — the body’s network of arteries, veins and capillaries, stretching more than 60,000 miles — to understand this wide-ranging disease and to find treatments that can stymie its most pernicious effects.

Some of the earliest insights into how COVID-19 can act like a vascular disease came from studying the aftermath of the most serious infections. Those reveal that the virus warps a critical piece of our vascular infrastructure: the single layer of cells lining the inside of every blood vessel, known as the endothelial cells or simply the endothelium.

Dr. William Li, a vascular biologist, compares this lining to a freshly resurfaced ice rink before a hockey game on which the players and pucks glide smoothly along.

“When the virus damages the inside of the blood vessel and shreds the lining, that’s like the ice after a hockey game,” said Li, a researcher and founder of the Angiogenesis Foundation. “You wind up with a situation that is really untenable for blood flow.”

In a study published this summer, Li and an international team of researchers compared the lung tissues of people who died of COVID-19 with those of people who died of influenza. They found stark differences: The lung tissues of the COVID victims had nine times as many tiny blood clots (“microthrombi”) as those of the influenza victims, and the coronavirus-infected lungs also exhibited “severe endothelial injury.”

“The surprise was that this respiratory virus makes a beeline for the cells lining blood vessels, filling them up like a gumball machine and shredding the cell from the inside out,” Li said. “We found blood vessels are blocked and blood clots are forming because of that lining damage.”

It’s already known that the coronavirus breaks into cells by way of a specific receptor, called ACE2, which is found all over the body. But scientists are still trying to understand how the virus sets off a cascade of events that cause so much destruction to blood vessels. Li said one theory is that the virus directly attacks endothelial cells. Lab experiments have shown that the coronavirus can infect engineered human endothelial cells.

It’s also possible the problems begin elsewhere, and the endothelial cells sustain collateral damage along the way as the immune system reacts — and sometimes overreacts — to the invading virus.

Endothelial cells have a slew of important jobs; these include preventing clotting, controlling blood pressure, regulating oxidative stress and fending off pathogens. And Li said uncovering how the virus jeopardizes the endothelium may link many of COVID-19’s complications: “the effects in the brain, the blood clots in the lung and elsewhere in the legs, the COVID toe, the problem with the kidneys and even the heart.”

In Spain, skin biopsies of distinctive red lesions on toes, known as chilblains, found viral particles in the endothelial cells, leading the authors to conclude that “endothelial damage induced by the virus could be the key mechanism.”

Is Blood Vessel Damage Behind COVID Complications?

With a surface area larger than a football field, the endothelium helps maintain a delicate balance in the bloodstream. These cells are essentially the gatekeeper to the bloodstream.

“The endothelium has developed a distant early warning system to alert the body to get ready for an invasion if there’s trouble brewing,” said Dr. Peter Libby, a cardiologist and research scientist at Harvard Medical School. When that happens, endothelial cells change the way they function, he said. But that process can go too far.

“The very functions that help us maintain health and fight off invaders, when they run out of control, then it can actually make the disease worse,” Libby said.

In that case, the endothelial cells turn against their host and start to promote clotting and high blood pressure.

“In COVID-19 patients, we have both of these markers of dysfunction,” said Dr. Gaetano Santulli, a cardiologist and researcher at the Albert Einstein College of Medicine in New York City.

The novel coronavirus triggers a condition seen in other cardiovascular diseases called endothelial dysfunction. Santulli, who wrote about this idea in the spring, said that may be the “cornerstone” of organ dysfunction in COVID patients.

“The common denominator in all of these COVID-19 patients is endothelial dysfunction,” he said. “It’s like the virus knows where to go and knows how to attack these cells.”

Runaway Immune Response Adds a Plot Twist

A major source of damage to the vascular system likely also comes from the body’s own runaway immune response to the coronavirus.

“What we see with the SARS-CoV-2 is really an unprecedented level of inflammation in the bloodstream,” said Dr. Yogen Kanthi, a cardiologist and vascular medicine specialist at the National Institutes of Health who’s researching this phase of the illness. “This virus is leveraging its ability to create inflammation, and that has these deleterious, nefarious effects downstream.”

When inflammation spreads through the inner lining of the blood vessels — a condition called endothelialitis — blood clots can form throughout the body, starving tissues of oxygen and promoting even more inflammation.

“We start to get this relentless, self-amplifying cycle of inflammation in the body, which can then lead to more clotting and more inflammation,” Kanthi said.

Another sign of endothelial damage comes from analyzing the blood of COVID patients. A recent study found elevated levels of a protein produced by endothelial cells, called von Willebrand factor, that is involved in clotting.

“They are through the roof in those who are critically ill,” said Dr. Alfred Lee, a hematologist at the Yale Cancer Center who coauthored the study with Hyung Chun, a cardiologist and vascular biologist at Yale.

Lee pointed out that some autoimmune diseases can lead to a similar interplay of clotting and inflammation called immunothrombosis.

Chun said the elevated levels of von Willebrand factor show that vascular injury can be detected in patients while in the hospital — and perhaps even before, which could help predict their likelihood of developing more serious complications.

But he said it’s not yet clear what is the driving force behind the blood vessel damage: “It does seem to be a progression of disease that really brings out this endothelial injury. The key question is, what’s the root cause of this?”

After they presented their data, Lee said, Yale’s hospital system started putting patients who were critically ill with COVID-19 on aspirin, which can prevent clotting. While the best combinations and dosages are still being studied, research indicates blood thinners may improve outcomes in COVID patients.

Chun said treatments are also being studied that may more directly protect endothelial cells from the coronavirus.

“Is that the end-all-be-all to treating COVID-19? I absolutely don’t think so. There’s so many aspects of the disease that we still don’t understand,” he said.

COVID Is Often a Vascular ‘Stress Test’

Early in the pandemic, Dr. Roger Seheult, a critical care and pulmonary physician in Southern California, realized the patients he expected to be most vulnerable to a respiratory virus, those with underlying lung conditions such as chronic obstructive pulmonary disease and asthma, were not the ones ending up disproportionately in his intensive care unit. Seheult, who runs the popular medical education website MedCram, said, “Instead, what we are seeing are patients who are obese, people who have large BMIs, people who have Type 2 diabetes and with high blood pressure.”

Over time, all those conditions can cause inflammation and damage to the lining of blood vessels, he said, including a harmful chemical imbalance known as oxidative stress. Seheult said infection with the coronavirus becomes an added stress for people with those conditions that already tax the blood vessels: “If you’re right on the edge and you get the wind blown from this coronavirus, now you’ve gone over the edge.”

He said the extensive damage to blood vessels could explain why COVID patients with severe respiratory problems don’t necessarily resemble patients who get sick from the flu.

“They are having shortness of breath, but we have to realize the lungs are more than just the airways,” he said. “It’s an issue with the blood vessels themselves.”

This is why COVID patients struggle to fill their blood supply with oxygen, even when air is being pumped into their lungs.

“The endothelial cells get leaky, so instead of being like saran wrap, it turns into a sieve and then it allows fluid from the bloodstream to accumulate in the air spaces,” Harvard’s Libby said.

Doctors who treat COVID-19 are now keenly aware that complications such as strokes and heart problems can appear even after a patient gets better and their breathing improves.

“They are off oxygen, they can be discharged home, but their vasculature is not completely resolved. They still have inflammation,” he said. “What can happen is they develop a blood clot, and they have a massive pulmonary embolism.”

Patients can be closely monitored for these problems, but one of the big unknowns for doctors and patients is the long-term effects of COVID-19 on the circulatory system. The Angiogenesis Foundation’s Li puts it this way: The virus enters your body and it leaves your body. You might or might not have gotten sick. But is that leaving behind a trashed vascular system?”

This story is part of a partnership that includes 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?’: Transition Interrupted

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Five days after the election was called for President-elect Joe Biden, President Donald Trump has not conceded — and instead ordered his administration not to begin the transition of power. That could have serious ramifications for health care, particularly as nearly every state is experiencing a spike in COVID-19 cases.

One piece of good news is that early results for a coronavirus vaccine made by Pfizer look promising. But that vaccine, even if it is approved soon, won’t likely be ready for wide distribution for several months.

And for the third time in eight years, the Supreme Court heard a case that could invalidate the Affordable Care Act. Judging from the oral arguments, though, it appears the justices are likely to leave most or even all of the law intact.

This week’s panelists are Julie Rovner of Kaiser Health News, Joanne Kenen of Politico, Stephanie Armour of The Wall Street Journal and Shefali Luthra of the 19th News.

Among the takeaways from this week’s podcast:

  • The transition teams advising Biden cannot officially contact current government officials. But many team members have long-standing relationships with people in the government and were talking to those officials before the election, so they have a good sense of what is happening in the administration.
  • The pandemic further complicates the handoff. The new administration will need to hit the ground running to distribute any coronavirus vaccine, so communication with Trump administration officials would be beneficial for the Biden team.
  • Two members of Biden’s COVID task force, Drs. Vivek Murthy, former surgeon general, and David Kessler, former commissioner of the Food and Drug Administration, have been briefing the former vice president since March on the threats of the coronavirus.
  • Since Democrats may not control the Senate — and if they do have control, it will be by the slimmest majority — Biden may be forced to make changes to health policy through executive actions and regulations. That will limit his ambitions.
  • Still, even these smaller moves can have major results, such as allowing Planned Parenthood to again participate in federal health programs to expand the number of providers from which low-income women can seek care.
  • The Pfizer vaccine requires extremely cold temperatures for storage, complicating the logistics for distribution. It is an obstacle but not an insurmountable one for most areas in this country.
  • Supreme Court justices signaled this week they might not strike the Affordable Care Act in its entirety. Several of the conservatives, including Justice Brett Kavanaugh, who was appointed by President Donald Trump, suggested that any ruling that the mandate to have insurance is unconstitutional does not have to doom the rest of the law.

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

Julie Rovner: KHN and The Washington Post’s “In Medical Schools, Students Seek Robust and Mandatory Anti-Racist Training,” by Elizabeth Lawrence

Joanne Kenen: KHN’s “Trump’s Anti-Abortion Zeal Shook Fragile Health Systems Around the World,” by Sarah Varney

Stephanie Armour: KHN’s “Biden Plan to Lower Medicare Eligibility Age to 60 Faces Hostility From Hospitals,” by Phil Galewitz

Shefali Luthra: Stat News’ “With a Meteoric Rise in Deaths, Talk of Waves Is Misguided, Say Covid-19 Modelers,” by Elizabeth Cooney

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When False Information Goes Viral, COVID-19 Patient Groups Fight Back

For decades, people struggling with illnesses of all kinds have sought help in online support groups. This year, such groups have been in high demand for COVID-19 patients, who often must recover in isolation.

But the fear and uncertainty regarding the coronavirus have made online groups targets for the spread of false information. And to help fellow patients, some of these groups are making it a mission to stamp out misinformation.

Shortly after Matthew Long-Middleton got sick on March 12, he joined a COVID-19 support group run by an organization called Body Politic on the messaging platform Slack.

“I had no idea where this road leads, and so I was looking for support and other theories and some places where people were going through a similar thing, including the uncertainty,” said Long-Middleton, 36, an avid cyclist who lives in Kansas City, Missouri. His illness started with chest discomfort, then muscle weakness, high fever, loss of appetite and digestive problems. In addition to all the physical symptoms, the mystery weighed on him, making him feel like he and other patients “have to figure this out for ourselves.”

But with the support came misinformation. Group members reported taking massive amounts of vitamins — including vitamin D, which can be harmful in excess — or trying other home remedies not backed by science.

Experts warned that such false or unverified information spread on online support groups can not only mislead patients, but also potentially undermine trust in science and medicine in general.

“Even if we’re not actively seeking information, we encounter these kinds of messages on social media, and because of this repeated exposure, there’s more likelihood that it’s going to seep into our thinking and perhaps even change the way that we view certain issues, even if there’s no real merit or credibility,” said Elizabeth Glowacki, a health communication researcher at Northeastern University.

In an effort to help fellow COVID-19 sufferers, some patients, like Vanessa Cruz, spend most of their days fact-checking their online support groups.

“It’s really become like a second family to me, and being able to help everybody is a positive thing that comes out of all this negativity we’re experiencing right now,” Cruz said.

Cruz, a 43-year-old mother of two, moderates the Facebook COVID-19 support group called “have it/had it” from her home in the Chicago suburbs. She’s also a “long-hauler” who has been dealing with COVID-19 symptoms, including fatigue, fever and confusion, since March.

The worldwide group has more than 30,000 members and has recently been buzzing with reports from India about treating COVID-19 with a common tapeworm medication (it’s not FDA-approved and there’s little evidence it works) — as well as speculation about President Donald Trump’s recent diagnosis.

Other troubling posts include people pushing hydroxychloroquine, which has not been proved effective in treating COVID-19, and sharing the viral video “America’s Frontline Doctors,” which promotes other unproven treatments and spreads conspiracy theories.

Cruz said supporting fellow patients can be a tricky balance of getting the facts right but also giving people who are scared the chance to be heard.

“It’s like you really don’t know what to question, what to ask for, how to reach for help,” Cruz said. “Instead of doing that, they just write up their story, basically, and they share it with everybody.”

To keep the group evidence-based, it has built up a 17-person fact-checking team, which includes two nurses and a biologist. Someone on the team reviews every post that goes up.

However, many online COVID-19 groups don’t have the resources or strategy to address misinformation.

Mel Montano, a 32-year-old writing instructor who lives in New York and has also felt sick since March, said she left a large Facebook support group because she was frustrated by the conspiracy theories that filled its posts.

“All of these conflicting theories completely took away from the focal point of it,” Montano said. “It was a mess.”

Montano is now a moderator of the Body Politic group on Slack.

Facebook and Twitter have made changes in their approaches toward COVID-19 misinformation, including additional fact-checking, removing posts that contain falsehoods and removing users or groups that spread them.

However, critics say more changes are needed.

Fadi Quran, director of campaigns for Avaaz, a human rights group that focuses on disinformation campaigns, said Facebook needs to revise the way it prioritizes content.

“Facebook’s algorithm prefers misinformation, prefers the sensational stuff that’s going to get clicks and likes and make people angry,” Quran said. “And so the misinformation actors, because of Facebook, will always have the upper hand.”

A study by Avaaz showed that misinformation and disinformation had been viewed on Facebook four times as often as information from official health groups, like the World Health Organization.

Facebook did not respond to inquiries for this story.

COVID-19 patient Long-Middleton thinks the problem goes deeper than getting the data right. He said a lot of bad information is spread because patients so badly want to find ways to feel better.

After nearly six months of symptoms, Long-Middleton said he’s returned to better health in the past month, though he continues to check in on fellow support group members who are still struggling.

He never tried risky treatments discussed in the group himself, but he understands why someone might.

“You want to find hope, but you don’t want the hope to lead you down a path that hurts you,” he said.

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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‘No Mercy’ Chapter 7: After a Rural Town Loses Hospital, Is a Health Clinic Enough?

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Family physician Maxwell Self is doing his same old job for a new employer. For two decades he was a doctor with Mercy Hospital. But when Mercy packed up and left, a federally qualified health center moved to town — into the hospital building itself — and hired Dr. Self.

The Community Health Center of Southeast Kansas does things differently.

“What CHC says really has teeth and they’re solid,” Self said. “There’s real follow-through. And I have a lot more, I feel like, freedom to take care of people the way I want to and to get them what they need.”

With nutrition counseling and mental health and addiction services, and even things like arranging rides for patients, the center offers people what they need to be healthy, clinic executives said — not only health care for when they’re sick.

In the final chapter of the podcast, we also meet Sherise Beckham, 31, who lost work as a dietitian at Mercy when the hospital closed — just as she was expecting her second child.

“Initially, I cried a lot because I would be losing my job as well as losing a place to have my baby,” Beckham said.

Beckham helps explain how much more difficult it can be to have a baby when a town loses full-service maternity care. Then, later when she gets a job at — where else? — the new CHC clinic, Beckham gives us a front-row seat to the new vision for health care in Fort Scott.

“Where It Hurts” is a podcast collaboration between KHN and St. Louis Public Radio. Season One extends the storytelling from Sarah Jane Tribble’s award-winning series, “No Mercy.”

Subscribe to Where It Hurts on iTunes, Stitcher, Google, Spotify or Pocket Casts.

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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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KHN’s ‘What The Health?’: Change Is in the Air

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Assuming former Vice President Joe Biden becomes President-elect Joe Biden and Republicans retain control of the Senate, the health agenda could be very different from what Democrats campaigned on. A GOP Senate is unlikely to want to pursue many of Biden’s agenda items, including expanding eligibility for Medicare, boosting financial assistance for people who buy insurance under the Affordable Care Act, and creating a federal “public option” insurance plan.

Meanwhile, no matter who is elected, the ACA is on the line next week as the more conservative Supreme Court hears oral arguments in a case that could potentially result in its total overturn. A decision in that case is not expected until sometime next year.

This week’s panelists are Julie Rovner of Kaiser Health News, Joanne Kenen of Politico, Kimberly Leonard of Business Insider and Mary Ellen McIntire of CQ Roll Call.

Among the takeaways from this week’s podcast:

  • Republicans and Democrats on Capitol Hill might find common ground on some smaller — but important — issues, such as restricting surprise medical bills, which consumers get after they receive care from doctors outside their insurance network. But changes in the GOP committee chairs could dim current efforts to reduce prescription drug prices.
  • One issue that might have bipartisan support next year is enhancement of the public health system. The coronavirus pandemic has shown that parts of the system have deteriorated in recent years.
  • Democrats’ dreams of major gains in both the House and Senate failed to materialize Tuesday. That suggests that their arguments that Democrats would protect the ACA did not carry as much weight this year as they did in 2018, when the party saw success in midterm elections.
  • Although the campaign is over, there’s no clear indication that the debate on how to attack COVID-19 will become less politicized. The fear of another economic shutdown and the consequences of that for millions of Americans is driving strong — and very divided — public sentiment on the issue.
  • The Trump administration appeared to be seeking to enhance the president’s campaign in Georgia when it announced Sunday that it would allow the state to starkly revamp its offerings of ACA marketplace plans in a couple of years.

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

Julie Rovner: The New York Times’ “A New Item on Your Medical Bill: The ‘Covid’ Fee,” by Sarah Kliff and Jessica Silver-Greenberg

Joanne Kenen: PBS NewsHour’s “Amid COVID-19 Pandemic, Wisconsin Voters Choose Biden Over Trump,” by Laura Santhanam

Kimberly Leonard: The Wall Street Journal’s “States Hire Consultants for Covid-19 Help, With Mixed – and Expensive – Results,” by Jean Eaglesham and Kirsten Grind

Mary Ellen McIntire: The AP’s “Counties With Worst Virus Surges Overwhelmingly Voted Trump,” by Carla K. Johnson, Hanna Fingerhut and Pia Deshpande

To hear all our podcasts, click here.

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

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‘No Mercy’ Chapter 6: Trickle-Down Heartache Reaches the Next Generation in a Rural Town With No Hospital

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Josh is 17. He said he smokes marijuana. He struggles with anger.

He’s also juggling some extraordinary responsibilities for a teenager. Josh’s mother died of a drug overdose when he was 3 years old and he has lived with his grandparents ever since. When his grandfather’s heart started failing, Josh and his grandmother followed as his grandfather was shuttled from one regional hospital to another. The family couldn’t pay their light bill and struggled to find the money to pay for gas for the car. They wanted to stay nearby as Josh’s grandfather recovered in the hospital, but paying for a hotel was another financial burden.

Josh said he had to be there to help even though it meant missing school.

“I’m just taking care of my family. I’m doing what I was raised and taught to do,” he said. “Gotta survive. Family sticks together.”

To protect his privacy and because Josh was a minor when he shared his story, we are not including his last name.

In Chapter 6 of “No Mercy,” he talks about the health care challenges his family faces — and his own struggles growing up in a town where drugs are readily available but jobs aren’t.

The podcast also spotlights new health services now available in Fort Scott. Mercy Hospital, which closed at the end of 2018, did not provide addiction or behavioral health services, but the new community health center in town does.

“I get the privilege of working with hardworking, blue-collared folks and they oftentimes view, you know, depression, anxiety or bipolar disorder or battles with addiction as a weakness,” said Eric Thomason, director of addiction treatment and behavioral health services.

“And there’s no hardworking person that wants to just sit here and admit that they have a problem. And so a lot of times we avoid it. And what happens when we avoid chronic illness, regardless of if it’s diabetes, hypertension or depression, is it gets worse.”

Thomason said part of the health center’s work is convincing people to feel comfortable enough to come in and get help.

“Where It Hurts” is a podcast collaboration between KHN and St. Louis Public Radio. Season One extends the storytelling from Sarah Jane Tribble’s award-winning series, “No Mercy.”

Subscribe to Where It Hurts on iTunes, Stitcher, Google, Spotify or Pocket Casts.

And to hear all KHN podcasts, click here.

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

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They Work in Several Nursing Homes to Eke Out a Living, Possibly Spreading the Virus

To make ends meet, Martha Tapia works 64 hours a week at two Orange County, California, nursing homes. She is one of thousands of certified nursing assistants who perform the intimate and physical work of bathing, dressing and feeding the nation’s fragile elderly.

“We do everything for them. Everything you do for yourself, you have to do for the residents,” Tapia said.

And she’s one of many in that low-paid field, predominantly women of color, who work at more than one facility.

In March, when the coronavirus began racing through nursing homes, the federal government banned visitors. (That guidance has since been updated.) But even with the ban, infections kept spreading. A team of researchers from UCLA and Yale University decided to examine the people who continued to enter nursing homes during that time: the employees.

Keith Chen, a behavioral economist and UCLA professor, said the key question is this: “The people who, we can infer, work in this nursing home — what other nursing homes do they work at?”

Using location data from 30 million smartphones when the visitor ban was in place helped the scientists “see” the movements of people going into and out of nursing homes. The data showed a lot of nursing home workers are — like Tapia — working at more than one facility. Chen said the findings suggest that staffers who work in multiple nursing homes are one source of the spread of infections.

“When you learn that over 20 of your workers are also spending time in other nursing homes, that should be a real red flag,” Chen said.

The Toll on Patients and Beyond

More than 84,000 residents and staff members of nursing homes and other long-term care facilities have died of COVID-19 across the U.S., representing 40% of all coronavirus fatalities in the country, according to KFF’s most recent analysis. (KHN is an editorially independent program of KFF.)

In California, the analogous toll is more than 5,700 deaths, making up 35% of all coronavirus fatalities in the state.

The UCLA team created maps of movement and found that on average each nursing home is connected to seven others through staff movement. Limiting nursing home employees to one facility could mean fewer COVID-19 infections — but that would hurt the workforce of people who say they work multiple jobs because of low wages.

After each of her shifts, Tapia worries she’ll bring the coronavirus home to her granddaughter. She tries to take precautions, including buying N95 masks from nurses. She knows it’s not just patients who are at risk. Nursing home workers such as Tapia are also contracting COVID-19 — in California alone, 153 of them have died since the pandemic began.

At the nursing home where she works in the morning, Tapia gets an N95 mask that she must only use — and reuse — in that facility. At her other nursing home job, in the afternoons, she gets a blue surgical mask to wear.

“They say they cannot give us N95 [masks],” she said, because she works in the “general area” where residents haven’t tested positive for the coronavirus.

She doesn’t want to work at multiple nursing homes, but her rent in Orange County is $2,200 a month, and her low pay and limited hours at each nursing home make multiple jobs a necessity.

“I don’t want to get sick. But we need to work. We need to eat, we need to pay rent. That’s just how it is,” Tapia said.

Staff Connections Equal Infections

The UCLA study also found that some areas of the country have a much higher overlap in nursing home staffing than others.

“There are some facilities in Florida, in New Jersey, where they’re sharing upwards of 50 to 100 workers,” said UCLA associate professor Elisa Long, who, along with her colleagues, examined data during the federal visitor ban from March to May. “This is over an 11-week time period, but that’s a huge number of individuals that are moving between these facilities; all of these are potential sources of COVID transmission.”

They also found the more shared workers a nursing home has, the more COVID-19 infections among the residents.

“Not only does it matter how connected your nursing home is, but what really matters is how connected your connections are,” Long said.

The researchers say they’ve informally dubbed these highly connected nursing homes as each state’s “Kevin Bacon of nursing homes,” after the Six Degrees of Kevin Bacon parlor game.

“We found that if you’re going to see a nursing home outbreak anywhere, it’s likely to spread to the Kevin Bacon of nursing homes in each state,” Chen said.

The team hopes that local health departments could use similar cellphone data methods as an early warning system. Using the test results from the “Kevin Bacon of nursing homes” as an indicator would be the first step.

“As soon as you detect an outbreak in one nursing home, you can immediately prioritize those other nursing homes that you know are at increased risk,” Chen said.

Prioritize Masks and Hand-Washing

The California Association of Health Facilities represents most nursing homes in the Golden State. In response to the study, the group said its members can’t prevent workers such as Tapia from taking jobs elsewhere, and they can’t pay them more, because California doesn’t pay them enough through Medicaid reimbursements.

Mike Dark, an attorney with the California Advocates for Nursing Home Reform, doesn’t buy that argument. He said the state already tried paying nursing homes more in 2006 — and that made them more profitable but not more safe and efficient. He said he’s skeptical that extra funding to pay staff would reach those workers.

“We know from past experience that money tends to go into the pockets of the executives and administrators who run these places,” Dark said.

He agreed that health workers such as Tapia should be paid more but cautioned against one idea being floated in some policy circles: limiting workers to one nursing home.

“Then you can wind up depriving some of the crucial health caregivers that we have in these facilities of their livelihoods, which can’t be a good solution,” he said.

Instead, he said, regulators need to focus on the basics, especially in the 100 California nursing homes with ongoing outbreaks, since it’s been shown that infection control measures work.

“Right now there’s poor access to [personal protective equipment]. There’s still erratic compliance with things like hand-washing requirements,” he said. “If we spent more time addressing those key issues, there would be much less concern about spread between facilities.”

Jackie Fortiér is health reporter for KPCC and LAist.com. This story is part of a partnership that includes KPCC, NPR and Kaiser Health News.

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

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‘An Arm and a Leg’: David vs. Goliath: How to Beat a Big Hospital in Small Claims Court

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When Jeffrey Fox and his wife got an outrageous medical bill for a simple test, he said to his wife, “No way am I paying this.” In a classic — and hilarious — David vs. Goliath story, Fox takes on a huge hospital, and wins.

He’s a bit of an expert in using small claims court to get satisfaction and shared detailed instructions with the rest of us.

Fox doesn’t only take on big opponents. He said even his small wins are a way to get better at standing up for himself.

It’s pretty good practice for us all.

Want more? Here are some extras:

Our episode Can They Freaking DO That?!? describes how some folks have used just the threat of small claims court to get outrageous bills lowered.

Law professor Christopher Robertson describes some of the legal theory behind this method in this post from a Harvard Law School blog.

Fox posted documents from his case and a brief narrative.

Finally, here’s this episode transcript.

“An Arm and a Leg” is a co-production of Kaiser Health News and Public Road Productions.

To keep in touch with “An Arm and a Leg,” subscribe to the newsletter. You can also follow the show on Facebook and Twitter. And if you’ve got stories to tell about the health care system, the producers would love to hear from you.

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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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KHN’s ‘What the Health?’: As Cases Spike, White House Declares Pandemic Over

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White House chief of staff Mark Meadows said this week that “we’re not going to control the pandemic,” effectively conceding that the administration has pivoted from prevention to treatment. But COVID-19 cases are rising rapidly in most of the nation, and the issue is playing large in the presidential campaign. President Donald Trump is complaining about the constant news reports about the virus, prompting former President Barack Obama to say Trump is “jealous of COVID’s media coverage.”

Meanwhile, as the case challenging the constitutionality of the Affordable Care Act heads to the Supreme Court on Nov. 10, open enrollment for individual health insurance under the law begins Sunday.

This week’s panelists are Julie Rovner of Kaiser Health News, Joanne Kenen of Politico, Tami Luhby of CNN and Anna Edney of Bloomberg News.

Among the takeaways from this week’s podcast:

  • Whichever candidate wins the presidency next week will have a heavy lift in mounting a strong public response to battle COVID-19. Polls suggest about a third of people do not believe some of the basic science about the virus or its prevention, such as that using masks can help stem transmission.
  • Dr. Scott Gottlieb, who once served as Food and Drug Administration commissioner under Trump, called for a temporary national mask mandate in his column in The Wall Street Journal. He suggested that masks should not be a political issue.
  • Gottlieb’s column has been supported by other commentators who suggest that masks need to become a social and cultural norm and compare the debate over their use to similar debates in the past about seat belts, smoking bans and harsh punishments for driving while intoxicated. Those measures all faced opposition from people who complained about civil liberties but gradually became accepted. The difference now is that public health advocates are looking for a quick acceptance of masks.
  • Part of the resistance to wearing face masks is that many people don’t understand their purpose and presume masks are for their own protection. But public health officials advocate masks as a way to protect others, especially vulnerable people, from any virus a mask wearer might shed, often without even realizing it.
  • Drugmakers and health experts are rolling back expectations about the timing of a COVID vaccine as the trials seek more data. One issue may be that not enough people in the placebo groups have contracted the coronavirus. That could be because people who volunteer for such an endeavor may be more aware of health issues and cautious about the disease.
  • Once a vaccine is approved, FDA and other federal health officials will face a number of complicating issues. Among them: How should trials of other vaccine candidates continue and how should the vaccine be distributed?
  • Enrollment for insurance plans on the Affordable Care Act’s marketplaces begins Sunday, but many consumers could be forgiven for not knowing that. There is precious little marketing or advertising for the plans, and some people think the Supreme Court is going to overturn the ACA, anyway, and its plans will go away. That’s not known yet and it may well be summer 2021 before there is an answer on that.

Also this week, Rovner interviews KHN’s Anna Almendrala, who reported the latest NPR-KHN “Bill of the Month” installment, about a patient who did everything right and got a big bill anyway. If you have an outrageous medical bill you would like to share with us, you can do that here.

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

Julie Rovner: The New York Times’ “A Chance to Expand Medicaid Rallies Democrats in Crucial North Carolina,” by Abby Goodnough

Joanne Kenen: The New Yorker’s “A President Looks Back on His Toughest Fight,” by Barack Obama

Tami Luhby: KHN’s “Florida Fails to Attract Bidders for Canada Drug Importation Program,” by Phil Galewitz

Anna Edney: The Wall Street Journal’s “Health Agency Halts Coronavirus Ad Campaign, Leaving Santa Claus in the Cold,” by Julie Wernau, James V. Grimaldi and Stephanie Armour

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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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As Anxieties Rise, Californians Buy Hundreds of Thousands More Guns

Handgun sales in California have risen to unprecedented levels during the COVID-19 pandemic, and experts say first-time buyers are driving the trend.

The FBI conducted 462,000 background checks related to handgun purchases in California from March through September, an increase of 209,000, or 83%, from the same period last year. That’s more than in any other seven-month period on record.

People who study gun ownership think the increase means more people are buying guns for the first time. Handguns, as opposed to rifles and shotguns, are often the first firearm purchase made by someone looking for protection.

Background checks related to long gun or other gun sales also rose statewide, by 110,000, or 54%, from March through September compared with the same period in 2019. While that increase is steep, it does not match the rise in long gun sales seen in California during periods, often following mass shootings, when state leaders have considered legislation to sharply rein in access to military-style assault rifles.

In California, background checks for handguns and long guns correlate with gun sales, federal and state data show. Other states have purchasing systems that can result in a disconnect between background checks and sales.

Even so, the national numbers are startling: The FBI conducted about 7.7 million background checks related to handgun sales from March through September, an increase of 3.9 million, or 104%, from the same period in 2019.

Gun rights activists, gun control supporters and public health experts largely agree that the increase in gun sales is driven by fear, uncertainty and longing for a greater sense of protection.

Some Californians worry about dark fallout from pervasive unemployment and a faltering economy. Others are disconcerted by the angry and sometimes destructive protests over police shootings and pandemic lockdowns. The upcoming election has added to the unease.

“Every dealer I know has a very low inventory of guns. They’re backlogged for months in filling orders because of this run on guns,” said Sam Paredes, executive director of Gun Owners of California, which advocates for fewer restrictions on gun purchases. “Every one of them, the first thing they say is, ‘Sam, you will not believe how many new gun buyers we have.’”

With about 3,000 firearm-related deaths occurring each year in California and 40,000 nationwide, gun ownership is increasingly viewed through the lens of public health. Several studies have drawn a connection between gun ownership and gun-related deaths.

Researchers at UC-Davis’ Violence Prevention Research Program said they are particularly concerned about the latest surge in sales, since many buyers appear to be introducing a gun into their home for the first time.

“There are obvious and well-documented risks associated with [going from] having no access to a firearm to having access to a firearm,” said Julia Schleimer, a data analyst with the UC-Davis program. “That extends to all household members, not just the person who owns the gun. And that’s for suicide, homicide, unintentional injury — basically for everyone, children included.”

Schleimer and her colleagues recently published a study examining the effects of the rise in gun sales during the pandemic. Using national data from the Gun Violence Archive, the study estimated that additional gun sales accounted for nearly 800 excess firearm injuries and deaths during assaults from March through May.

Recent FBI statistics show a rise in homicides and aggravated assaults, crimes often committed with guns, in large California cities and across the nation in the first half of 2020.

Dr. Garen Wintemute, director of the UC-Davis violence prevention program, is among the experts concerned about the connection between gun sales and a rise in domestic violence incidents as families have been forced to shelter together amid pandemic-related quarantines and shutdowns.

“If a firearm is involved, risk that intimate partner violence will have a fatal outcome goes up by a factor of five,” Wintemute said.

U.S. firearm suicide rates rose for several years leading up to 2020. Public health advocates fear that the mental strain of the pandemic combined with access to more guns will only exacerbate that trend.

“People have been cooped up and under tension with anxiety and depression,” said Dr. Bill Durston, president of Americans Against Gun Violence. “Adding a gun to that is like adding gasoline to a fire.”

For now, preliminary data does not show an increase in suicides in California during the pandemic. There were 1,621 suicides in California from March through July, down from 1,930 the year before, according to the California Department of Public Health.

It may be years before the full effects of the increase in gun sales during the pandemic are clear. In California, six of the top 10 months for background checks related to handgun sales have occurred during the pandemic. More than 60,000 handgun background checks were sold in September alone, double the number from September 2019.

Paredes said some dealers tell him more than 70% of their buyers are new customers. People “find themselves in a position where they’re thinking, ‘What might be the next step with the pandemic?’ That they might have to protect themselves in their own homes,” he said.

Even when the pandemic begins to taper off, Paredes expects the impact on gun sales to linger as first-time buyers become second- and third-time buyers.

“We will continue to see an increase,” he said, “because you’re going to have millions of people out there who are now going to experience guns.”

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



This KHN story first published on California Healthline, a service of the California Health Care Foundation.

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

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‘No Mercy’ Chapter 5: In Rural America, Cancer Care Is Often Far From Home

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Sixty-five-year-old Karen Endicott-Coyan is living with a blood cancer.  Her chemotherapy takes less than 30 minutes. Before the hospital closed, it was just a short drive into the small town of Fort Scott, Kansas, for her to get treatment.

But these days getting to chemo means a trek on rural roads and narrow highways, driving help from her sister-in-law and some Ritz crackers tucked into her purse to steady her stomach on the way home. The whole trip should take less than three hours. Endicott-Coyan puts on her makeup, her diamond earrings and powers through.

“If I can help it, I’m not going to go over there looking like a sick person,” Endicott-Coyan said. “I don’t like looking like a sick person. That’s just me.”

Endicott-Coyan had a long career in hospital administration, and she uses that expertise to try to smooth out her newly fractured health care. But during every minute of the trip, a nagging worry at home steals her energy and attention. In this chapter of the podcast, host-reporter Sarah Jane Tribble goes along for the ride and is witness to the stress and frustration.

The journey illuminates one reason people in rural America are more likely to die from cancer than patients in metro areas.

Click here to read the episode transcript.

“Where It Hurts” is a podcast collaboration between KHN and St. Louis Public Radio. Season One extends the storytelling from Sarah Jane Tribble’s award-winning series, “No Mercy.”

Subscribe to Where It Hurts on iTunes, Stitcher, Google, Spotify or Pocket Casts.

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KHN’s ‘What the Health?’: A Little Good News and Some Bad on COVID-19

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For the first time in a long time, there is some good news about the coronavirus pandemic: Although cases continue to climb, fewer people seem to be dying. And there are fewer cases than expected among younger pupils in schools with in-person learning. But the bad news continues as well — including a push for “herd immunity” that could result in the deaths of millions of Americans.

Meanwhile, the Trump administration is doubling down on efforts to allow states to require certain people with low incomes to prove they work, go to school or perform community service in order to keep their Medicaid health benefits. The administration is appealing a federal appeals court ruling to the Supreme Court and just granted Georgia the right to impose a work requirement.

This week’s panelists are Julie Rovner of Kaiser Health News, Margot Sanger-Katz of The New York Times, Paige Winfield Cunningham of The Washington Post and Alice Miranda Ollstein of Politico.

Among the takeaways from this week’s podcast:

  • Opinions seem to be slowly shifting on opening schools around the country. As fall approached, many people were hesitant to send their children back to school because they feared a resurgence of coronavirus infections, but early experiences seem to show that there has been little transmission among young kids in classrooms.
  • Even with good results in those school districts that have reopened, however, the debate about whether schools should be conducting in-person learning is quite polarized. President Donald Trump repeatedly calls for all schools to resume, while groups, such as unions representing teachers and other employees, are more likely to be calling for continued online learning.
  • California, which had a strong resurgence of the virus during the summer, is seeing signs of success in fighting back. The state has been among the most aggressive in shutting down normal activities to reduce case levels. It devised a county-specific method to determine closures, restrictions and reopenings — and it appears to be working.
  • A proposal by some researchers to move the country toward a “herd immunity” plan, in which officials would expect the virus to spread among the general population while also trying to protect the most vulnerable — such as people living in nursing homes — is gaining support among some of Trump’s advisers. Public health advocates are raising alarms because it would likely lead to hundreds of thousands more deaths. They also fear the administration’s focus on restoring normalcy would by default move in this direction.
  • Federal researchers this week announced that nearly 300,000 excess deaths have been recorded this year and much of it is attributed to COVID-19 or the lack of other health care by people who could not or did not seek treatments because they were frightened by the pandemic.
  • With the Senate poised to confirm Amy Coney Barrett, who opposes abortion, to the Supreme Court within days, the fate of the landmark Roe v. Wade decision is in question. If the court overruled that decision, abortion policies would likely fall back to individual states. A recent report on the effects of such a scenario finds that a huge swath of the South and the Midwest would be left without a local facility offering abortion services.

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

Julie Rovner: Cook’s Illustrated’s “The Best Reusable Face Masks,” by Riddley Gemperlein-Schirm, and The Washington Post’s “Consumer Masks Could Soon Come With Labels Saying How Well They Work,” by Yeganeh Torbati and Jessica Contrera

Margot Sanger-Katz: The Hill’s “Republicans: Supreme Court Won’t Toss ObamaCare,” by Peter Sullivan

Paige Winfield Cunningham: The Wall Street Journal’s “Some California Hospitals Refused Covid-19 Transfers for Financial Reasons, State Emails Show,” by Melanie Evans, Alexandra Berzon and Daniela Hernandez

Alice Miranda Ollstein: ProPublica’s “Inside the Fall of the CDC,” by James Bandler, Patricia Callahan, Sebastian Rotella and Kirsten Berg

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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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‘No Mercy’ Chapter 4: So, 2 Nuns Step Off a Train in Kansas … A Hospital’s Origin Story

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Ever since Mercy Hospital went “corporate,” things just haven’t been the same — that’s what lots of locals in Fort Scott, Kansas, said when the Mercy health system shuttered the only hospital in town.

It’s been years since Catholic nuns led Mercy Hospital Fort Scott, but town historian Fred Campbell is wistful for his boyhood in the 1940s when sisters in habits walked the hallways.

“Well, I had never, ever been in a hospital. And here came these ladies in flowing robes and white bands around their faces. And I was scared to death. But it wasn’t long ’til I found that, first thing I know, they had some iced Coca-Cola. I still remember them putting their hand on my head to see if I had a fever.”

For more than 100 years, Mercy Hospital — and the nuns who started it all — cared for local people. But in recent years, Fort Scott’s economy and the hospital’s finances faltered. Campbell hoped both could survive.

“Mercy Corporation, can you stay with us longer?” he wondered.

In Chapter 4 of Season One: No Mercy, podcast host Sarah Jane Tribble carries that question to Sister Mary Roch Rocklage, the powerhouse who consolidated all the Mercy hospitals in the Midwest.

Click here to read the episode transcript.

“Where It Hurts” is a podcast collaboration between KHN and St. Louis Public Radio. Season One extends the storytelling from Sarah Jane Tribble’s award-winning series, “No Mercy.”

Subscribe to Where It Hurts on iTunes, Stitcher, Google, Spotify or Pocket Casts.

And to hear all KHN podcasts, click here.

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

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‘An Arm and a Leg’: Vetting TikTok Mom’s Advice for Dealing With Debt Collectors

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TikTok mom Shaunna Burns used to be a debt collector, so she knows a few things about what’s legal and what’s not when a company contacts you to settle a debt. We fact-checked her advice with a legal expert: Jenifer Bosco, an attorney with the National Consumer Law Center.

Bosco said most of Burns’ advice totally checks out.

A recent report from ProPublica shows that debt collectors have thrived during the pandemic; they’re out in force to get people to pay up. But we have rights. Scroll down for some consumer protection resources.

You don’t need to have heard our earlier episode about Burns and her story; you can start right here. (Both conversations contain lots of strong language, so maybe listen when the kids aren’t around.)

Meanwhile, here are links to resources:

Burns’ Dealing-With-Debt-Collectors TikTok Videos

Be sure to note Jen Bosco’s legal caveats, but Burns will get you in the fighting spirit.

“An Arm and a Leg” is a co-production of Kaiser Health News and Public Road Productions.

To keep in touch with “An Arm and a Leg,” subscribe to the newsletter. You can also follow the show on Facebook and Twitter. And if you’ve got stories to tell about the health care system, the producers would love to hear from you.

To hear all Kaiser Health News podcasts, click here.

And subscribe to “An Arm and a Leg” on iTunesPocket CastsGoogle Play or Spotify.

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?’: Democrats May Lose on SCOTUS, But Hope to Win on ACA

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Republicans appear to be on track to confirm Judge Amy Coney Barrett to the Supreme Court before Election Day, cementing a 6-3 conservative majority on the high court regardless of what happens Nov. 3. Democrats, meanwhile, lacking the votes to block the nomination, used the high-profile hearings to batter Republicans for trying to overturn the Affordable Care Act.

Meanwhile, a number of scientific journals that typically eschew politics, including the prestigious New England Journal of Medicine, threw their support to Democratic presidential candidate Joe Biden, citing what they call the Trump administration’s bungling of the coronavirus pandemic.

This week’s panelists are Julie Rovner of Kaiser Health News, Mary Ellen McIntire of CQ Roll Call, Shefali Luthra of The 19th and Sarah Karlin-Smith of Pink Sheet.

Among the takeaways from this week’s podcast:

  • The lack of progress on a bipartisan coronavirus relief package is making both Democrats and Republicans nervous as they approach Election Day without something to help voters.
  • During hearings on the nomination of Judge Amy Coney Barrett for the Supreme Court, Democrats were consistently on message, seeking to focus public attention before the election on the threat that Republicans pose to the Affordable Care Act as the law goes before the court next month. Four members of the Senate Judiciary Committee, which will vote on the nomination, are up for reelection. Also on the committee is Sen. Kamala Harris, the Democrats’ vice presidential candidate.
  • The public health optics of the hearing were jarring for some viewers. Although the committee chairman said the room was set up to meet federal health guidelines, Republican senators often did not wear masks, including Sens. Thom Tillis (N.C.) and Mike Lee (Utah), who both were diagnosed with COVID-19 after attending a White House celebration for Barrett.
  • The lack of masks could add to confusion about public health messages. And voters sometimes find it insulting that politicians play down risks that the public is called upon to assume.
  • Barrett’s testimony did not change many perceptions of her. Although she was extremely careful not to reveal her personal views on issues that could come before the court, including the ACA and abortion, both Democrats and Republicans highlighted her strong conservative credentials.
  • Scientific American and the New England Journal of Medicine have published stinging critiques of the current administration’s policies on science and medicine. Although it’s not clear what impact the editorials will have, they are a sign of the further politicization of public health.

This week, Rovner also interviews Dr. Ashish Jha, dean of the Brown University School of Public Health. Jha talked about the challenges public health professionals have faced in trying to deal with the COVID-19 pandemic.

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

Julie Rovner: The Atlantic’s “How to Tell If Socializing Indoors Is Safe,” by Olga Khazan

Shefali Luthra: The New York Times’ “A $52,112 Air Ambulance Ride: Coronavirus Patients Battle Surprise Bills,” by Sarah Kliff

Mary Ellen McIntire: KHN’s “Making Money Off Masks, COVID-Spawned Chain Store Aims to Become Obsolete,” by Markian Hawryluk

Sarah Karlin-Smith: Politico’s “Health Officials Scrambling to Produce Trump’s ‘Last-Minute’ Drug Cards by Election Day,” by Dan Diamond

Also mentioned in this week’s podcast:

Bill of the Month update: KHN’s “Moved by Plight of Young Heart Patient, Stranger Pays His Hospital Bill,” by Laura Ungar

Scientific journal endorsements: The New England Journal of Medicine’s “Dying in a Leadership Vacuum

Scientific American Endorses Joe Biden,” by The Editors

To hear all our podcasts, click here.

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

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COVID Crackdowns at Work Have Saved Black and Latino Lives, LA Officials Say

Los Angeles County officials attribute a dramatic decline in COVID-19 death and case rates among Blacks and Latinos over the past two months to aggressive workplace health enforcement and the opening of tip lines to report violations.

Now, officials intend to cement those gains by creating workplace councils among employees trained to look for COVID-19 prevention violations and correct or report them — without fear of being fired or punished.

Cal/OSHA, the state’s workplace safety and health authority, is overwhelmed with complaints and tips about COVID-19 violations, and the county’s health investigators — there were officially 346 of them as of last Friday — can’t possibly keep tabs on all of Los Angeles’ more than 240,000 businesses, labor advocates say.

The councils could help keep Los Angeles from backsliding on its progress in mitigating cases and racial disparities in the fall as more businesses are likely to reopen, said Tia Koonse, a researcher with the UCLA Labor Center and co-author of an assessment of the workplace council proposal. The L.A. County Board of Supervisors is expected to approve an ordinance this month requiring businesses to permit employees to form the councils, which would troubleshoot compliance issues and report to the health department when necessary.

Critics, including many business leaders, say the measure will create more red tape at the worst possible time for the economy. But labor groups and some businesses say it is crucial to fighting the pandemic. Workers around the country have been sacked or reprimanded for complaining about COVID-related safety violations, and laws protecting them are spotty.

“Workers have a right to be in a safe space and shouldn’t face any retaliation” for noting poor practices, said Barbara Ferrer, director of the L.A. County Public Health Department. Low-wage workers have been “tremendously disadvantaged” by having to work outside the home in contact with other people, often without sufficient protection, she said.

During the upsurge of COVID cases that followed Memorial Day weekend family gatherings and business openings, Latinos in Los Angeles were dying at a rate more than four times higher than that of whites, while Blacks were twice as likely as whites to die of the disease. Two months later, death rates among Blacks and Latinos had fallen by more than half and were approaching the rate for whites, according to age-adjusted data from the county health department.

While four times as many Latinos as whites were reported COVID-positive in late July, the Latino case rates were only 64% higher by mid-September. The positivity rate among Blacks was 60% higher than that of whites in late July, but the disparity had waned by mid-September.

Experts can’t be certain that any one policy is responsible for the decline in deaths among Blacks and Latinos in Los Angeles — and state and county rates have declined for the entire population in recent weeks. But Ferrer attributed the progress to her department’s focus on workplace enforcement of health orders, which include rules about physical distancing, providing face coverings for workers and requiring face coverings for customers.

“If you’re in violation, at this point we can either issue citations, or there are cases where we just close the place down because the violations are egregious,” she said.

The sharp racial disparities that characterized the pandemic from the beginning are under even more scrutiny now that California has become the first state to make “health equity” a factor in its decisions to allow expanded reopening.

Large counties may not advance toward full reopening until their most disadvantaged neighborhoods, and not just the county as a whole, meet or are lower than the targeted levels of disease. The criteria prod local governments to invest more in testing, contact tracing and education in poor neighborhoods with high levels of the disease.

Ferrer’s focus on workplaces crystallized during a crackdown on Los Angeles Apparel, a clothing factory that had pivoted to face mask manufacturing during the pandemic. Despite the ready inventory of masks, an outbreak at the factory resulted in at least 300 cases — and four deaths.

The health department, acting on a tip from community health centers flooded with sick Los Angeles Apparel workers, shut down the factory on June 27. That action highlighted the need to bring the government and labor unions together to fight the pandemic, said Jim Mangia, CEO of St. John’s Well Child & Family Center, a chain of community health centers in South L.A.

“At St. John’s, almost all of our patients are the working poor,” Mangia said. “They were getting infected at work and bringing it home to their families, and I think intervening at the workplace is what really made all the difference.”

Early in the pandemic, Ferrer had also set up an anonymous complaint line for employees who want to report workplace violations. It gets about 2,000 calls a week, she said. As of Oct. 10, the department’s website lists 132 workplaces that have had three or more confirmed COVID-19 cases, with a total of 2,191 positives. Another table dated Oct. 7 lists 124 citations — mostly to gyms and places of worship — for failing to comply with a health officer order.

“Fortunately, we’re not like Cal/OSHA, in the sense that it doesn’t take us months to complete an investigation,” Ferrer said. “We’re able to move more swiftly under the health officer orders to actually make sure that we’re protecting workers.”

Public health councils are the next phase in Ferrer’s plan to keep workers safe. The plan stemmed from the response of Overhill Farms, a frozen-food factory in Vernon, California, after an outbreak of more than 20 cases and one death. The factory and its temporary job agency were hit with more than $200,000 in proposed penalties from Cal/OSHA in September, but before the fines landed, the factory leadership was already responding by beginning to hold meetings with workers to improve safety there.

“They found that the workers helped them bring down infection rates and helped solve problems,” said Roxana Tynan, executive director of the Los Angeles Alliance for a New Economy, a worker advocacy organization.

While it’s not exactly a feel-good story about corporate beneficence, the turnaround at Overhill Farms added credence to the benefits of workplace councils, said Koonse of UCLA.

No company would have to spend more than 0.44% of its payroll cost on the health councils, she estimated.

Still, the idea has gotten a mixed reception from businesses. In an Aug. 24 statement, CEO Tracy Hernandez of the L.A. County Business Federation wrote that the proposal would add “burdensome and convoluted programs that will further hinder an employer’s ability to meet demands, get back on their feet, and adequately serve their employees and customers.”

But Jim Amen, president of the eight-store Super A Foods grocery chain, said businesses should welcome the councils as a way to keep lines of communication open. Such practices have kept infection rates low at his stores, even without a mandate, Amen said.

“All I know is, for Super A, our employees are heavily involved in everything we do,” Amen said.

Labor groups see the councils as a crucial way for workers to raise concerns without fear of retaliation.

“In low-wage industries like the garment industry, workers coming together gets them fired,” said Marissa Nuncio, director of the Garment Worker Center, a nonprofit that mainly serves immigrants from Mexico and Central America.

While disparities are narrowing in L.A. County, some shops are still unsafe and potential whistleblowers aren’t confident their reports to the county’s tip line are being acted on, she said.

“We continue to get calls from our members who are sick, have COVID and are hospitalized,” Nuncio said. “And the most obvious location for them to have been infected is in their workplace, because so many precautions are not being taken.”

KHN data reporter Hannah Recht contributed to this article.

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

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KHN’s ‘What the Health?’: Trump vs. COVID

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President Donald Trump’s COVID-19 diagnosis — and that of two dozen or more other officials in the White House and Capitol Hill — has scrambled an already confusing autumn. The president’s illness has thrown into doubt the remaining two presidential debates, and positive tests for several Republican senators may threaten the effort to push through a new Supreme Court justice before Election Day.

Meanwhile, it looks increasingly unlikely Congress will approve another round of economic relief before the election, even though that would be good for the president’s political fortunes and could help Democrats, too. And the Food and Drug Administration and the Centers for Disease Control and Prevention continue to fight for scientific credibility.

This week’s panelists are Julie Rovner of Kaiser Health News, Alice Miranda Ollstein of Politico, Kimberly Leonard of Business Insider and Erin Mershon of Stat News.

Among the takeaways from this week’s podcast:

  • Trump’s physician, Dr. Sean Conley, has been heavily criticized for his lack of transparency about the president’s health while battling the coronavirus. Conley repeatedly said federal rules under the HIPAA law limited his ability to answer reporters’ questions. That’s because HIPAA (the Health Insurance Portability and Accountability Act of 1996) requires a patient’s consent to release medical information.
  • Nonetheless, Trump’s COVID diagnosis renews questions about whether the public has a right to know the details of a president’s health status, especially this year when both candidates are older than 70. Trump’s opponent, former Vice President Joe Biden, has released only limited information, too.
  • Trump’s decision to unilaterally call off negotiations on a coronavirus relief package baffled and concerned Republican lawmakers and strategists because it undermines their narrative that the Democrats have refused to budge during talks.
  • Although the president has said he would support smaller stimulus bills that would help specific industries or consumers, it’s not clear what Congress would be willing to push out before the election. So, many Republican lawmakers are turning their attention to the upcoming hearings on the Supreme Court nomination of Amy Coney Barrett to rally support.
  • The widespread cases of COVID-19 tied to the White House highlight the president’s messages about masks, social isolation and other protective measures and have the potential to alienate voters, especially those who have lost loved ones or know people who have been afflicted with the disease.
  • Trump’s comments after coming home from the hospital urging the public to not be afraid of the virus or let it “dominate your life” have tapped into frustration by many people who have suffered from the economic consequences of the pandemic and are eager to put the issue behind them.
  • In the vice presidential debate Wednesday, Democratic Sen. Kamala Harris was criticized by Vice President Mike Pence for undermining public confidence in a vaccine when she said she wouldn’t take it if it were being pushed by Trump and not endorsed by public health officials. It’s a tricky issue for Democrats who believe Trump is using the vaccine trials to generate political support and his promise of approval by Election Day is politicizing the process. Yet, they know the public is eager for a successful vaccine.

This week, Rovner also interviews Amy Howe, co-founder of SCOTUSblog and host of the “SCOTUStalk” podcast. Howe explains what the Supreme Court might do with the latest case challenging the constitutionality of the Affordable Care Act.

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

Julie Rovner: The Atlantic’s “Trump’s Doctor Comes From a Uniquely American Brand of Medicine,” by Eleanor Cummins

Alice Miranda Ollstein: The New York Times’ “How Much Would Trump’s Coronavirus Treatment Cost Most Americans?” by Sarah Kliff

Kimberly Leonard: Business Insider’s “Meet the 30 Leaders Under 40 Who Are Transforming the Future of Hhealthcare in 2020,” by Lydia Ramsey Pflanzer

Erin Mershon: Kaiser Health News’ “Not Pandemic-Proof: Insulin Copay Caps Fall Short, Fueling Underground Exchanges,” by Markian Hawryluk

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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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‘No Mercy’ Chapter 2: Unimaginable, After a Century, That Their Hospital Would Close

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Closing a hospital hurts. In Fort Scott, Kansas, no one was a bigger symbol for that loss — or bigger target for the town’s anger — than hospital president Reta Baker. Baker was at the helm when the hospital doors closed.

“I don’t even like going out in the community anymore, because I get confronted all the time,” Baker said. “Someone confronted me at Walmart. You know — ‘How could you let this happen?’”

The closure put Baker at bitter odds with City Manager Dave Martin, who some in town call “the Little Trump” of Fort Scott. Martin said his town wasn’t given the chance to keep the hospital open.

Click here to read the episode transcript.

“Where It Hurts” is a podcast collaboration between KHN and St. Louis Public Radio. Season One extends the storytelling from Sarah Jane Tribble’s award-winning series, “No Mercy.”

Subscribe to Where It Hurts on iTunes, Stitcher, Google, Spotify or Pocket Casts.

And to hear all KHN podcasts, click here.

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

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‘An Arm and a Leg’: TikTok Mom Takes On Medical Bills

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Shaunna Burns went viral on TikTok, partly because of a series of videos dishing out real-talk advice on fighting outrageous medical bills. She said the way to deal with medical debt is to be vigilant about what debt you incur in the first place.

“What you can say is I don’t want you to run any tests or do any procedures or anything without running it by me,” she said.

Burns has three children of her own, and she has become the virtual mom that thousands of Gen Z followers love. She’s funny, smart and relatable — and she has stories that’ll make your hair stand on end. Oh, and she can swear like a sailor. So maybe listen to this episode when the kids aren’t around. Also, some of her stories are kind of intense.

(You can first check the transcript to see if this episode is one you want to share with your kids.)

“An Arm and a Leg” is a co-production of Kaiser Health News and Public Road Productions.

To keep in touch with “An Arm and a Leg,” subscribe to the newsletter. You can also follow the show on Facebook and Twitter. And if you’ve got stories to tell about the health care system, the producers would love to hear from you.

To hear all Kaiser Health News podcasts, click here.

And subscribe to “An Arm and a Leg” on iTunesPocket CastsGoogle Play or Spotify.

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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Watch: Young Man Faces Medical Bankruptcy — Even With Insurance

“CBS This Morning” tells the story of Matthew Fentress, a young man who developed serious heart disease after a bout of flu when he was just 25. Now 31, he owes more than $10,000 in hospital bills. KHN Editor-in-Chief Elisabeth Rosenthal explains that the same cardiomyopathy Fentress got can also be a complication of COVID-19.

Fentress’ story is the latest in the ongoing crowdsourced Bill of the Month investigation, a collaboration with KHN, NPR and “CBS This Morning.”

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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Evictions Damage Public Health. The CDC Aims to Curb Them ― For Now.

In August, Robert Pettigrew was working a series of odd jobs. While washing the windows of a cellphone store he saw a sign, one that he believes the “good Lord” placed there for him.

“Facing eviction?” the sign read. “You could be eligible for up to $3,000 in rent assistance. Apply today.”

It seemed a hopeful omen after a series of financial and health blows. In March, Pettigrew, 52, learned he has an invasive mass on his lung that restricts his breathing. His doctor told him his condition puts him at high risk of developing deadly complications from COVID-19 and advised him to stop working as a night auditor at a Motel 6, where he manned the front desk. Reluctantly, he had to leave that job and start piecing together other work.

With pay coming in less steadily, Pettigrew and his wife, Stephanie, fell behind on the rent. Eventually, they were many months late, and the couple’s landlord filed to evict them.

Then Pettigrew saw the rental assistance sign.

“There were nights I would lay in bed and my wife would be asleep, and all I could do was say, ‘God, you need to help me. We need you,’” Pettigrew said. “And here he came. He showed himself to us.”

As many as 40 million Americans faced a looming eviction risk in August, according to a report authored by 10 national housing and eviction experts. The Centers for Disease Control and Prevention cited that estimate in early September when it ordered an unprecedented, nationwide eviction moratorium through the end of 2020.

That move — a moratorium from the country’s top public health agency — spotlights a message experts have preached for years without prompting much policy action: Housing stability and health are intertwined.

The CDC is now citing stable housing as a vital tool to control the coronavirus, which has killed more than 200,000 Americans. Home is where people isolate themselves to avoid transmitting the virus or becoming infected. When local governments issue stay-at-home orders in the name of public health, they presume that residents have a home. For people who have the virus, home is often where they recover from COVID-19’s fever, chills and dry cough — in lieu of, or after, a hospital stay.

But the moratorium is not automatic. Renters have to submit a declaration form to their landlord, agreeing to a series of statements under threat of perjury, including “my housing provider may require payment in full for all payments not made prior to and during the temporary halt, and failure to pay may make me subject to eviction pursuant to state and local laws.”

Confusion surrounding the CDC’s order means some tenants are still being ordered to leave their homes.

Princeton University is tracking eviction filings in 17 U.S. cities during the pandemic. As of Sept. 19, landlords in those cities have filed for more than 50,000 evictions since March 15. The tally includes about 11,900 in Houston, 10,900 in Phoenix and 4,100 in Milwaukee.

It’s an incomplete snapshot that excludes some major American cities such as Indianapolis, where local housing advocates said court cases are difficult to track, but landlords have sought to evict thousands of renters.

Children raised in unstable housing are more prone to hospitalization than those with stable housing. Homelessness is associated with delayed childhood development, and mothers in families that lose homes to eviction show higher rates of depression and other health challenges.

Mounting research illustrates that even the threat of eviction can exact a physical and mental toll from tenants.

Nicole MacMillan, 38, lost her job managing vacation rentals in Fort Myers, Florida, in March when the pandemic shut down businesses. Later, she also lost the apartment where she had been living with her two children.

“I actually contacted a doctor, because I thought, mentally, I can’t handle this anymore,” MacMillan said. “I don’t know what I’m going to do or where I’m going to go. And maybe some medication can help me for a little bit.”

But the doctor she reached out to wasn’t accepting new patients.

With few options, MacMillan moved north to live with her grandparents in Grayslake, Illinois. Her children are staying with their fathers while she gets back on her feet. She recently started driving for Uber Eats in the Chicagoland area.

“I need a home for my kids again,” MacMillan said, fighting back tears. The pandemic “has ripped my whole life apart.”

Searching for Assistance to Stay at Home

That store window sign? It directed Pettigrew to Community Advocates, a Milwaukee nonprofit that received $7 million in federal pandemic stimulus funds to help administer a local rental aid program. More than 3,800 applications for assistance have flooded the agency, said Deborah Heffner, its housing strategy director, while tens of thousands more applications have flowed to a separate agency administering the state’s rental relief program in Milwaukee.

Persistence helped the Pettigrews break through the backlog.

“I blew their phone up,” said Stephanie Pettigrew, with a smile.

She qualifies for federal Social Security Disability Insurance, which sends her $400 to $900 in monthly assistance. That income has become increasingly vital since March when Robert left his motel job.

He has since pursued a host of odd jobs to keep food on the table — such as the window-washing he was doing when he saw the rental assistance sign — work where he can limit his exposure to the virus. He brings home $40 on a good day, he said, $10 on a bad one. Before they qualified for rent assistance, February had been the last time the Pettigrews could fully pay their $600 monthly rent bill.

Just as their finances tightened and their housing situation became less stable, the couple welcomed more family members. Heavenly, Robert’s adult daughter, arrived in May from St. Louis after the child care center where she worked shut down because of concerns over the coronavirus. She brought along her 3-year-old son.

Through its order, the CDC hopes to curtail evictions, which can add family members and friends to already stressed households. The federal order notes that “household contacts are estimated to be 6 times more likely to become infected by [a person with] COVID-19 than other close contacts.”

“That’s where that couch surfing issue comes up — people going from place to place every few nights, not trying to burden anybody in particular, but possibly at risk of spreading around the risk of coronavirus,” said Andrew Bradley of Prosperity Indiana, a nonprofit focusing on community development.

The Pettigrews’ Milwaukee apartment — a kitchen, a front room, two bedrooms and one bathroom — is tight for the three generations now sharing it.

“But it’s our home,” Robert said. “We’ve got a roof over our head. I can’t complain.”

Housing Loss Hits Black and Latino Communities

A U.S. Census Bureau survey conducted before the federal eviction moratorium was announced found that 5.5 million of American adults feared they were either somewhat or very likely to face eviction or foreclosure in the next two months.

State and local governments nationwide are offering a patchwork of help for those people.

In Massachusetts, the governor extended the state’s pause on evictions and foreclosures until Oct. 17. Landlords are challenging that move both in state and federal court, but both courts have let the ban stand while the lawsuits proceed.

“Access to stable housing is a crucial component of containing COVID-19 for every citizen of Massachusetts,” Judge Paul Wilson wrote in a state court ruling. “The balance of harms and the public interest favor upholding the law to protect the public health and economic well-being of tenants and the public in general during this health and economic emergency.”

The cases from Massachusetts may offer a glimpse of how federal challenges to the CDC order could play out.

By contrast, in Wisconsin, Gov. Tony Evers was one of the first governors to lift a state moratorium on evictions during the pandemic — thereby enabling about 8,000 eviction filings from late May to early September, according to a search of an online database of Wisconsin circuit courts.

Milwaukee, Wisconsin’s most populous city, has seen nearly half of those filings, which have largely hit the city’s Black-majority neighborhoods, according to an Eviction Lab analysis.

In other states, housing advocates note similar disparities.

“Poor neighborhoods, neighborhoods of color, have higher rates of asthma and blood pressure — which, of course, are all health issues that the COVID pandemic is then being impacted by,” said Amy Nelson, executive director of the Fair Housing Center of Central Indiana.

“This deadly virus is killing people disproportionately in Black and brown communities at alarming rates,” said Dee Ross, founder of the Indianapolis Tenants Rights Union. “And disproportionately, Black and brown people are the ones being evicted at the highest rate in Indiana.”

Across the country, officials at various levels of government have set aside millions in federal pandemic aid for housing assistance for struggling renters and homeowners. That includes $240 million earmarked in Florida, between state and county governments, $100 million in Los Angeles County and $18 million in Mississippi.

In Wisconsin, residents report that a range of barriers — from application backlogs to onerous paperwork requirements — have limited their access to aid.

In Indiana, more than 36,000 people applied for that state’s $40 million rental assistance program before the application deadline. Marion County, home to Indianapolis, had a separate $25 million program, but it cut off applications after just three days because of overwhelming demand. About 25,000 people sat on the county’s waiting list in late August.

Of that massive need, Bradley, who works in economic development in Indiana, said: “We’re not confident that the people who need the help most even know about the program — that there’s been enough proactive outreach to get to the households that are most impacted.”

After Milwaukeean Robert Pettigrew saw that sign in the store window and reached out to the nonprofit Community Advocates, the group covered more than $4,700 of the Pettigrews’ rental payments, late charges, utility bills and court fees. The nonprofit also referred the couple to a pro-bono lawyer, who helped seal their eviction case — that means it can’t hurt the Pettigrews’ ability to rent in the future, and ensures the family will have housing at least through September. The CDC moratorium has added to that security.

The federal eviction moratorium, if it withstands legal challenges from housing industry groups, “buys critical time” for renters to find assistance through the year’s end, said Emily Benfer, founding director of the Wake Forest Law Health Justice Clinic.

“It’s protecting 30 to 40 million adults and children from eviction and the downward spiral that it causes in long-term, poor health outcomes,” she said.

Doctor: Evictions Akin to ‘Toxic Exposure’

Megan Sandel, a pediatrician at Boston Medical Center, said at least a third of the 14,000 families with children that seek treatment at her medical center have fallen behind on their rent, a figure mirrored in national reports.

Hospital officials worry that evictions during the pandemic will trigger a surge of homeless patients — and patients who lack homes are more challenging and expensive to treat. One study from 2016 found that stable housing reduced Medicaid spending by 12% — and not because members stopped going to the doctor. Primary care use increased 20%, while more expensive emergency room visits dropped by 18%.

A year ago, Boston Medical Center and two area hospitals collaborated to invest $3 million in emergency housing assistance as community organizing focused on affordable housing policies and development. Now the hospitals are looking for additional emergency funds, trying to boost legal resources to prevent evictions and work more closely with public housing authorities and state rental assistance programs.

“We are a safety-net hospital. We don’t have unlimited resources,” Sandel said. “But being able to avert an eviction is like avoiding a toxic exposure.”

Sandel said the real remedy for avoiding an eviction crisis is to offer Americans substantially more emergency rental assistance, along the lines of the $100 billion included in a package proposed by House Democrats in May and dubbed the Heroes Act. Boston Medical Center is among the 26 health care associations and systems that signed a letter urging congressional leaders to agree on rental and homeless assistance as well as a national moratorium on evictions for the entire pandemic.

“Without action from Congress, we are going to see a tsunami of evictions,” the letter stated, “and its fallout will directly impact the health care system and harm the health of families and individuals for years to come.”

Groups representing landlords urge passage of rental assistance, too, although some oppose the CDC order. They point out that property owners must pay bills as well and may lose apartments where renters can’t or won’t pay.

In Milwaukee, Community Advocates is helping the Pettigrews look for a more affordable apartment. Robert Pettigrew continues attending doctors’ appointments for his lungs, searching for safe work. He looks to the future with a sense of resolve — and a request that no one pity his family.

“Life just kicks you in the butt sometimes,” he said. “But I’m the type of person — I’m gonna kick life’s ass back.”

For this story, NPR and KHN partnered with the investigative journalism site Wisconsin Watch, Side Effects Public Media, Wisconsin Public Radio and WBUR.

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?’ Replay: What’s at Stake When High Court Hears ACA Case

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The “What the Health?” panelists are taking a break for two weeks. But since the Supreme Court recently scheduled arguments in the case challenging the constitutionality of the Affordable Care Act, it seemed like a good opportunity to replay an episode from March, when the law turned 10.

As the “What the Health?” panelists point out in this episode, that’s a milestone that many considered unlikely. The past decade for the health law has been filled with controversy and several near-death experiences. But the law also brought health coverage to millions of Americans and laid the groundwork for a shift to a health system that pays for quality rather than quantity.

Yet the future of the law remains in doubt. Many progressive Democrats would like to scrap it in favor of a “Medicare for All” system that would be fully financed by the federal government. Republicans would still like to repeal or substantially alter it. And GOP officials have brought the case asking the Supreme Court to invalidate the entire law. Those arguments will be heard on Nov. 10.

This special episode, which first aired March 19, also includes a discussion between “What the Health?” host Julie Rovner and Kathleen Sebelius, who was secretary of Health and Human Services during the development, passage and implementation of the health law. KHN published a transcript of that interview.

Rovner, Joanne Kenen of Politico and Mary Agnes Carey of KHN, who have all covered the law from the start, discuss the ACA’s past, present and future.

To hear all our podcasts, click here.

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

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Prognosis for Rural Hospitals Worsens With Pandemic

Jerome Antone said he is one of the lucky ones.

After becoming ill with COVID-19, Antone was hospitalized only 65 miles away from his small Alabama town. He is the mayor of Georgiana — population 1,700.

“It hit our rural community so rabid,” Antone said. The town’s hospital closed last year. If hospitals in nearby communities don’t have beds available, “you may have to go four or five hours away.”

As COVID-19 continues to spread, an increasing number of rural communities find themselves without their hospital or on the brink of losing already cash-strapped facilities.

Eighteen rural hospitals closed last year and the first three months of 2020 were “really big months,” said Mark Holmes, director of the Cecil G. Sheps Center for Health Services Research at the University of North Carolina-Chapel Hill. Many of the losses are in Southern states like Florida and Texas. More than 170 rural hospitals have closed nationwide since 2005, according to data collected by the Sheps Center.

It’s a dangerous scenario. “We know that a closure leads to higher mortality pretty quickly” among the populations served, said Holmes, who is also a professor at UNC Gillings School of Global Public Health. “That’s pretty clear.”

One 2019 study found that death rates in the surrounding communities increase nearly 6% after a rural hospital closes — and that’s when there’s not a pandemic.

Add to that what is known about the coronavirus: People who are obese or live with diabetes, hypertension, asthma and other underlying health issues are more susceptible to COVID-19. Rural areas tend to have higher rates of these conditions. And rural residents are more likely to be older, sicker and poorer than those in urban areas. All this leaves rural communities particularly vulnerable to the coronavirus.

Congress approved billions in federal relief funds for health care providers. Initially, federal officials based what a hospital would get on its Medicare payments, but by late April they heeded criticism and carved out funds for rural hospitals and COVID-19 hot spots. Rural hospitals leapt at the chance to shore up already-negative budgets and prepare for the pandemic.

The funds “helped rural hospitals with the immediate storm,” said Dr. Don Williamson, president of the Alabama Hospital Association. Nearly 80% of Alabama’s rural hospitals began the year with negative balance sheets and about eight days’ worth of cash on hand.

Before the pandemic hit this year, hundreds of rural hospitals “were just trying to keep their doors open,” said Maggie Elehwany, vice president of government affairs with the National Rural Health Association. Then, an estimated 70% of their income stopped as patients avoided the emergency room, doctor’s appointments and elective surgeries.

“It was devastating,” Elehwany said.

Paul Taylor, chief executive of a 25-bed critical access hospital and outpatient clinics in northwestern Arkansas, accepted millions in grants and loan money Congress approved this spring, largely through the CARES (Coronavirus Aid, Relief and Economic Security) Act.

“For us, this was survival money and we spent it already,” Taylor said. With those funds, Ozarks Community Hospital increased surge capacity, expanding from 25 beds to 50 beds, adding negative pressure rooms and buying six ventilators. Taylor also ramped up COVID-19 testing at his hospital and clinics, located near some meat-processing plants.

Throughout June and July, Ozarks tested 1,000 patients a day and reported a 20% positive rate. The rate dropped to 16.9% in late July. But patients continue to avoid routine care.

Taylor said revenue is still constrained and he does not know how he will pay back $8 million that he borrowed from Medicare. The program allowed hospitals to borrow against future payments from the federal government, but stipulated that repayment would begin within 120 days.

For Taylor, this seems impossible. Medicare makes up 40% of Ozarks’ income. And he has to pay the loan back before he gets any more payments from Medicare. He’s hoping to refinance the hospital’s mortgage.

“If I get no relief and they take the money … we won’t still be open,” Taylor said. Ozarks provides 625 jobs and serves an area with a population of about 75,000.

There are 1,300 small critical access hospitals like Ozarks in rural America and, of those, 859 took advantage of the Medicare loans, sending about $3.1 billion into the local communities. But many rural communities have not yet experienced a surge in coronavirus cases — national leaders fear it will come as part of a new phase.

“There are pockets of rural America who say, ‘We haven’t seen a single COVID patient yet and we do not believe it’s real,’” Taylor said. “They will get hit sooner or later.”

Across the country, the loss of patients and increased spending required to fight and prepare for the coronavirus was “like a knife cutting into a hospital’s blood supply,” said Ge Bai, associate professor of health policy and management at the Johns Hopkins Bloomberg School of Public Health in Baltimore.

Bai said the way the federal government reimbursed small rural hospitals through federal programs like Medicare before the pandemic was faulty and inefficient. “They are too weak to survive,” she said.

In rural Texas about two hours from Dallas, Titus Regional Medical Center chief executive Terry Scoggin cut staff and furloughed workers even as his rural hospital faced down the pandemic. Titus Regional lost about $4 million last fiscal year and broke even each of the three years before that.

Scoggin said he did not cut from his clinical staff, though. Titus is now facing its second surge of the virus in the community. “The last seven days, we’ve been testing 30% positive,” he said, including the case of his father, who contracted it at a nursing home and survived.

“It’s personal and this is real,” Scoggin said. “You know the people who are infected. You know the people who are passing away.”

Of his roughly 700 employees, 48 have tested positive for the virus and one has died. They are short on testing kits, medication and supplies.

“Right now the staff is strained,” Scoggin said. “I’ve been blown away by their selflessness and unbelievable spirit. We’re resilient, we’re nimble, and we will make it. We don’t have a choice.”

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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Feeling Anxious and Depressed? You’re Right at Home in California.

It’s official, California: COVID-19 has left us sick with worry and increasingly despondent. And our youngest adults — ages 18 to 29 — are feeling it worst.

Weekly surveys conducted by the U.S. Census Bureau from late April through late July offer a grim view of the toll the pandemic has taken on the nation’s mental health. By late July, more than 44% of California adult respondents reported levels of anxiety and gloom typically associated with diagnoses of generalized anxiety disorder or major depressive disorder, a stunning figure that rose through the summer months alongside the menacing spread of the coronavirus.

America at large has followed a similar pattern, with about 41% of adult respondents nationwide reporting symptoms of clinical anxiety or depression during the third week of July. By comparison, just 11% of American adults reported those symptoms in a similar survey conducted in early 2019.

The July responses showed a marked geographic variance, with residents of Western and Southern states, where the virus remains most virulent, registering greater mental distress, on average.

The findings reflect a generalized sense of hopelessness as the severity of the global crisis set in. Most adults have been moored at home in a forced stasis, many in relative isolation. The unemployment rate hit its highest rate since the Great Depression of the 1930s. Thousands of families across California and tens of thousands across the U.S. have lost people to the virus. There is no clear indication when — or even if — life will return to normal.

“The pandemic is the first wave of this tsunami, and the second and third waves are really going to be this behavioral health piece,” said Jessica Cruz, executive director of the National Alliance on Mental Illness (NAMI) California.

The surveys were part of a novel partnership between the National Center for Health Statistics and the Census Bureau to provide relevant statistics on the coronavirus’s impact. In weekly online surveys over three months, the Census Bureau asked about 900,000 Americans questions to quantify their levels of anxiety or depression. The four survey questions are a modified version of a common screening tool physicians use to diagnose mental illness.

Respondents were asked how often during the previous seven days they had been bothered by feeling hopeless or depressed; had felt little interest or pleasure in doing things; had felt nervous or anxious; or had experienced uncontrolled worry. They were scored based on how often they had experienced those symptoms in the previous week, ranging from never to nearly every day. High scores on the anxiety questions indicated symptoms associated with generalized anxiety disorder. High scores on the depression questions indicated symptoms of major depressive disorder.

In both California and the nation, symptoms of depression and anxiety were more pronounced among young adults, and generally decreased with age. For example, nearly 3 in 4 California respondents between ages 18 and 29 reported “not being able to stop or control worrying” for at least several of the previous seven days. And 71% reported feeling “down, depressed or hopeless” during that time.

Interestingly, respondents 80 and older — an age group far more likely to suffer and die from COVID-19 — reported nowhere near the same levels of distress. Just 40% reported feeling down or hopeless for at least several days in the previous week, and 42% reported uncontrollable worry.

Cruz said that may be because young adults are more comfortable expressing worry and sadness than their parents and grandparents, adding that such openness is a good thing. However, even before the pandemic, suicide rates among teens and young adults had been on a yearslong climb nationwide, and California emergency rooms had registered a sharp rise in the number of young adults seeking care for mental health crises.

Some researchers have cited the ubiquitous reach of social media — and with it an increased sense of inferiority and alienation — as factors in the rise in mental health struggles among younger generations. COVID-19 could be exacerbating those feelings of isolation, Cruz said.

The Census surveys also found higher rates of depression and anxiety among those who have lost jobs during the pandemic. Young adults in the service sector have been hit particularly hard by the wide-scale economic shutdowns. In July, the unemployment rate among U.S. workers ages 20 to 24 was 18%, compared with 9% among workers 25-54, according to the U.S. Bureau of Labor Statistics.

Others noted that many other young adults who would normally be immersed in college life are stuck on the couch in their parents’ home, staring at a professor on Zoom, with little social life and no paid work after class.

“Some of the things that generally help improve mood have been more difficult and more challenging now,” said Paul Kim, director of counseling services at the University of California-Davis. “So I think some of our counselors’ work is to help them think through, ‘How is it, for example, you stay socially connected while socially distant?’”

Californians with lower incomes also reported higher levels of anxiety or depression. About 72% of California respondents with household incomes below $35,000 reported “little interest or pleasure in doing things” for at least several of the previous seven days, according to an average of survey results from July 2 through July 21.

“People have had a lot of trouble accessing unemployment benefits — that has not been an easy path,” said Jo Campbell, a therapist and integrated operations director at Hill Country Community Clinic, which provides services to clients, many of them economically disadvantaged, in Shasta County.

Some experts said they worry that the tumble toward depression and anxiety could outlast the pandemic itself, particularly if the economy lapses into a prolonged recession.

“The pandemic will likely have short- and long-term implications on mental health and substance use,” said Laura Pancake, a vice president at Pacific Clinics, one of the largest mental health service providers in Southern California. The pandemic, she added, “has only exacerbated existing challenges that many face, including unemployment, poor health and other barriers.”

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


This KHN story first published on California Healthline, a service of the California Health Care Foundation.

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

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‘An Arm and a Leg’: How to Fight Bogus Medical Bills Like a Bulldog

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After Izzy Benasso had knee surgery, she and her dad received a letter from a surgical assistant giving notice that he “had been present” at the procedure.

The surgical assistant was out-of-network and seemed to be laying the groundwork to get the Benassos to pay his fee.

Steve Benasso wrote a letter right back, basically telling the guy to buzz off: He had no intention of paying the surgical assistant. Because the bill was a surprise, Benasso suggested that the surgical assistant try to get the money from the insurance company, or negotiate for some part of the knee surgeon’s payment.

Benasso first shared his story with KHN and NPR for the Bill of the Month series.

There are two explanations for Benasso’s chutzpah.

One: “Steve is the kind of person to check every receipt twice and argue over any discrepancies he finds,” his daughter said.

Two: He had lots of experience haggling over medical bills in particular. As a human resources director, he specializes in defending his colleagues against bogus bills and unfair insurance denials.

“I am a bulldog on this stuff,” he said. “I do it every month.”

In this episode, learn how Steve became such a bulldog, and the tips he has for the rest of us.

“An Arm and a Leg” is a co-production of KHN and Public Road Productions.

To keep in touch with “An Arm and a Leg,” subscribe to the newsletter. You can also follow the show on Facebook and Twitter. And if you’ve got stories to tell about the health care system, the producers would love to hear from you.

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Deadly Mix: How Bars Are Fueling COVID-19 Outbreaks

From the early days of the U.S. coronavirus outbreak, states have wrestled with the best course of action for bars and nightclubs, which largely have their economic prospects tied to social gatherings in tight quarters. As the virus has pinched the industry’s lifeblood, bar owners in a handful of states are fighting in court against government orders that they stay closed.

But public health experts and top health officials, including the nation’s top infectious diseases official, Dr. Anthony Fauci, have said: When bars open, infections tend to follow.

Some states moved quickly to shutter bars early in the pandemic for months or longer, keeping them entirely closed or open only under very strict conditions. Many other states moved to reopen bars on a faster timeline — only to shut them down again as viral case counts rebounded this summer.

“We’re big targets. It’s just wrong,” said Steve Smith, whose Nashville, Tennessee, businesses include honky-tonks that serve alcohol and cater to tourists. But some legal experts said public health authorities have broad power to close down any business they deem particularly risky.

“They can’t regulate in ways that are arbitrary or capricious,” said Lawrence Gostin, a law professor at Georgetown University. “But if there’s good evidence that a certain class of establishment is causing the spread of infectious diseases, it’s absolutely clear that they have the right — in fact, they have the duty — to do it.”

The evidence that bars are a particular problem has continued to grow, said Dr. Ogechika Alozie, an infectious disease specialist in El Paso, Texas.

“If you were to create a petri dish and say, How can we spread this the most? It would be cruise ships, jails and prisons, factories, and it would be bars,” said Alozie. He was a member of the Texas Medical Association committee that created a COVID-19 risk scale for common activities, such as shopping at the grocery store.

Bars top the list as the riskiest.

“You can’t drink through the mask, so you’re taking off your mask. There are lots of people, tight spaces and alcohol is a dis-inhibitor — people change their behaviors,” said Alozie.

‘What Am I Going to Do?’

At The Beer Junction in West Seattle, the stools are stacked in the corner. These days the craft brewery’s taps flow for to-go drinks only.

“It would be very lively,” owner Allison Herzog said about the brewery’s pre-pandemic days. “It is weird to come in here and not feel that vibrancy.”

The coronavirus pandemic has compromised the bedrock of Herzog’s business: people gathering together to drink, talk, laugh and let loose in one another’s company.

“I wake up and I think, every day, what am I going to do to keep going?” Herzog said.

In the spring, The Beer Junction shut down indoor service as the coronavirus swept through Washington state. Then, as coronavirus numbers improved, restrictions on restaurants and bars were eased in the early summer. Finally, Herzog was allowed to open up a few tables and serve a limited number of customers indoors.

“I could hear people laughing in the bar,” she recalled. “It just touched my heart and it felt like something was normal again.”

But the reprieve did not last long.

By late July, the coronavirus had made a resurgence in the Seattle area and Washington Gov. Jay Inslee soon put another ban on indoor service at places that sold alcohol — including Herzog’s bar.

Even though it’s hard on her bottom line, she said, she believes the risk of the coronavirus justifies the decision.

“I trust that they will open when it’s responsible and scale back when it’s responsible,” Herzog said.

What the Evidence Shows

There are now many examples across the U.S. of bars and nightclubs that have fueled outbreaks.

In July, Louisiana rolled back its limited opening of bars, reporting that more than 400 people had caught the coronavirus from interactions at those businesses. Texas and Arizona ordered bars to close down when infections skyrocketed and customers continued to crowd into bars. In Michigan, public health authorities have traced nearly 200 cases back to a now-infamous East Lansing pub.

While bars can ask customers to wear masks and sit at tables, Alozie is skeptical that such guidance, however well-intentioned, can be successful, even when bargoers plan to be prudent.

“The reality is, man proposes, God disposes,” he said. “Alcohol disposes even more.”

An outbreak linked to a bar and grill in southwestern Washington state is instructive. For karaoke night, the staff spaced the tables, checked temperatures at the door, even put up plexiglass barriers near the singers. Nonetheless, a few weeks later, close to 20 customers and employees had been infected.

“You’re asking customers who are drinking and doing karaoke to follow the physical distancing and masking requirements,” said Dr. Alan Melnick, director of the Clark County Health Department, which conducted the investigation. “So that was challenging in this particular situation.”

The chance of catching the virus through tiny airborne respiratory droplets, known as aerosols, goes up significantly in indoor spaces. When some states reopened bars after the first round of lockdowns, Jose Luis-Jimenez, who studies the behavior of aerosols, was dismayed.

“I thought these were superspreading events waiting to happen, and look — that’s what happened,” said Luis-Jimenez, a professor at the University of Colorado-Boulder. “It was irresponsible.”

Many of the risk factors for airborne transmission of the coronavirus come together in a bar — think of each one like a “check mark” that adds to a person’s overall risk.

And behavior matters, said Luis-Jimenez. It can determine whether an indoor gathering becomes a superspreading event, which is why a bar is more problematic than even a restaurant.

“I would put my money that a bar is where the transmission is most likely to occur [compared with a restaurant] because that’s where you’re most likely to have people that are shouting and who are not wearing masks,” he said.

Bars Are Fighting Back

Bars and taverns have brought legal challenges to coronavirus restrictions in Colorado, Florida, Arizona, Tennessee, Texas and Louisiana.

In Arizona, more than 60 bars filed a lawsuit to overturn the governor’s order to shut them down. Ilan Wurman, an associate professor of law at Arizona State University, is representing the bar owners who argue that the state has unfairly singled them out, while letting restaurants stay open late and serve alcohol.

“Either treat them all equally and shut them all down — or treat them all equally and allow them all to conform to reasonable health measures,” Wurman argued. “What you can’t do is pick out a criterion, something like alcohol, that’s totally arbitrary and that totally discriminates.”

Gostin, the Georgetown University legal scholar, said courts historically have sided with public health decisions — even as recently as last month.

The U.S. Supreme Court rejected a Nevada church’s challenge to limitations on holding services, although attorneys for the church had argued that the restrictions on worship services were more onerous than the ones placed on casinos and restaurants.

“We have to remember we’re in an emergency,” Gostin said, regarding the court’s decision. “The health department should have reasonable discretion so as long as it’s acting on the basis of good evidence.”

Closing bars has a “double effect,” according to Dr. Joshua Sharfstein, vice dean for Public Health Practice and Community Engagement at Johns Hopkins’ Bloomberg School of Public Health. “It reduces the spread of the virus within the bar and it makes everyone take this situation more seriously.”

Sharfstein, who is a former secretary of health and mental health services for the state of Maryland, said he thinks, in most communities, keeping bars open will only set back other efforts to reopen society.

“You can’t look at the decision about bars separate from the need to save lives in nursing homes or to be able to open schools,” Sharfstein said. “They’re all connected.”

This story is part of a partnership that includes 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?’: Democrats in Array (For Now)

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Democrats have shown a remarkably united front, including on health care, in their socially distant, made-for-TV convention this week. That’s likely due, at least in part, to the physical separation of party members who disagree on issues — this year they cannot chatter on live television — and to the party truly being united in its desire to defeat President Donald Trump in November.

Meanwhile, the coronavirus pandemic continues to complicate efforts around the country to get students back to school, from preschool to college. And the Trump administration’s effort to eliminate anti-discrimination protections in health care for transgender people is put on hold by a federal judge.

This week’s panelists are Julie Rovner of Kaiser Health News, Margot Sanger-Katz of The New York Times, Paige Winfield Cunningham of The Washington Post and Shefali Luthra of The 19th.

Among the takeaways from this week’s podcast:

  • Democrats’ online convention has helped make the party seem unified. But on health policy, divisions remain even though Vice President Joe Biden has agreed to broaden some of his plans, such as lowering the eligibility age for Medicare and agreeing to have federal regulators run a public option plan he is advocating. Progressives in the party still hope to move the debate next year back to establishing a “Medicare for All” system.
  • The heated Democratic primary campaign put a good deal of focus on health policy, including whether to support a Medicare for All system and efforts to make health care more affordable. But the convention rhetoric on health hasn’t focused much attention on that and instead has played up issues surrounding the Trump administration’s response to the coronavirus pandemic.
  • The emphasis on COVID-19 in recent months has also pushed out much of the debate on the issues of high drug prices and surprise bills.
  • As the question of a mail slowdown has enveloped the country, concerns are being raised about mail delivery of prescription drugs, especially for seniors and veterans. Despite anecdotal reports of missed deliveries, most drug industry experts say problems haven’t been widespread.
  • The controversies about reopening schools — both K through 12 and colleges — point to difficulties with the country’s COVID testing program. It is too hard and too expensive for schools to be able to test enough students to guarantee that the virus isn’t spreading.
  • Schools may want to reconsider which age groups they target for returning to the classroom. Since there is little evidence that younger kids spread the virus widely and since they may need the in-classroom experience more, it could make sense to bring them back to school sooner than older students. Plus, older students generally can better handle online classes.
  • Federal health officials have recently warned that the pandemic is having an impact on mental health for many people, raising levels of depression and anxiety. The physical isolation and the economic stresses are fueling much of that.
  • The Trump administration’s rule overturning an Obama administration rule on transgender protections in the Affordable Care Act has been put on hold by a federal judge. But the Obama-era rule had also been put on hold by another judge. So the question is in limbo until higher courts — perhaps the Supreme Court — take up the case.

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

Julie Rovner: The Washington Post’s “Can Dogs Detect the Novel Coronavirus? The Nose Knows,” by Frances Stead Sellers

Margot Sanger-Katz: The Atlantic’s “The Plan That Could Give Us Our Lives Back,” by Robinson Meyer and Alexis C. Madrigal

Paige Winfield Cunningham: Stat News’ “Seven Months Later, What We Know About Covid-19 – And the Pressing Questions That Remain,” by Andrew Joseph, Helen Branswell and Elizabeth Cooney.

Shefali Luthra: KHN’s “Back to the Future: Trump’s History of Promising a Health Plan That Never Comes,” by Victoria Knight

To hear all our podcasts, click here.

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

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COVID Testing Choke Points

In some ways, the nation’s COVID testing system is like a game of Jenga: When one piece falters, the entire tower collapses.

Take Sacramento County, home to 1.5 million people and California’s capital. Coronavirus cases started surging in late June, and on July 15, 360 residents were diagnosed, marking an ominous single-day record.

Around that time, people flocked to testing sites run by the state, county, local health systems and other providers, and CVS, the first major retail establishment to start testing in Sacramento County.

But securing a test became next to impossible for many people. Even as Gov. Gavin Newsom touted California’s ability to test roughly 100,000 people per day, Sacramento’s time slots filled quickly, five county-run testing sites temporarily shuttered, and some health care providers limited testing to symptomatic patients.

For those lucky enough to get tested, results took days — sometimes weeks — to return, rendering them essentially useless.

“Results should come in 24 to 48 hours, ideally, from when people are exhibiting symptoms,” said Sacramento County Public Health Officer Dr. Olivia Kasirye. “It impacts our ability to take action and do contact investigations.”

So what happened? Sacramento, like other counties across the state and nation, has been plagued by a series of choke points in its testing system since the pandemic began. During the summer surge, at least two bottlenecks — caused by the sheer volume of tests and a shortage of lab processing supplies — dramatically constricted testing capabilities and slowed results.

“It’s pretty stunning that we are still having these bottlenecks. It was understandable when New York was struggling in March, but why is California struggling now?” said David Lazer, a professor at Northeastern University and co-author of a recent report on turnaround times for test results across the U.S. “It’s a local manifestation of national shortages.”

(Hannah Norman/KHN; Getty Images)

The first choke point emerged in Sacramento as people flocked to testing sites, placing a heavy burden on commercial labs that processed tests, such as Quest Diagnostics and LabCorp.

With COVID hot spots flaring this summer in Sacramento and beyond, the labs faced mounting backlogs, sometimes delaying results by more than a week. During Quest’s second-quarter earnings call in late July, Steve Rusckowski, the company’s chairman, president and CEO, addressed why the lab was struggling to keep up with demand — even as it rapidly increased testing capacity, which is now at 150,000 diagnostic tests a day.

Beyond catering to regions with high numbers of COVID-19 cases, Rusckowski said the lab was also responding to the testing needs of patients scheduled for surgery, high-risk residents at places like nursing homes and prisons, employers testing their workers, and universities requiring tests for returning students.

“There has been … broader availability of testing, where people now have access to asymptomatic testing and very convenient locations,” Rusckowski said. In July, Quest performed 3.5 million diagnostic tests, the company said, compared with 1.5 million in May.

Tests from Sacramento residents were among those, including people who visited the state-funded, drive-thru testing site run by Verily Life Sciences. Pharmacy giant CVS, with its 11 testing locations in the county and more than 1,800 nationwide, also sent its load to Quest, in addition to other commercial labs.

Quest said it has shortened its average turnaround time for tests to two to three days.

Smaller regional operations have popped up to ease the demand. Before the pandemic, Folsom, California-based StemExpress focused primarily on collecting and distributing blood and bone marrow for research and treatments. In early April, the company started processing COVID-19 tests. Now, StemExpress performs tests for Sacramento and other counties, health care systems, private businesses and even the Sacramento Kings NBA team.

About one-third of its business is now diagnostic COVID testing, according to Hether Ide, a company vice president. The lab has the capacity to process 10,000 tests per day, though it generally averages that in a week, Ide said.

To keep up this swift pace, StemExpress early on turned to its supplier, ThermoFisher, for certified COVID testing machines and secured year-long pre-purchasing contracts for the necessary supplies and chemicals. The company hired more than 30 people and staffs round-the-clock shifts to guarantee results in 48 to 72 hours. Still, it’s a fraction of what Quest churns through daily.

“It was a huge front-end financial investment — millions of dollars,” Ide said. “We had to buy the equipment and supply chain.”

Source: KHN reporting and a California COVID-19 Testing Task Force report. (Hannah Norman/KHN; Getty Images)

This brings us to the second major bottleneck: the supplies that big and small labs need to process tests.

In early July, Sacramento had to temporarily close five of its county-funded testing sites because the county’s testing partner, UC Davis Health, could not secure enough reagents — the chemical mixtures necessary to process COVID-19 tests — from Roche, the Swiss manufacturer of its “SUV”-sized lab machine. Major labs nationwide were scrambling for the same reagents.

To get the testing sites back up and running, Sacramento turned to StemExpress — which in April began securing lab supplies intended to last an entire year — to process the tests that UC Davis Health could not. The health system now has adequate supplies and is running about 2,500 tests per week, including some for the county, a UC Davis Health spokesperson said.

Sacramento County has reduced its turnaround time to 72 hours for results, the county said. Sacramento has also recently added community testing sites.

Manufacturers of lab processing supplies have struggled for months to keep up with the global demand. In a recent earnings call, Roche CEO Thomas Schinecker said the company had increased production of PCR testing machines and materials to approximately four times the normal levels. PCR tests, using a polymerase chain reaction, are the most common type used to detect COVID-19.

To avoid relying on one particular manufacturer, many labs use a variety of equipment. For instance, both Quest and BioReference Laboratories operate four FDA authorized testing systems, including ones made by Roche and Hologic, which are the sole makers of their proprietary reagents.

“These labs don’t want to put all their eggs in one basket,” said Marlene Sautter, director of laboratory services at Premier Inc., a group purchasing organization that works with 4,000 U.S. hospitals and health systems.

At the same time, major health systems, including those in Sacramento, face their own supply and testing shortages as they compete for the same equipment.

Kaiser Permanente has ramped up its purchasing of machines, testing kits and chemicals from vendors, and even built a 7,700-square-foot COVID-testing lab in Berkeley, which opened in June. (KHN, which produces California Healthline, is not affiliated with Kaiser Permanente.)

Collection Supplies

Earlier in the pandemic, a different supply shortage plagued testing sites in Sacramento: swabs used to collect specimens from people’s nasal cavities for the PCR tests.

In March, Maine-based Puritan Medical Products and Italian company Copan Diagnostics, the two leading manufacturers of these specialized nasal swabs, struggled to keep up with the accelerating demand.

In response, U.S. manufacturers expanded their efforts and Puritan received $75.5 million from the federal government in late April to make more swabs. California’s testing task force, in concert with the Federal Emergency Management Agency, said in an early-summer report that it had secured about 14 million swabs. Still, the report says that’s not enough to last through 2020.

Sautter fears that the upcoming flu season will add additional strain on the availability of swabs. Because the flu and COVID-19 share similar symptoms, more people will likely seek testing, and flu tests use the same type of swabs, she noted.

Plus, it’s never clear when one of the Jenga pieces will falter because of manufacturing delays, supply shortages or a spike in testing volume that could jam the system again.

“We really expected a decrease in COVID this summer. Obviously it hasn’t happened,” Sautter said. “Until there’s a vaccine, there’s going to be continued testing demand. Even then, I don’t know if anyone knows when this will be done.”

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?’: Kamala Harris on Health

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California Sen. Kamala Harris, the newly named running mate for presumptive Democratic presidential nominee Joe Biden, doesn’t have a lot of background in health policy. But that’s unlikely to prevent Republicans from using her on-again, off-again support for “Medicare for All” against her in the fall campaign.

Meanwhile, with talks between Congress and the Trump administration over the next round of COVID-19 relief at a standstill, President Donald Trump is trying to fill the void with executive orders. What’s unclear is whether the president has the authority to do some of what he is proposing — or whether it will work to help people in dire economic and health straits.

This week’s panelists are Julie Rovner of KHN, Kimberly Leonard of Business Insider, Joanne Kenen of Politico and Mary Agnes Carey of KHN.

Among the takeaways from this week’s podcast:

  • Although Harris isn’t closely associated with health care issues, one created problems for her last fall during her failed presidential bid. She was an original co-sponsor of the Medicare for All bill put forward by Sen. Bernie Sanders (I-Vt).
  • Trump’s executive order to suspend payroll taxes is causing consternation. It’s not clear if the order applies to both Social Security and Medicare or whether employers will follow the order. There is no indication that Congress would accept the president’s plan — and, if lawmakers don’t, workers and companies would owe the back taxes by the end of the year.
  • The tax suspension also has handed Democrats a club for the fall campaign. They are charging that the lack of revenue would endanger the Social Security and Medicare trust funds and could affect consumer benefits. Trump has replied that money from the federal government’s general fund would be used to fill the gap, but with the pandemic causing an economic upheaval, there’s no guarantee the government could afford that.
  • The president has promised he will shortly issue an executive order to protect coverage for people with medical conditions. The Affordable Care Act, which Trump has repeatedly pledged to abolish, already carries that protection, so this could be an attempt to offer Republicans a shield if the case before the Supreme Court overturns the law or some of its provisions. Previous vows by the president to offer health care plans have largely gone unfulfilled.
  • The administration is seeking to change the U.S. reliance on foreign nations, largely China and India, for prescription drugs and is moving to mandate that the government buy only U.S.-manufactured medications. Although the effort enjoys bipartisan support, it could end up increasing drug prices.
  • The recent announcement that the federal government is offering Kodak a $765 million loan to begin making chemicals that could be used in drug manufacturing triggered new scrutiny of the company. Stock trades made before the announcement, major escalation of the company’s lobbying efforts in Washington and a leak about the pending deal are all being analyzed.
  • The KHN-Guardian spotlight on the deaths of health care workers from COVID-19 points to a longer-term issue: shortages of medical professionals in key care fields.

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

Julie Rovner: The Wall Street Journal’s “Covid-19 Data Reporting System Gets Off to Rocky Start,” by Robbie Whelan

Joanne Kenen: The Texas Tribune and ProPublica’s “ICE Is Making Sure Migrant Kids Don’t Have COVID-19 — Then Expelling Them to ‘Prevent the Spread’ of COVID-19,” by Dara Lind and Lomi Kriel

Kimberly Leonard: The Philadelphia Inquirer’s “Coronavirus Is Changing Childbirth in the Philadelphia Region, Including Boosting Scheduled Inductions,” by Sarah Gantz

Mary Agnes Carey: The New York Times’ “Inside the Fight to Save Houston’s Most Vulnerable,” by Sheri Fink, Emily Rhyne and Erin Schaff

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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Listen: Will Telemedicine Outlast the Pandemic?

Julie Rovner, KHN’s chief Washington correspondent, on Tuesday joined WDET’s “Detroit Today” host Stephen Henderson and Dr. George Kipa, the deputy chief medical officer at Blue Cross Blue Shield of Michigan, to talk about the future of telemedicine and whether Medicare and private insurers will continue to pay for those services. You can listen to the discussion here.

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

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Behind the Byline: The Count — And the Toll

 

Although the coronavirus pandemic shut down many organizations and businesses across the nation, KHN has never been busier ― and health coverage has never been more vital. We’ve revamped our Behind the Byline YouTube series and brought it to Instagram TV.

Journalists and producers from across KHN’s newsrooms take you behind the scenes in these bite-size videos to show the ways they are following the story, connecting with sources and sorting through facts — all while staying safe.

Lydia Zuraw: The Count — and the Toll

The Guardian and KHN are documenting the lives of U.S. health care workers who have died of COVID-19 complications after being exposed to the coronavirus on the job. Profiles from the Lost on the Frontline project are updated twice a week. So, for months, California Healthline producer Lydia Zuraw has spent endless hours preparing photos, managing text and gathering assets to make sure the posts look great for publication. As the countless faces pass her desk, the death toll is sometimes “emotionally draining,” Zuraw said. But the work has also been a reminder that each person had a family, hobbies and people who loved them, she said.

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

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‘An Arm and a Leg’: Financial Self-Defense School Is Now in Session

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When you need medical care, it can be a lot like entering a casino — playing for your financial life with the deck stacked against you.

But in this episode, reporter Celia Llopis-Jepsen offers insight and tips no dealer will divulge. She got a health care executive to talk honestly — maybe more honestly than he realized — about how his company and others are playing the game when they send patients huge bills.

When she investigated one man’s $80,000 bill, here’s what Llopis-Jepsen found:

Providers who took some of the $175 billion in pandemic-related bailout funds that Congress authorized in March had to promise not to ding patients with surprise bills for COVID-related care. But don’t expect your provider to merely tell you if that rule applies in your case. (That $80,000 bill did not include a footnote that said, “Once insurance pays us, you can forget all about this.”)

If you get a bill for COVID treatment, you can look up the provider yourself. Llopis-Jepsen found a government database where you can see if your provider took bailout funds.

She also has a tip sheet for pushing back against your medical bills.

And this story — which shows you don’t always owe what you are charged — is packed with insight, too.

Podcast Scheduling Announcement

From here on out, look for financial self-defense lessons from “An Arm and a Leg” every two weeks, instead of occasional seasons. Because it is always a good time to learn how to stand up against unfair medical bills.

“An Arm and a Leg” is a co-production of Kaiser Health News and Public Road Productions.

To keep in touch with “An Arm and a Leg,” subscribe to the newsletter. You can also follow the show on Facebook and Twitter. And if you’ve got stories to tell about the health care system, the producers would love to hear from you.

To hear all Kaiser Health News podcasts, click here.

And subscribe to “An Arm and a Leg” on iTunesPocket CastsGoogle Play or Spotify.

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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Listen: ACA Heading to Supreme Court — Again

Julie Rovner, KHN’s chief Washington correspondent, joins “SCOTUStalk” podcast host Amy Howe to talk about the upcoming Supreme Court hearing on the Affordable Care Act.

The two look at the law’s history before the court — it will be the seventh hearing in eight years on the ACA or one of its provisions — and what issues might be important to the justices, including whether Republican state officials bringing the case have standing or whether their argument that the elimination of the tax for people who don’t get insurance dooms the entire law.

The court’s decision will have widespread effects: More than 20 million people have gained coverage under changes set forth in the law. You can listen to the podcast here on Acast or on Spotify.

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

Listen: NPR Interview About Less Lethal Weapons That Can Maim Or Kill

The streets in many U.S. cities have erupted with protests recently and police and federal officers have fired rubber bullets and other projectiles into crowds, injuring or even blinding some of the participants. This has been going on for decades, yet efforts to crack down on less-lethal ammo have failed locally and nationally. KHN senior correspondent Jay Hancock spoke with NPR’s Ailsa Chang on “All Things Considered” about why efforts to curb their use have failed.

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.

KHN’s ‘What The Health?’: Republicans in COVID Disarray

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President Donald Trump’s pivot to a more serious view of the coronavirus pandemic didn’t last long. This week, he was again touting hydroxychloroquine, an antimalarial drug that has not been shown to work against the virus. Meanwhile, on Capitol Hill, Republicans continue to struggle to come up with a proposal for the next round of COVID-19 relief even as earlier bills expire. That’s leaving millions of Americans without the ability to pay rent or meet other necessary expenses, as the economy continues to sink.

Also on the agenda, at least briefly, is the subject of high drug prices. Once considered a leading health issue for the 2020 elections, it has been all but wiped from the headlines by the pandemic. Trump issued a series of executive orders he said would produce an immediate impact, but experts point out they are mostly wish lists of things the president has already said he supports.

This week’s panelists are Julie Rovner of Kaiser Health News, Alice Miranda Ollstein of Politico, Mary Ellen McIntire of CQ Roll Call and Anna Edney of Bloomberg News.

Among the takeaways from this week’s podcast:

  • Despite much disarray on Capitol Hill about which coronavirus relief economic provisions Republican senators will agree on, there is largely agreement within the party and among Democrats on the health provisions, such as the need for more money for testing and for health care providers.
  • Senate Majority Leader Mitch McConnell insists the stimulus package must include liability protection for employers to protect businesses struck by a COVID-19 outbreak through no fault of their own. But Democrats are opposed and argue that the promise of liability waivers may keep employers from taking adequate safety precautions.
  • The Atlantic magazine recently explored the issue of “hygiene theater” in which people take measures they hope will keep the coronavirus at bay — such as excessive scrubbing, temperature checks, etc. — that science suggests have limited or no effect. These measures may give people comfort, but the efforts can also be dangerous in that they give a false sense of security and divert attention and resources from other, more complicated methods to stop the disease.
  • Much attention in recent weeks has been given to the development of a vaccine. Several options are in advanced stages of testing. But public health advocates fear that the speed of the testing and the administration’s past erroneous statements about the disease may raise fears among consumers about taking the vaccine. Nonetheless, Democrats looking ahead to the election worry that the administration will make a major announcement about vaccine availability as an October surprise.
  • COVID-19 has basically eclipsed efforts to make progress on several other key health issues that were expected before the election, including drug pricing and surprise medical bills.
  • With great fanfare this week, Trump announced orders for the administration to move toward new drug pricing policies. But the orders have little or no effect and haven’t created any momentum for advancing legislation in Congress.
  • The president surprised many people this week when he announced he was loaning Kodak millions of dollars to produce ingredients needed for the generic drug industry. Many of those chemicals have been made overseas, so the effort does follow the administration’s quest to establish more manufacturing in the U.S. But one reason few companies do the work here is that there is not a big profit margin on the drugs.

Also this week, Rovner interviews KHN’s Markian Hawryluk, who reported the July NPR-KHN “Bill of the Month” installment, about a surprise bill from a surprise participant in the operating room: a surgical assistant. If you have an outrageous medical bill you would like to share with us, you can do that here.

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

Julie Rovner: The New York Times’ “Disability Pride: The High Expectations of a New Generation,” by Joseph Shapiro

Alice Miranda Ollstein: Politico’s “Pelosi Mandates Wearing Masks on the House Floor After Gohmert Case,” by Heather Caygle and Sarah Ferris

Mary Ellen McIntire: The Atlantic’s “Why Can’t We Just Have Class Outside?” by Olga Khazan

Anna Edney: ProPublica’s “How to Understand COVID-19 Numbers,” by Caroline Chen

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.

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.

Dental and Doctors’ Offices Still Struggling with COVID Job Loss

California’s outpatient health care practices largely shrugged off two recessions, adding more than 400,000 jobs during a two-decade climb from the start of 2000 to early 2020. It was an enviable growth rate of 85% and a trend largely mirrored on the national level.

Then came COVID-19.

Anecdotal stories abound about the crushing impact the pandemic has had on a range of outpatient medical services, from pediatric and family medical practices to dental offices, medical labs and home health care. In California, as in many other states, thousands of doctors, dentists and other health care providers temporarily closed offices this spring as state health officials directed them to suspend non-urgent visits. Many others sat open but largely idle because patients were too scared to visit the doctor given the risk of running into someone with COVID-19 in the waiting room.

As the economy has reopened, so have many medical offices. But the latest state and federal employment data underscores the lingering toll the pandemic has taken on the health care sector.

In California, employment in medical offices providing an array of outpatient care fell by 159,300 jobs, or 18%, from February to April, according to California’s Employment Development Department. The sector has recovered some, but job totals in June remained 7% below pre-crisis levels, the latest figures show. Data is not yet available for July, when COVID-19 cases in California again began to rise sharply and communities across much of the state reverted to partial shutdowns.

Nationwide, employment in outpatient care fell by about 1.3 million jobs, or 17%, from February to April, and in June also remained 7% below pre-crisis levels.

Doctors’ offices typically rely on patient volume for revenue. Without it, they can’t make payroll. Many small medical clinics weren’t flush with cash before the crisis, making COVID-19 an existential threat.

“Never in our history have we had more than a month’s cash on hand,” said Dr. Sumana Reddy, owner of the Acacia Family Medical Group in Monterey County. “Think of it that way.”

Reddy operates two clinics, one in Salinas and the other in the town of Prunedale. Many of her clients come from rural areas where poverty is common. When COVID-19 hit and stay-at-home orders took effect, the number of patients coming to the practice fell by about 50%, Reddy said. To keep her patients safe and her business afloat, Reddy largely shifted to telehealth so she could provide care online.

She also turned to federal aid. “I took the stimulus money,” she said. “I asked for advances from anywhere I could get that. So, now I’m tapped out. I’ve done every single thing that I can think of to do. And there’s nothing more to do.”

By late June, patient volume at Reddy’s practice stood at roughly 70% of the level seen before the crisis.

Many dental offices have been hit even harder. From February to April, the number of dental office employees in California fell by 85,000, or 60%, a rate of decline that outpaced even job losses in the state’s restaurant industry. Nationwide, dental employment fell by about 546,000 from February to April, a 56% decline.

“March, April, mid-May — we were pretty much closed except for emergency care,” said Dr. Natasha Lee, who owns Better Living Through Dentistry, a practice in San Francisco’s Inner Sunset neighborhood. “While dental offices were considered essential, most were closed due to guidance from health departments and the CDC to postpone routine and preventative medical and dental care and just to limit things to emergency.”

Lee has reopened her clinic but is doing less business. She and her staff need extra time to clean tools and change their personal protective equipment.

“With the social distancing, the limiting [of] patients in the office at a time and the slowdown we’ve had, we’re probably seeing about, I’d say, two-thirds of our normal capacity in our practice,” she said in late June.

As for employment, California hospitals have fared better than outpatient medical offices. Hospitals shed about 2% of jobs from February to June.

“They have more capacity in a large organization to withstand the same shock,” said John Romley, a professor and economist at the University of Southern California’s Leonard D. Schaeffer Center for Health Policy and Economics.

Romley said he is optimistic the health care sector overall will recover faster than some other sectors of the economy, since health care remains a necessity.

Still, red flags abound. The recent spike in COVID-19 cases and deaths in many parts of the nation raises the specter of future shutdowns and, with them, additional health care layoffs. In California, Gov. Gavin Newsom recently ordered a second shutdown for dine-in restaurants, movie theaters and bars statewide, as well as churches, gyms and barbershops in much of the state. For now, dental and doctors’ offices can continue operating.

But it’s uncertain when patients will feel comfortable returning to the doctor for routine and preventive care. A series of Census Bureau surveys conducted between June 11 and July 7 found that 42% of Californians who responded had put off medical care in the previous four weeks because of the pandemic. About 33% said they needed medical care for something unrelated to COVID-19 but did not get it.

“I’ve been telling my staff and patients that we should prepare for things to stay not too different for six months to a year,” Reddy said, “which is pretty depressing for most people to think about.”

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


This KHN story first published on California Healthline, a service of the California Health Care Foundation.

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

Watch: When a Surprise Helper During Surgery Is Out-of-Network

Gayle King of “CBS This Morning” spoke with KHN Editor-in-Chief Elisabeth Rosenthal about the latest installment of KHN-NPR’s Bill of the Month. College student Izzy Benasso underwent surgery for a torn meniscus after a tennis injury last summer and was surprised to be contacted afterward by a surgical assistant, who said he would be billing her insurance more than a thousand dollars.

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.

KHN’s ‘What The Health?’: Trump Twists on Virus Response

Can’t see the audio player? Click here to listen on SoundCloud.

President Donald Trump — who has spent the past six months trying to play down the coronavirus pandemic — seems to have pivoted. In back-to-back briefings on July 21 and 22, Trump cautioned that the U.S. is in a dangerous place vis-a-vis the pandemic. He urged the public to wear masks — although he has rarely worn one in public.

Meanwhile, Republicans in the Senate are scrambling to put together a package for the next COVID-19 relief bill, facing a July 31 deadline, when some of the benefits passed in the spring expire. House Democrats passed their bill in May.

This week’s panelists are Julie Rovner of Kaiser Health News, Joanne Kenen of Politico, Margot Sanger-Katz of The New York Times and Tami Luhby of CNN.

Among the takeaways from this week’s podcast:

  • Although Trump’s renewed emphasis on COVID-19 has surprised some of his critics, it may persuade his supporters to take actions promoted by public health officials. Trump’s emphasis on the importance of face coverings, perhaps coupled with the rising number of cases in parts of the country, could convince people who were otherwise dismissive of masks. People who do not necessarily trust public health officials may listen to Trump.
  • Republicans on Capitol Hill are in disarray on how to approach the next coronavirus relief bill. They are not in lockstep with the White House and are not supporting Trump’s call for a payroll tax cut.
  • One reason members of Congress are not eager to cut the payroll taxes is that the economic downturn has spurred concerns the Medicare and Social Security trust funds are being depleted faster than expected. However, analysts point out that when employment rises again, some of those concerns could dissipate.
  • A key sticking point in the economic relief package is whether to extend the bump in unemployment benefits that Congress approved in the spring. Lawmakers are facing a hard deadline on the issue because that money runs out next week, and the prohibition on evictions that was also part of an earlier COVID-19 relief bill ends even sooner. With rent, mortgages and other bills coming due Aug. 1, unemployed consumers could face a tough beginning of the month.
  • The Food and Drug Administration has approved limited use of pool testing for COVID-19. That allows approved labs to put together a small number of tests to run at once, thus conserving some of the materials needed for the process. If the pool tests positive, then those people whose results were pooled have to be tested again individually. The efforts have limited usefulness when rates of transmission are high in a community, but they may be helpful in specific settings, such as schools or workplaces.
  • New data shows that opioid addiction ticked back up in 2019, after a slight decline. Part of the problem is the growing use of the powerful — and dangerous — drug fentanyl. Economic woes also play a role. Addiction is often referred to as an epidemic of despair.
  • Although it’s unlikely the judicial system will overrule the administration’s efforts to bolster short-term insurance plans — which are generally less expensive but don’t offer as much protection for consumers as policies sold on the Affordable Care Act’s marketplaces — they could be circumvented if Democrats take over the White House. Even still, Democrats would likely have to find a way to make ACA plans more affordable.

Also this week, Rovner interviews Pam Fessler of NPR about her new book, “Carville’s Cure.” It’s a history of the United States’ only federal leprosarium, on an abandoned sugar plantation along the Mississippi River in Louisiana.

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

Julie Rovner: The Washington Post’s “Keep an Eye on Your Coronavirus Budget,” by Leana Wen

Tami Luhby: The New York Times’ “This Hospital Cost $52 Million. It Treated 79 Virus Patients,” by Brian M. Rosenthal

Joanne Kenen: The Washington Post’s “Trump Keeps Boasting About Passing a Cognitive Test — But It Doesn’t Mean What He Thinks It Does,” by Ashley Parker and William Wan

Margot Sanger-Katz: The New York Times’ “During Coronavirus Lockdowns, Some Doctors Wondered: Where Are the Preemies?” by Elizabeth Preston

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.

Listen: Outbreak of Trench Fever Grips Coloradans

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

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

You can listen to the conversation here.

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

Medicaid Mystery: Millions of Enrollees Haven’t Materialized in California

The predictions were dire: Coronavirus lockdowns would put millions of Americans out of work, stripping them of their health insurance and pushing them into Medicaid, the health insurance program for low-income people.

In California, Gov. Gavin Newsom’s administration projected that the pandemic would force about 2 million additional people to sign up for the state’s Medicaid program, called Medi-Cal, by July, raising enrollment to an all-time high of 14.5 million Californians — more than one-third of the state’s population.

But July is almost over, and Medi-Cal enrollment has hovered around 12.5 million since March, when the pandemic shut down much of the economy — though enrollment ticked up in May and June, according to the latest data from the state Department of Health Care Services, which administers the program.

Essentially, enrollment hasn’t budged even though nearly 3 million Californians are newly unemployed.

“It’s a mystery,” said Anthony Wright, executive director of Health Access California, an advocacy group for health consumers. “We have lots of plausible explanations, but they don’t seem to add up.”

Even the state is stumped. The enrollment data is preliminary, and Medi-Cal officials expect the numbers to grow as eligibility appeals and other “unusual cases” are resolved, but not by 2 million people, said Norman Williams, spokesperson for the Department of Health Care Services.

The department based its projections on the state’s experience with the Great Recession a decade ago, a comparison that it now acknowledges was misguided because the pandemic did not spur a purely economic crisis. The state failed to predict people would avoid care at clinics and hospitals during this public health crisis, and thus be less likely to need coverage immediately.

“The current situation is far more complex because it involves both economic and health decisions, creating a more complicated picture more closely related to that seen during the 1918 influenza pandemic,” Williams said in a prepared statement.

Even with the faulty comparison, it’s not clear why more Californians haven’t enrolled, he said.

“The state prepared an estimate based on the best data available, during an unprecedented and rapidly evolving situation,” he said.

The miscalculation meant the state likely allocated more money to Medi-Cal than the program now needs, even as lawmakers struggled to find ways to prevent deep health care cuts and close a massive $54 billion budget deficit as they negotiated the 2020-21 state budget in May and June.

And a more accurate estimate could have potentially funded new programs, such as expanding Medi-Cal to unauthorized immigrants age 65 and up, some state lawmakers and advocacy groups said.

Newsom backed that expansion of Medi-Cal, estimated to cost $80.5 million in the first year, in his January budget proposal but abandoned it in May, citing California’s financial crisis spurred by the pandemic.

“We are talking about life-or-death services, so to say I’m frustrated is putting it mildly,” said state Sen. Holly Mitchell (D-Los Angeles), who chairs the Senate budget committee and leads budget negotiations in the upper house. “It’s irritating to me that they can be so off.”

The new state budget puts Medi-Cal’s overall cost at $115 billion, of which $2.4 billion in state money has been earmarked for caseload growth. Yet it’s unclear how much of that could have been available to fund other programs or stave off cuts had the caseload projection been more accurate, department officials acknowledged.

Most states predicted their Medicaid enrollment would rise due to the pandemic, though many are seeing similar delays in Medicaid sign-ups, said Cindy Mann, a partner at the legal and consulting firm Manatt Health who served as federal Medicaid director for the Centers for Medicare & Medicaid Services during the Obama administration.

Washington state, like California, hasn’t seen its Medicaid caseload grow as expected, said MaryAnne Lindeblad, its Medicaid director. It projected up to 95,000 people would join the program by now, yet it has seen 80,000 new enrollees since March.

“It’s been a little bit surprising,” she said. “There’s so much going on in people’s lives right now and signing up for Medicaid doesn’t seem to be one of them.”

Yet a record number of Americans have lost health insurance as a result of the COVID-19 pandemic and corresponding economic crash, according to a new report from Families USA, a national health advocacy group. California experienced the largest increase in newly uninsured residents of any state so far when an estimated 689,000 people lost coverage between February and May this year, the study shows.

“It’s a different kind of downturn and that might explain some of the reason we’re seeing lags across the country,” Mann said. “But unless unemployment numbers turn around dramatically, which is not the prediction, I think we will see the number of uninsured people continuing to grow and turn to the program.”

There are several theories about why Californians who have lost their jobs during the pandemic have not yet enrolled in Medi-Cal.

For one, signing up for food and housing assistance appears “more urgent” than signing up for Medi-Cal, Williams said.

The pandemic has also created new sign-up hurdles. With libraries, schools, community centers and county health care offices largely closed during lockdowns, uninsured residents have had fewer places to enroll. Hospitals and clinics also frequently enroll uninsured people into the program, but many healthy people are avoiding treatment for fear of being infected with COVID-19.

And those who have lost jobs may still have work-based coverage because employers planned to rehire them and kept them on job-based insurance plans, or because they’ve signed up for COBRA insurance temporarily.

Enrollment could also be lagging because the service industry has been hit hard, and many low-income workers in restaurants, bars or salons were already enrolled in Medi-Cal.

“About a quarter who were at risk of losing jobs were already enrolled when the crisis started,” said Laurel Lucia, director of health care programs at the Center for Labor Research and Education at the University of California-Berkeley.

Vanessa Poveda lost her health insurance after losing her job as a server at a San Francisco gastropub. She thinks she probably qualifies for Medi-Cal but hasn’t signed up yet, in part because the task feels daunting. (Courtesy of Lindsay Thomas)

Vanessa Poveda, 28, wasn’t among the service workers already enrolled in Medi-Cal when the crisis hit. Instead, she had health insurance through her job as a server at Bartlett Hall, an upscale gastropub near San Francisco’s Union Square.

When Poveda was laid off during the first round of coronavirus closures in March, the restaurant extended her health coverage for 30 days before it expired, she said. Now unemployed and uninsured, she thinks she probably qualifies for Medi-Cal but hasn’t signed up.

“I haven’t really gotten around to it,” she said.

Because Poveda is relatively healthy, she said, enrolling in coverage isn’t as urgent as some of her other needs.

“Medical insurance is definitely a top priority for me,” she said, “but I also need a roof over my head.”

In California, another factor may be at play. The Trump administration’s “public charge” policy may be having an outsize impact on Medi-Cal enrollment because of the state’s large immigrant population, said Hamutal Bernstein, a researcher at the Urban Institute. The rule allows federal immigration officials to more easily deny permanent residency status to those who depend on certain public benefits such as Medicaid.

“A lot of immigrant families are being disproportionately impacted by economic and health hardship and are increasingly needing some of this assistance,” Bernstein said. But “a lot of people are afraid of getting any kind of help.”

Federal rules also prevent the state from kicking anyone off Medicaid during the pandemic, which means people who normally would have fallen off the program will stay enrolled, contributing to the state’s inflated projections, Williams said.

The department said it is working to get out the word that Medi-Cal is available, but Mitchell is urging the state to do more.

“I’m concerned not enough outreach is being done,” she said. “We expect people to magically know they may qualify for Medi-Cal and they should go online and apply.”


This KHN story first published on California Healthline, a service of the California Health Care Foundation.

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

Listen: How the Pandemic Further Politicized Public Health

KHN Midwest correspondent Lauren Weber joined Texas Public Radio’s David Martin Davies on “The Source” call-in show to discuss her recent reporting on how politics is shaping the public health response to the coronavirus pandemic.

Weber has been reporting on the issue in collaboration with the Associated Press for the ongoing “Underfunded and Under Threat” series. She and her colleagues wrote about the threats that local public health officials face amid a backlash about pandemic restrictions. That’s led at least 34 state and local public health leaders to resign, retire or get fired in 17 states since April, the KHN-AP review found. The series also explores how public health has not been a political priority for years, with state public health spending per person falling 16% from 2010 to 2018 nationally when adjusted for inflation.

You can hear the conversation here.

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

Behind The Byline: ‘Reporting From a Distance’

Although the coronavirus pandemic shut down many organizations and businesses across the nation, KHN has never been busier — and health coverage has never been more vital. We’ve revamped our Behind The Byline YouTube series and brought it to Instagram TV.

Journalists and producers from across KHN’s newsrooms take you behind the scenes in these bite-size videos to show the ways they are following the story, connecting with sources and sorting through facts — all while staying safe.

Anna Almendrala — Reporting From a Distance

KHN reporters have had to change the way they interact with the people during in-person interviews — in order to keep themselves and others safe. Los Angeles correspondent Anna Almendrala takes us with her as she speaks with street vendors across the Los Angeles area. Sometimes the protective layers she wears create, well, social distance: “I’m shocked that people have agreed to talk to me when I’m looking like this,” Almendrala said. An interview with one face mask seller probably would have ended with a hug if it weren’t for COVID-19, she said.

As Coronavirus Patients Skew Younger, Tracing Task Seems All But Impossible

Younger people are less likely to be hospitalized or die of COVID-19 than their elders, but they circulate more freely while carrying the disease, and their cases are harder to trace. Together, these facts terrify California hospital officials.

People under 50 make up 73% of those testing positive for the disease in the state since the beginning of June, compared with 52% before April 30. That shift isn’t comforting to Dr. Alan Williamson, chief medical officer of Eisenhower Health in Riverside County’s Coachella Valley.

“It honestly worries me more because it means that this is now established in the community,” he said.

As the virus spreads throughout the United States, figuring out how patients were exposed becomes increasingly difficult, which makes it nearly impossible to stop viral transmission. Younger people with COVID-19 are also less likely to pick up the phone when a contact tracer calls, health officials say. And hospitals are seeing case numbers rise among staffers, who are getting infected in their communities, not necessarily at work.

Los Angeles and nearby counties, whose populations are heavily Latino, have been driving California’s COVID spike and account for a disproportionate number of its cases, as they have since the pandemic’s early days.

The massive wave of new infections has caused deaths among people ages 18 to 40 to slowly mount, from six in the first 10 days of May in Los Angeles County, for example, to 22 in the same period of July.

Hospitalizations have soared among the younger age group, which made up about 10% of people hospitalized in April but account for more than 25% now. Los Angeles County reported Wednesday that 2,193 people were hospitalized with the virus, the highest number since the pandemic started. It gave no detailed age breakdown.

The first wave of patients in March and April at Eisenhower Medical Center, Eisenhower Health’s 463-bed flagship hospital, were mostly nursing home residents and retirees who lived in the area part time. Most were white.

But in June, as the virus spread through the rest of the Coachella Valley — famous for producing dates, citrus and other crops — it also sickened people from the region’s year-round Latino agricultural workforce. While these patients are younger and usually don’t need hospitalization, Williamson has noticed a new trend among those who do.

“Quite frequently, there would be in their history that there are two or three or more other family members that are home and COVID-positive,” he said. “I didn’t see that before.”

In the eastern part of the valley, where multigenerational or multifamily households are common, COVID-positive patients don’t always have the space or resources to live in strict isolation as they recover.

“These are young people living in a household with little kids, teenagers and 70-year-old grandparents,” he said. “That’s not a good formula.”

Most of the younger patients have a benign course of illness. Johnny Luna, 34, who lives in a two-bedroom apartment in the Boyle Heights section near downtown Los Angeles, got tested for COVID-19 in May after experiencing what felt like a mild asthma attack, with shortness of breath and fatigue.

When he received a letter with a positive test result a week later, Luna was dumbfounded. He had no idea where he might have been exposed, since he, his partner and school-age daughter had followed public health recommendations to the letter.

“I washed my hands until they were chapped and dried, and took all the suggested measures,” he said. “In fact, this was the only thing in my entire life that’s gotten me to stop biting my nails.”

As cases mount, contact tracers are having less success getting COVID-positive patients to pick up the phone, said Dr. Jeffrey Gunzenhauser, chief medical officer at the Los Angeles County Department of Public Health. Contact tracers had been able to complete an interview with positive patients more than 70% of the time up until about three weeks ago, he said. Now, the rate is as low as 65%.

“It could be that older individuals who traditionally use phones are more willing to answer phones, whereas younger people might communicate through texting and other means, so maybe they’re less likely to,” he said.

To increase pickups, the department has asked telephone companies to label all calls from contact tracers as “LA Public Health” when they flash on a phone’s display. The department has convened focus groups among young adults to figure out ways to better communicate with them.

In Luna’s case, AltaMed Health Services, which administered his COVID-19 test, said it tried to call him three days in a row and left two voicemails before sending the letter. Luna said that he never received the calls or voicemails — and that the same thing happened to people he knows.

At the beginning of the pandemic, infected patients usually had a good sense of where they were exposed to the virus, and by whom, said Patricia Marquez Sung, an epidemiologist with USC Verdugo Hills Hospital, a 158-bed facility in Glendale, in L.A. County.

People showing up at the Verdugo Hills emergency department with COVID symptoms in June were significantly younger than earlier this year, hospital data shows — and more ER patients say they have “no idea” where they could have contracted the virus, Sung said.

“What that’s telling me is that, potentially, we’re getting a little bit lax with the vigilance in masking, staying home and hand-washing,” Sung said. “People have

gotten restless and their perceptions of risk are a lot lower than three or four months ago.”

Even health care workers are getting restless and venturing out more. Verdugo Hills’ sister hospital, the 401-bed Keck Hospital of USC near downtown L.A., is seeing a rise in health care worker infections from community spread. During the last 10 days of June, 20 staffers tested positive; the hospital’s in-house contact tracing team determined that none of them were exposed to COVID-19 patients at work. In the previous 3½ months the hospital had recorded a total of 68 positives among staff.

Public health officials and political leaders are urging younger people to refrain from parties and large gatherings, and emphasizing the possibility of asymptomatic or pre-symptomatic transmission to more vulnerable populations.

These cautionary messages are especially urgent amid a growing consensus that the virus can linger in the air indoors, said Chris Van Gorder, CEO of Scripps Health, a large nonprofit health system in San Diego County. Previously, leading public health groups like the World Health Organization had said the virus was mostly transmitted directly from person to person, in respiratory droplets that rapidly sink to the ground unless they’re inhaled.

The shift in thinking has painful implications for people — including health care workers — eager to return to indoor restaurant dining and other businesses, said Van Gorder. Some 201 COVID-19 infections were reported among county health care workers in the first week of July, compared with 72 in the last week of May.

Van Gorder learned that some hospital employees went to casinos when they reopened, and another group “decided to go off to dinner together in Little Italy. They know better, and they got sick.”

“I think California was doing a phenomenal job flattening the curve, but there was so much pressure to reopen that we reopened too fast,” he said. “We’re seeing the consequences of that now.”

KHN’s ‘What the Health?’: The Trump Administration’s War on Fauci


Can’t see the audio player? Click here to listen on SoundCloud.


Not only does the Trump administration lack a comprehensive plan for addressing the ongoing coronavirus pandemic, it spent much of the past week working to undercut one of the nation’s most trusted scientists, Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases. Reporters were given “opposition research” noting times when Fauci was allegedly wrong about the course of the pandemic, and Peter Navarro, a trade adviser to President Donald Trump, published an op-ed in USA Today attacking Fauci personally.

Meanwhile, the Supreme Court may not hear the case challenging the constitutionality of the Affordable Care Act before the November elections, although its existence is likely to serve as fodder for Democrats up and down the ballot.

And lower courts have been active on the reproductive health front since the high court declined to fully exercise its anti-abortion majority. Federal judges in Tennessee and Georgia blocked abortion bans, while one in Maryland blocked an administration rule requiring insurance companies that sell plans on the Affordable Care Act exchanges to send customers a separate bill for abortion coverage if it is offered.

This week’s panelists are Julie Rovner of Kaiser Health News, Alice Miranda Ollstein of Politico, Paige Winfield Cunningham of The Washington Post and Erin Mershon of Stat News.

Among the takeaways from this week’s podcast:

  • Despite rosy pronouncements by federal officials that testing efforts in the country are progressing well, many states still report problems getting supplies they need, and delays in getting test results are making contact tracing all but impossible.
  • The testing problems create major hurdles to opening schools on time, as testing and contact tracing have been prerequisites to open schools safely.
  • Researchers are complaining that the Trump administration’s decision to have hospitals report their coronavirus data to HHS, instead of the Centers for Disease Control and Prevention, may make it difficult for them to study aspects of the outbreak.
  • Groups that oppose abortion see efforts by Chief Justice John Roberts to moderate decisions this year as a signal he may not be receptive to their arguments to overturn Roe v. Wade, which legalized abortion nationally. The chance to get one more conservative on the court to replace one of the current liberals could galvanize more support for President Donald Trump’s reelection campaign.
  • On the issue of abortion, House Democrats surprised some people by keeping the Hyde Amendment — which outlaws federal spending for abortions in nearly all cases — in the HHS appropriations bill. That was likely an effort to protect vulnerable Democrats in conservative districts.

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

Julie Rovner: The New Yorker’s “How Trump Is Helping Tycoons Exploit the Pandemic,” by Jane Mayer

Alice Miranda Ollstein: The New York Times Magazine’s “Why We’re Losing the Battle With Covid-19,” by Jeneen Interlandi

Erin Mershon: The New York Times’ “Bottleneck for U.S. Coronavirus Response: The Fax Machine,” by Sarah Kliff and Margot Sanger-Katz

Paige Winfield Cunningham: Politico’s “Inspector General: Medicare Chief Broke Rules on Her Publicity Contracts,” by Dan Diamond and Adam Cancryn


To hear all our podcasts, click here.

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

Vacuna contra el coronavirus: ¿en qué punto está la investigación?

A más de cuatro meses del comienzo de la pandemia en los Estados Unidos, ¿qué tan cerca está el país y el mundo de una vacuna segura y efectiva? Científicos dicen que ven un progreso constante y expresan un optimismo cauteloso de que una vacuna podría estar lista para la próxima primavera del hemisferio norte.

A principios de julio, había cerca de 160 ensayos de  vacunas en todo el mundo, según la Organización Mundial de la Salud (OMS).

En general, el ensayo de una vacuna tiene varias fases. En la inicial, la vacuna se administra a 20 a 100 voluntarios sanos. El enfoque en esta fase es asegurarse que la vacuna sea segura y observar cualquier efecto secundario.

En la segunda fase, hay cientos de voluntarios. Además de monitorear la seguridad, los investigadores intentan determinar si las vacunas producen una respuesta del sistema inmunitario.

La tercera fase involucra a miles de pacientes. Esta etapa continúa evaluando los primeros objetivos, además de cuán efectiva es la vacuna para proteger a las personas expuestas al patógeno, en este caso el coronavirus.

Esta fase también recopila datos sobre efectos secundarios negativos más raros.

En circunstancias normales, todo este proceso tarda años en completarse. Pero en el caso del coronavirus, el tiempo apremia. Esto ha estimulado más asociaciones público-privadas y ha aumentado significativamente la financiación.

Las tres vacunas más avanzadas se encuentran en la fase 3.

Una está siendo desarrollada por investigadores de la Universidad de Oxford en el Reino Unido. Utiliza una versión debilitada de un virus que causa resfríos comunes en chimpancés. Luego, los investigadores agregaron proteínas, conocidas como antígenos, del nuevo coronavirus, con la esperanza de que pudieran “entrenar” al sistema inmune humano para combatir al virus si entra en contacto con él.

Otra candidata en un ensayo de fase 3 se está desarrollando en China. Utiliza una versión muerta, y por lo tanto segura, del nuevo coronavirus para estimular una reacción inmune.

Y el 15 de julio, la empresa de biotecnología Moderna, que se está asociando con los Institutos Nacionales de Salud de los Estados Unidos, anunció que pasaría a la fase 3 de su vacuna en dos semanas.

Otras dos han llegado a la fase 2, mientras que ocho están terminando sus ensayos de la fase 1 e iniciando el trabajo en la fase 2.

Todas estas vacunas están siendo desarrolladas por una combinación de corporaciones e instituciones en varios países. Estos esfuerzos buscan aprovechar una gama de tecnologías.

Una usa material de ARN que proporciona las instrucciones para que un cuerpo produzca los antígenos necesarios. Este es un enfoque relativamente no probado para la vacunación, pero si funciona, tiene aspectos que podrían facilitar su fabricación. Otro enfoque es similar, pero usa ADN en lugar de ARN.

La compañía estadounidense de biotecnología, Novavax, recibe fondos federales para producir una vacuna que utiliza una proteína hecha en laboratorio para producir una respuesta inmune.

Hay 10 investigaciones de otras vacunas en fase 1, y unas 140 todavía no han alcanzado todavía la fase clínica.

Expertos dicen que tener este número de vacunas potenciales en desarrollo es impresionante, justamente por lo nuevo que es el coronavirus.

“En general, el ritmo de desarrollo y avance a los ensayos de fase 3 es impresionante”, dijo Matthew B. Laurens, profesor asociado del Centro de Desarrollo de Vacunas y Salud Global de la Escuela de Medicina de la Universidad de Maryland. “Las asociaciones público-privadas han tenido mucho éxito y están logrando objetivos para el desarrollo rápido de vacunas”.

Además, el hecho de que se estén probando varios enfoques distintos significa que no estamos poniendo todos los huevos en una sola canasta.

“Necesitaremos varias candidatas si alguna presenta problemas en la producción o efectos inesperados cuando se use en un número grande de personas”, explicó Laurens.

Mientras tanto, en un momento de creciente escepticismo público sobre el gobierno y las vacunas, la Administración de Medicamentos y Alimentos (FDA) recientemente publicó pautas adicionales sobre la efectividad de la vacuna.

Las pautas de la FDA “reafirmaron el riguroso proceso de la FDA para aprobar cualquier vacuna. Eso da una gran seguridad”, dijo William Schaffner, profesor de medicina preventiva y enfermedades infecciosas en el Centro Médico de la Universidad de Vanderbilt. “Cuanto más hablamos de hacer las cosas rápido, más piensa el público, ‘probablemente están usando atajos’”.

Si se quiere obtener la aprobación de la agencia, la vacuna debe prevenir o disminuir la gravedad de la enfermedad al menos en un 50%.

¿Qué tan rápido tendremos acceso a una vacuna viable?

A principios de abril, Kathleen M. Neuzil, directora del Centro de Desarrollo de Vacunas y Salud Global de la Universidad de Maryland, dijo a Politifact que si todo salía bien, podría haber cinco o seis ensayos de vacunas dentro de los seis meses siguientes. Ahora, tres meses y medio después, ese número es el triple.

Anthony Fauci, director del Instituto Nacional de Alergias y Enfermedades Infecciosas, y otros funcionarios se han mantenido consistentes en su estimación del tiempo: 12 a 18 meses desde el comienzo de la pandemia, o aproximadamente a fines de la primavera de 2021.

Queda por ver qué tan rápido se pueden producir y distribuir las vacunas una vez aprobadas para uso general. Las autoridades también están lidiando con quiénes tendrán acceso primero. Por lo tanto, no está claro cuánto tiempo tendría que esperar una persona para vacunarse.

Laurens dijo que no está muy preocupado por la distribución, porque eso es algo con lo que los funcionarios tienen una larga experiencia. “Existen programas bien establecidos para la distribución de vacunas, incluso para la vacunación estacional de grandes cantidades de individuos”, dijo.

William Schaffner, experto en infecciosas del Centro Médico de la Universidad Vanderbilt, dijo que una señal de esperanza es que el coronavirus en sí parece ser relativamente estable. Ha habido preocupación de que el nuevo coronavirus, como muchos otros virus, estuviera mutando con el tiempo. Si el virus cambia mucho, podría convertirse en un problema que perjudica la investigación de vacunas.

Pero hasta ahora, eso no ha sucedido. Incluso si surge evidencia de que las mutaciones están haciendo que el virus sea más transmisible, o que una nueva variante esté enfermando a las personas, eso no debería afectar el proceso de la vacuna. “El núcleo central del virus seguirá siendo el mismo”, dijo Schaffner.

En el ultimo mes ha habido poca información sobre el avnace en las vacunas, pero Schaffner no esta preocupado sobre este silencio.

“en el ensayo de una vacuna, si aparece un efecto adverso el estudio se detiene”, dijo. “Por eso el silencio es Bueno, nos enteraríamos si pasara algo malo”.

Listen: A Bureaucratic Shuffle for Hospital COVID Data

Julie Rovner, KHN’s chief Washington correspondent, on Wednesday joined Rob Ferrett, host of “Central Time” on Wisconsin Public Radio, to discuss the Trump administration’s announcement that hospital data on coronavirus cases will no longer be routed to the Centers for Disease and Control and Prevention and instead will go to the Department of Health and Human Services.

Some critics have suggested this could allow officials to politicize the reports and may make it more difficult for independent researchers to get access to the data. You can hear the conversation here.

A Coronavirus Vaccine: Where Does It Stand?

More than four months into the coronavirus pandemic, how close are the U.S. and the world to a safe and effective vaccine? Scientists say they see steady progress and are expressing cautious optimism that a vaccine could be ready by spring.

As of early July, roughly 160 vaccine projects were underway worldwide, according to the World Health Organization.

Generally, a vaccine trial has several phases. In an initial phase, the vaccine is given to 20 to 100 healthy volunteers. The focus in this phase is to make sure the vaccine is safe, and to note any side effects.

In the second phase, there are hundreds of volunteers. In addition to monitoring safety, researchers try to determine whether shots produce an immune-system response.

The third phase involves thousands of patients. This phase continues the goals of the first two, but adds a focus on how effective the vaccine is in protecting people exposed to the pathogen, in this case the coronavirus. This phase also collects data on more unusual negative side effects.

In ordinary circumstances, these phases take years to complete. But for the coronavirus, the timeline is being shortened. This has spurred more public-private partnerships and significantly increased funding.

Here’s a rundown of the vaccine candidates that are furthest along in the clinical phases:

The three vaccine candidates that are furthest along are in phase 3.

One is being developed by researchers at Oxford University in the U.K. It uses a weakened version of a virus that causes common colds in chimpanzees. Researchers then added proteins, known as antigens, from the novel coronavirus, in the hope that these could prime the human immune system to fight the virus once it encounters it.

Another candidate in a phase 3 trial is being developed in China. It uses a killed, and thus safe, version of the novel coronavirus to spur an immune reaction.

And on July 15, the biotech company Moderna, which is partnering with the National Institutes of Health, announced that it would be moving to phase 3 within two weeks.

Two others have made it as far as phase 2, while eight others are finishing their phase 1 trials while also beginning phase 2 trials.

These candidates are being developed by a mix of corporations and institutions in several countries. These efforts seek to leverage a range of technologies.

One uses RNA material that provides the instructions for a body to produce the needed antigens itself. This is a relatively untested approach to vaccination, but if it works, it has aspects that could make it easier to manufacture. Another approach is similar, but uses DNA instead of RNA.

One U.S. biotech firm, Novavax, is receiving federal funding to produce a vaccine that uses a lab-made protein to inspire an immune response.

Beyond these, another 10 vaccine candidates are in phase 1 clinical trials, while 140 haven’t reached the clinical phase yet.

Having so many potential vaccines this far along is impressive, experts say, given the short time scientists have known about the novel coronavirus.

“Overall, the pace of development and advancement to phase 3 trials is impressive,” said Matthew B. Laurens, associate professor at the University of Maryland School of Medicine’s Center for Vaccine Development and Global Health. “The public-private partnerships have been highly successful and are achieving goals for rapid vaccine development.”

In addition, the fact that several types of vaccine approaches are being tested means we aren’t putting all of our eggs in one basket.

“We will need several candidates should any one of these experience difficulties in manufacturing or show a safety signal when implemented in larger numbers of people,” Laurens said.

Meanwhile, at a time of rising public skepticism of government and vaccines, the Food and Drug Administration recently released additional guidelines on vaccine effectiveness. The new guidance requires vaccines to prevent or decrease the severity of the disease at least 50% of the time if they are to win the agency’s approval.

The FDA guidelines “reaffirmed the very rigorous FDA process for approving any vaccine. That gives a great deal of reassurance that this was going to be handled by the book,” said William Schaffner, a professor of preventive medicine and infectious diseases at Vanderbilt University Medical Center. “The more we talk about doing things fast, the more the public thinks, ‘They’re probably cutting corners.’”

How fast will we have access to a workable vaccine?

In early April, Kathleen M. Neuzil, director of the University of Maryland’s vaccine center, told PolitiFact that if all went well, there might be five or six vaccines in trials within six months. Now, 3 1/2 months later, there are two to three times that number.

Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, and other officials have remained consistent in their estimation of the timeline: 12 to 18 months from the start of the pandemic, or roughly the late spring of 2021.

Schaffner told PolitiFact that he continues to see the first quarter of 2021 as a reasonable target. “I think that’s where the needle is pointing,” he said.

It remains to be seen how fast vaccines can be manufactured and distributed once approved for general use. Officials are also grappling with which Americans will get access first. So it’s unclear how long a person would have to wait to get vaccinated.

Laurens said he is not overly concerned about the distribution, because that is something that officials have long experience with. “Well-established programs exist for vaccine distribution, including for seasonal vaccination of large numbers of individuals,” he said.

Another hopeful sign, Schaffner said, is that the coronavirus itself seems to be relatively stable. There had been concern that the novel coronavirus, like many other viruses, is mutating over time. If the virus changes enough, that could become a problem that bedevils vaccine researchers.

But so far, that hasn’t happened. Even if evidence emerges that mutations are making the virus more transmissible, or that a new variant is making people sicker, that shouldn’t affect the vaccine process. “The central core of the virus would remain the same,” Schaffner said.

During the past month, there has been relatively little news about how much progress is being made on particular vaccines. Schaffner is not worried by the relative quiet.

“In a vaccine trial, if there’s an adverse safety finding, the guillotine comes down and that trial is stopped,” he said. “So quiet is good, because we’d know if something bad happens.”

Listen: Colorado Cuts Back Health Care Programs Amid Dual Crises

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

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

You can hear the conversation here.

KHN’s ‘What The Health?’: ‘Open The Schools, Close The Bars’


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How to safely open the nation’s schools this fall has become the latest spat in attempting to deal with the COVID-19 pandemic. President Donald Trump and Vice President Mike Pence have decried the guidelines issued by the Centers for Disease Control and Prevention as too complicated and expensive and ordered a new set. Meanwhile, tests for the virus remain difficult to get, particularly in states experiencing spikes, and getting results to patients is taking increasingly longer, making contact tracing effectively impossible.

Also this week, the Supreme Court handed the Trump administration a victory, upholding a set of regulations aimed at making it easier for employers to decline to offer birth control as part of their health insurance — even though it is generally required under the Affordable Care Act.

And Oklahoma voters narrowly approved a ballot measure to expand the Medicaid program, becoming the latest Republican-dominated state where voters opted for something that had been rejected by their elected officials.

This week’s panelists are Julie Rovner of KHN, Joanne Kenen of Politico, Mary Ellen McIntire of CQ Roll Call and Kimberly Leonard of Business Insider.

Among the takeaways from this week’s podcast:

–Although the Supreme Court upheld — at least for now — the changes made to ACA contraception coverage, Congress could rescind the policy, which might happen if Democrats gain control of the Senate next year. The rule could also be struck down by a lower court on grounds that were not reached in the current lawsuit.

–Much attention has been paid to the Trump administration’s rule on contraception coverage. But at the same time, the administration has been chipping away at other programs that provide birth control to many low-income women.

–With Trump doubling down on his support of Republican state officials’ legal challenge to the ACA, the federal health law could play a role again in the fall election. But it will likely also be linked to other health issues, including the government’s response to the coronavirus pandemic.

–The Medicaid vote in Oklahoma comes as the pandemic has created economic havoc, and it’s not clear where the state will get its share of the costs for the federal-state program that provides health coverage to low-income residents.

–Even after four months of battling COVID-19 in the U.S., people are still waiting in long lines to get a test, and results are slow because of the huge demand. Some consumer advocates hope a new stimulus package will provide more funding, but what’s really needed to help the economy and the schools is a rapid, inexpensive test that can be self-administered.

Also this week, Rovner interviews KHN’s Sarah Varney, who reported the latest KHN-NPR “Bill of the Month” installment, about an essential health worker with suspected COVID-19 who was sent to the emergency room, where she did not get a COVID test — but did get a large bill. If you have an outrageous medical bill you would like to share with us, you can do that here.

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

Julie Rovner: The New York Times’ “Sweden Has Become the World’s Cautionary Tale,” by Peter S. Goodman.

Kimberly Leonard: The Atlantic’s “The Pandemic Experts Are Not Okay,” by Ed Yong.

Joanne Kenen: The New Yorker’s “The Emotional Evolution of Coronavirus Doctors and Patients,” by Dhruv Khullar.

Mary Ellen McIntire: Science News’ “How Making a COVID-19 Vaccine Confronts Thorny Ethical Issues,” by Bethany Brookshire.


To hear all our podcasts, click here.

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

Behind The Byline: ‘Everybody Hit Record’

Although the coronavirus pandemic shut down many organizations and businesses across the nation, KHN has never been busier ― and health coverage has never been more vital. We’ve revamped our Behind The Byline YouTube series and brought it to Instagram TV

Journalists and producers from across KHN’s newsrooms take you behind the scenes in these bite-size videos to show the ways they are following the story, connecting with sources and sorting through facts — all while staying safe.

Julie Rovner – ‘Everybody Hit Record’

What happens when KHN’s podcast “What The Health?” goes from an in-person studio production to essentially a super-long Zoom meeting? Chief Washington Correspondent — and podcast host — Julie Rovner has some behind-the-screens advice: Turn off that noisy air conditioner and that bubbling fish tank, politely ask your quarantine crew to quiet down, and everybody hit record — at the same time if possible. The smartest health care podcast in the business: KHN’s “What The Health?” posts on Thursdays.