Big Business Boosts Vaccine Effort, but It’s ‘Complex Choreography’ to Get Shots in Arms 


This story is part of a partnership that includes NPR and KHN. It can be republished for free.

As states await the promise of a renewed federal pandemic response and expand the number of Americans who qualify for a shot, some governors are trying to scale up their covid vaccine operations — and smooth out the kinks — with the help of the private sector.

In Washington state, Starbucks, Microsoft and Costco are lending logistical expertise and manpower to public health agencies that are trying to dispatch their doses of vaccines more efficiently.

Over the weekend, thousands of people filed through the Charlotte Motor Speedway in North Carolina — now serving as a mass vaccine site — run by Honeywell and other local businesses that have partnered with the state.

And on Monday, Google pledged $150 million to “promote vaccine education and equitable distribution” and to make it easier for people to find “when and where to get the vaccine.”

This backup from businesses comes as states continue to navigate uncertainty around when they’ll receive doses. A patchwork of vaccination eligibility rules and ways to sign up for a shot have left many Americans confused, frustrated and even frightened, as those at high risk of serious complications from the covid virus continue to wait with little news on when they’ll be inoculated.

Washington Gov. Jay Inslee calls private enterprise the “arsenal” of the coronavirus vaccination campaign, comparing the partnership to the production of battleships during World War II, but even Inslee, a Democrat, did not oversell the immediate impact.

“This is not going to be an expectation of an Amazon delivery system,” Inslee said while announcing his state’s plan last week. “There will be times when people will not have dosages available in their community because there isn’t enough being delivered.”

Washington and more than half of all states have opened up vaccines to anyone 65 and older — greatly spiking demand — yet a major hang-up continues to be making use of all the delivered vaccines.

Of the approximately 41 million vaccines delivered to states, more than 19 million have not yet been given, according to data from the Centers for Disease Control and Prevention.

“It’s a dance that requires a lot of complex choreography,” said Alison Buttenheim, an associate professor of nursing and health policy at the University of Pennsylvania.

“We aren’t always so innovative and nimble in public health and this is the moment where we need that — we need innovation and we need states trying different things.”

The Washington state partnership is using Starbucks to streamline the vaccine clinics, Microsoft to provide tech support and space on its campus, and Costco to manage logistics around delivering the shots.

Every state should be looking to its businesses to fill gaps in the vaccination operations, whether around online scheduling, public messaging or the nitty-gritty details of coordinating delivery and clinics, Buttenheim said.

“There’s no one corporate entity that’s going to solve this, but most have something to offer,” she said.

Many public health departments have struggled with making the vaccine process “customer friendly” because they don’t typically provide this kind of direct service, said Dr. Marcus Plescia, chief medical officer for the Association of State and Territorial Health Officials (ASTHO), which represents state health directors.

“It has been challenging to scale those kinds of things up,” he said. “Then you add in that public health departments have been dealing with covid for a year, with limited resources and people are tired.”

In North Carolina, Atrium Health, a nonprofit health care system, is part of the business partnership with Honeywell that aims to give 1 million shots by July.

“It allows us as the health care system to focus on what we do best — getting the shots in the arms and making sure people are tolerating it and the aftercare,” said Dr. Scott Rissmiller, Atrium’s executive vice president.

“Our hospitals are full, and it’s the same people that are working in our hospitals that we are needing to redeploy for the vaccines.”

Looking Ahead 

The Biden administration has pledged more transparency around the availability of doses and enlisted the Federal Emergency Management Agency to set up mass vaccination sites, as many as 100 in the next month.

While the pace of vaccination has picked up, public health experts warn the U.S. must move faster as at least one more contagious variant of the virus shows up in a growing number of states and threatens to drive another devastating surge.

A federal partnership with large pharmacies has faced criticism for not moving more quickly. Some states have gone through the majority of their doses, while others have used fewer than half of what’s been delivered.

Public health can get a boost from the private sector, but there are limits to what can be outsourced, said epidemiologist Jennifer Nuzzo of Johns Hopkins University.

“This isn’t just handing somebody a package; this is a clinical encounter,” said Nuzzo.

Data entry involves sensitive personal information, and the actual vaccinators need to be trained and credentialed.

Nuzzo, who has studied the U.S. capacity for mass vaccination, estimates the U.S. will need anywhere from 100,000 to 184,000 people to staff vaccine clinics, of which 17,000 would have to be vaccinators, to meet the Biden administration’s goal of 100 million shots in 100 days.

“I think it would be extraordinarily difficult to just find those vaccinators,” she said.

The private sector may be able to contribute, but Nuzzo cautioned that any partnerships cannot appear to favor the employees of the company.

Last week, Amazon offered to assist the Biden administration on the vaccine rollout and has signaled it hopes to vaccinate its own front-line workers as soon as possible.

The shaky supply has limited the ability of some states to pursue mass vaccine sites, and many providers are still hesitant to schedule vaccines too far in advance. A hospital in Arlington, Virginia, canceled 10,000 appointments after the state changed how it allocates its supply of vaccines.

In Arizona, which has two mass vaccine sites so far, appointments are already booked through February.

Since the early days of the vaccine rollout — when the Trump administration promised 20 million doses before 2021 — the public has received confusing messages about when they’ll be able to get a shot.

States still face the challenge of how to set realistic expectations. Many are ramping up their capacity for giving vaccines, even before the supply has caught up.

“The worry I have is that if we create expectations for how quickly people can get vaccinated and then don’t deliver, people will become perhaps jaded or disappointed or, worse, mistrustful of vaccination efforts,” she said.

More than half of unvaccinated Americans say they need more information about when or where they’ll get vaccinated, according to a national survey from the Kaiser Family Foundation. (KHN is an editorially independent program of KFF.)

At his grocery store in Everett, Wash., Wil Peterson, a cashier, hears this confusion around the vaccine process from his co-workers.

“There’s a lot of information that’s been floating around, so I’m just trying to keep up with the latest developments,” said Peterson, who’s in his 50s and expects his turn to get a shot will come sometime in February.

Peterson worries about catching the virus every day he goes to work and still deals with customers who refuse to wear masks, so he’s eager to get vaccinated.

But he also knows it may not go smoothly, after hearing from a friend who tried to sign up for his shot.

“But the site crashed, so I’m kind of bracing for maybe that happening when I try to do it, but I’m hoping that won’t be the case,” he said.

This story is part of a partnership that includes 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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‘We’re Not Controlling It in Our Schools’: Covid Safety Lapses Abound Across US

Computer science teacher Suzy Lebo saw covid-19 dangers frequently in her Indiana high school: classes with about 30 students sitting less than 18 inches apart. Students crowding teachers in hallways. Students and staff members taking off their masks around others.

“I’m concerned,” said Lebo, who teaches at Avon High School in the Indianapolis suburbs. “We’re not controlling the virus in our county. We’re not controlling it in our state. And we’re not controlling it in our schools.”

President Joe Biden’s covid response proposes $130 billion to improve school safety, offers federal guidance for making schools safer and improves workplace protections to safeguard teachers and other workers from covid.

This comes after many school districts and states holding in-person classes have ignored recommendations from public health officials or written their own questionable safety rules — creating a tinderbox where covid can sicken and kill.

A KHN analysis of federal and state Occupational Safety and Health Administration data found more than 780 covid-related complaints covering more than 2,000 public and private K-12 schools. But those pleas for help likely represent only a small portion of the problems, because a federal loophole prevents public school employees from lodging them in 24 states without their own OSHA agencies or federally approved programs for local and state employees. Still, the complaints filed provide a window into the safety lapses: Employees reported sick children coming to school, maskless students and teachers less than 6 feet apart, and administrators minimizing the dangers of the virus and punishing teachers who spoke out.

KHN also found that practices contradicting safety experts’ advice are codified into the patchwork of covid rules put out by states and districts. For instance, about half of states don’t require masks for all students — including 11 that have exempted schoolchildren of various ages from mandatory masks, with New Hampshire excluding all K-12 students. Districts can craft stricter rules than their states but often don’t.

“The response to the virus has been politicized,” said Dr. Chandy John, an expert in pediatric infectious diseases at the Indiana University School of Medicine. “There’s a willingness to ignore data and facts and go with whatever you’re hearing from the internet or from political leaders who don’t have any scientific knowledge.”

But even with Biden’s rollout of new school safety steps, struggles over balancing the need for education with covid safety are sure to continue, since it will be months before the nationwide vaccine rollout reaches all school staff members, and the shots haven’t yet been approved for kids.

Meanwhile, the scope of covid in schools remains unknown. Biden’s order calls for tracking it on the federal level, which wasn’t happening. States haven’t collected uniform data either. The Covid Monitor, a project launched by volunteers and public health researchers, has counted more than 505,000 cases in K-12 schools — more than a quarter of them among staffers. Although kids are less likely than adults to become seriously ill, recent research suggests they can spread the virus even if asymptomatic. The American Federation of Teachers estimates covid-19 has killed at least 325 school employees, though it’s unclear whether they caught it at school.

Among them was Susanne Michael, 47, a fourth grade teacher at Harrisburg Elementary School in northeastern Arkansas. As a cancer survivor with diabetes, she rarely went anywhere outside her home this past fall, according to her husband, Keith. She told him she worried about catching the coronavirus while teaching, but she “went and did it because she loved it.”

She tried her best to keep more than 20 students 6 feet apart, he said, but told him it was nearly impossible.

Though she always wore a mask, he doesn’t know if every student did. According to the district’s website, masks are required in grades 4-12 “when social distancing is not feasible,” and “physical distancing will be practiced to the extent practical.” District leaders did not respond to requests for comment.

Michael wound up hospitalized on a ventilator. Doctors let her husband visit in protective gear because he, too, had the virus. He held her hand as she slipped away Oct. 1.

The loss hits him hardest at night. “For 27 years, I always had somebody there next to me,” he said. “It’s difficult and weighs on your mind and heart a lot when you’re laying there in an empty bed and your best friend’s gone.”

She left five children, ages 3 to 22, including a former student and her two siblings adopted in July.

A Litany of Lapses

Doctors said covid risks can be drastically reduced by following straightforward safety practices.

“First and foremost, mask mandate, mask mandate, mask mandate,” said Dr. Jason Newland, a pediatrics and infectious diseases professor at Washington University in St. Louis.

But school employees across the nation complain such measures don’t exist or aren’t enforced.

“School officials openly scoff at covid-19 and believe it is a hoax. This attitude trickles down to staff, so hardly anyone has been wearing their mask or wearing it correctly,” an unidentified employee of Hart Public Schools, in rural western Michigan, wrote in an OSHA complaint in September. The complaint also described large crowds of students sitting too close in cafeterias. The employee alleges being terminated for whistleblowing.

Hart Superintendent Mark Platt said in an email that he won’t comment on personnel matters, but “takes seriously its health and safety protocols for students and staff.” The district’s covid preparedness and response plan requires staffers and older students to wear masks in classrooms, common areas and buses, while K-5 students must wear them everywhere except in their own classrooms with their own class.

At the public Avon Community School Corp. in Indiana, Lebo said, problems festered since the beginning of the fall semester in July, when an OSHA complaint was lodged. In addition to crowding in the halls and difficulty keeping students 6 feet apart in classrooms, Lebo said, the school’s many extracurricular activities — including football, wrestling and show choir — brought their own risks.

Avon schools spokesperson Kevin Carr wouldn’t comment except to say students and staff members have tried their best to abide by the district’s health and safety protocols.

Over the semester ending in December, Avon schools reported 346 covid cases among nearly 9,800 in-person students and staffers, a rate of 3.5% compared with 2.1% for 1,412 remote learners. The covid rate reached 5.5% at the high school, which went remote briefly in the fall after the number of people quarantining skyrocketed.

Like the vast majority of school OSHA complaints, the one about Avon was closed without an inspection. Across all industries, research shows, just a small percentage of pandemic-related complaints have led to inspections or fines.

A Biden executive order on worker safety calls for OSHA to bolster enforcement and work with states and local governments to ensure workers, including those in the public sector, are protected from covid.

Without strong laws, “workers are facing big challenges: Do I speak up? Do I show up to work?” said Rebecca Reindel, director of occupational safety and health for the AFL-CIO. “They’re making a decision between needing a paycheck and risking bringing the virus home.”

Varied, Questionable Guidance

That decision gets even harder when potentially unsafe practices are written into official recommendations.

Missouri and Iowa, for example, advise that students exposed to covid don’t need to be quarantined as long as infected and exposed children are both wearing masks correctly — which goes against Centers for Disease Control and Prevention advice to quarantine anyone who has had close contact with a person who has the virus.

Some districts in South Carolina, Tennessee, Florida and Nebraska — with green lights from the Trump administration and their states — classified teachers as “critical infrastructure workers,” allowing them to keep working after exposure if they don’t develop symptoms.

A superintendent in Billings, Montana, told administrators in October to “disrupt the 15-minute timeline” required to be deemed a close contact “through movement, distancing or masking.” Following media reports, he issued a statement saying he hadn’t intended to “game the system” and no one should move students to avoid quarantines.

In many communities, mask rules are lax.

In Missouri, where there’s no statewide mask rule, Ozark School District requires them only “when social distancing is not an option,” according to its website, which describes spacing desks and using barriers to give people a “break” from masks.

Lakeland Joint School District in Idaho recommends masks when physical distancing isn’t possible. Dacia Chaffee, parent of an eighth grader and a high school freshman in the district, said “it’s almost like normal,” with few students wearing masks. Her kids don’t either, she said; they don’t want to stand out.

Public health experts said making schools safer will require clear, consistent data and guidance — and political will. They said governments also need to give public schools enough resources to keep more than 50 million students and 3.2 million teachers safe. A recent CDC report estimated that the cost of covid mitigation measures for the 2020-21 school year ranges from $55 per student for items such as masks, plexiglass barriers and face shields to $442 per student with added custodians and transportation, such as buses and drivers, to allow for better physical distancing.

And crucially, experts said, covid policies for schools must be rooted in science, not politics.

“Behaviors and attitudes flow from the top down,” said Dr. Mark Schleiss, a pediatrics professor at the University of Minnesota Medical School. “We have to hold people accountable. This is a life-and-death situation.”

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

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California’s Top Hospital Lobbyist Cements Influence in Covid Crisis

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

#SB977 would give California’s AG unprecedented decision-making authority over your health care. Tell #CAleg to support access to quality health care. #NoOnSB977 pic.twitter.com/6ch0svvqeu

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

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

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

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

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

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

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

Methodology

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

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

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

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

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Estados permiten contratar profesionales de salud extranjeros por la pandemia

Cuando los hospitales de todo el país luchan contra la nueva ola de la pandemia, no son camas ni ventiladores lo que escasean. Son las personas que cuidan de los enfermos.

Pero existe mano de obra altamente calificada de médicos, enfermeras y otros trabajadores de salud, con formación en el extranjero, que no se aprovecha debido a las dificultades para la obtención de licencias y credenciales.

Según el Migrant Policy Institute de Washington D.C., unos 165,000 inmigrantes formados en el extranjero, que ya están en los Estados Unidos, tienen títulos en campos relacionados con la salud, pero están desempleados o subempleados en medio de la crisis.

Muchos de estos trabajadores cuentan con una enorme experiencia en epidemias, como el SARS, el Ébola o el VIH, en otros países, pero deben permanecer al margen de la pandemia de covid.

La pandemia pone de manifiesto las barreras para la concesión de licencias que ya existían, pero muchos creen que puede servir de llamada de atención para que las legislaturas estatales aborden la cuestión para esta crisis y las que vengan.

Ya hay cinco estados —Colorado, Massachusetts, Nevada, Nueva Jersey y Nueva York— que han adaptado sus normativas de concesión de licencias para permitir que los profesionales de salud, con formación internacional, presten sus servicios durante la crisis de personal provocada por la pandemia.

“Hay taxistas, dependientes, personas que pasean a tu perro, que también son médicos y enfermeros en sus países de origen, y no pueden integrarse en el sistema tal y como está establecido”, dijo Jina Krause-Vilmar, CEO de Upwardly Global, una organización sin fines de lucro que ayuda a los profesionales inmigrantes a incorporarse al mercado laboral.

Médicos como Sussy Obando, inmigrante colombiana de 29 años, tuvo que sortear todo tipo de trabas para que Estados Unidos le reconociera su título. En 2013, se graduó de seis años de la escuela de medicina en Colombia, y pasó un año tratando a pacientes en comunidades desatendidas. Pero cuando Obando llegó a los Estados Unidos, sus credenciales y experiencia no fueron suficientes.

Aunque las normativas para la obtención de estas certificaciones difieren de un estado a otro, los médicos formados en el extranjero suelen tener que aprobar un examen de licencia médica que cuesta más de $3,500 y, a continuación, completar al menos un año de formación en el puesto de trabajo, lo que en Estados Unidos se conoce como residencia.

Para muchos, incluida Obando, eso significa aprender inglés y la terminología médica pertinente. También se necesita experiencia clínica en los Estados Unidos para poder optar a una residencia, algo que los médicos formados aquí consiguen mediante rotaciones durante la carrera de medicina.

“Si no conoces a nadie en este campo, tienes que ir de puerta en puerta para encontrar a alguien que te dé la oportunidad de hacer rotaciones clínicas”, explicó Obando.

Envió correos electrónicos a los médicos hispanos que encontró en internet para ver si podía hacer una rotación clínica con uno de ellos. Acabó pagando para hacer una rotación de psiquiatría en la Facultad de Medicina McGovern de la Universidad de Texas, en Houston.

“Intenté dedicarme a la medicina interna”, contó Obando. “Pero como la psiquiatría era menos costosa, tuve que optar por eso”.

También trabajó durante casi un año como voluntaria en el Centro Oncológico MD Anderson de Texas, y ahora colabora en los ensayos clínicos de las vacunas contra covid en el Centro de Desarrollo de Medicamentos de Texas.

Ha solicitado una residencia a través de un programa nacional que pone en contacto a los graduados de las facultades de medicina con las plazas de residencia. Pero es difícil conseguir una plaza para los médicos formados en el extranjero, porque muchas están destinadas a graduados de las facultades de medicina estadounidenses. Y muchos programas de residencia sólo están abiertos a los recién licenciados, no a los médicos que llevan años ejerciendo en sus países de origen.

“Es competitivo para la gente que se ha formado en Estados Unidos acceder a un programa de residencia”, señaló Jacki Esposito de World Education Services, una organización sin fines de lucro que ayuda a los inmigrantes a encontrar trabajo. “Si te has formado fuera de Estados Unidos, es aún más difícil”.

Por eso, estados como Colorado han suavizado el requisito de residencia durante la emergencia declarada por covid.

Gracias a una orden ejecutiva del gobernador demócrata, Jared Polis, en abril, los funcionarios estatales crearon un programa de licencias temporales, permitiendo a los médicos comenzar a ejercer bajo supervisión durante seis meses, y luego lo extendieron hasta junio de 2021.

Los funcionarios crearon una vía similar hacia la licencia temporal para los graduados de escuelas de medicina internacionales que carecían del año mínimo de formación en residencia.

Colorado también creó licencias temporales para enfermeras formadas en el extranjero, auxiliares de enfermería certificados, asistentes médicos y muchos otros profesionales de salud. Todas estas licencias requieren la supervisión de un profesional autorizado y sólo son válidas mientras siga vigente la declaración de emergencia de salud pública del gobernador.

El estado relajó también las reglas para esos trabajadores de la salud, permitiéndoles realizar cualquier tarea que les asignen sus supervisores.

“Así que, si eres un terapeuta ocupacional, puedes administrar vacunas siempre que te lo asignen y estén seguros de que tienes la capacidad y el conocimiento”, indicó Karen McGovern, subdirectora de asuntos legales de la división de profesiones y ocupaciones del Departamento de Agencias Reguladoras de Colorado. “Durante la pandemia, un profesional puede ir más allá de su especialidad para ayudar en lo que pueda ser útil”.

Hasta mediados de diciembre, el estado había recibido 36 solicitudes de médicos formados en el extranjero que querían obtener licencias temporales, aunque sólo un solicitante ha cumplido todos los criterios hasta ahora.

Nueva Jersey, por su parte, recibió más de 1,100 solicitudes de licencias médicas temporales el año pasado. (Michigan también emitió una orden ejecutiva que permitía las licencias temporales, pero posteriormente fue anulada).

Muchos de los profesionales médicos que se han quedado al margen tienen habilidades y experiencia únicas que serían inestimables durante la pandemia. Victor Ladele, de 44 años, terminó la carrera de medicina en Nigeria y trató a pacientes durante una sequía en Níger en 2005, en medio del genocidio de Darfur en Sudán Occidental en 2007 y tras una guerra civil en Liberia en 2010.

Su familia se trasladó a Estados Unidos unos años después, pero Ladele fue reclutado para ayudar en el brote de ébola en África Occidental en 2014. Lo que pensó que sería una estancia de tres meses se convirtió en una misión de dos años.

Ahora, de vuelta en Edmond, Oklahoma, trabajando en un programa de la ONU que ayuda a nuevas empresas, Ladele ha descubierto que los retos de esta pandemia son parecidos a muchas de sus experiencias del pasado.

Ha visto cómo un programa de localización de contactos de ébola indicaba a las personas con tos o fiebre que llamaran a una línea de atención telefónica, y de ahí se los enviaba a un centro de salud.

Pero tan pronto como se puso en marcha la iniciativa, empezaron a correr rumores en las redes sociales de que los médicos europeos de los centros traficaban con órganos. Hicieron falta meses de contacto con los líderes tribales y religiosos de África Occidental para restablecer la confianza en el sistema.

También fue testigo de cómo se difundía información falsa sobre covid y las mascarillas durante la pandemia.

“Si en Oklahoma, los funcionarios de salud pública hubieran hecho una labor de divulgación entre los pastores de las iglesias y hubieran obtenido su apoyo para el uso de mascarillas, habría más gente usándolas”, aseguró Ladele.

Lo ideal para Ladele sería dedicar la mitad de su tiempo a atender pacientes, pero el proceso de concesión de licencias sigue siendo un reto.

“No es insuperable”, dijo. “Pero cuando pienso en todos los obstáculos para obtener la credencial aquí, no estoy seguro de que merezca la pena el esfuerzo”.

Upwardly Global, una organización sin fines de lucro con sede en Nueva York ha ayudado a profesionales de salud a navegar el sistema de solicitud y obtención de credenciales. Muchos profesionales formados en el extranjero nunca han tenido que redactar currículos o hacer entrevistas de trabajo.

Aunque la pandemia ha facilitado la entrada en unos pocos estados de forma temporal, Krause-Vilmar cree que podría ser un modelo para abordar la escasez de personal en zonas desatendidas de todo el país.

Hasta septiembre de 2020, la Administración Federal de Recursos y Servicios de Salud ha designado más de 7,300 zonas con escasez de personal donde se necesitan 15,000 profesionales de salud adicionales.

“Llevamos mucho tiempo con una crisis de acceso a la salud, especialmente en las zonas rurales del país”, señaló. “¿Por qué no empezamos a pensar en un futuro con más licencias permanentes para esta gente que nos está ayudando a recuperarnos y a reconstruir?”.

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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Amid Covid Health Worker Shortage, Foreign-Trained Professionals Sit on Sidelines

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As hospitals nationwide struggle with the latest covid-19 surge, it’s not so much beds or ventilators in short supply. It’s the people to care for the sick.

Yet a large, highly skilled workforce of foreign-educated doctors, nurses and other health practitioners is going largely untapped due to licensing and credentialing barriers. According to the Migration Policy Institute think tank in Washington, D.C., some 165,000 foreign-trained immigrants in the U.S. hold degrees in health-related fields but are unemployed or underemployed in the midst of the health crisis.

Many of these workers have invaluable experience dealing with infectious disease epidemics such as SARS, Ebola or HIV in other countries yet must sit out the covid pandemic.

The pandemic highlights licensing barriers that predate covid, but many believe it can serve as a wake-up call for state legislatures to address the issue for this crisis and beyond. Already, five states — Colorado, Massachusetts, Nevada, New Jersey and New York — have adapted their licensing guidelines to allow foreign-trained health care workers to lend their lifesaving skills amid pandemic-induced staff shortages.

“These really are the cabdrivers, the clerks, the people who walk your dog,” said Jina Krause-Vilmar, CEO of Upwardly Global, a nonprofit that helps immigrant professionals enter the U.S. workforce. “They also happen to be doctors and nurses in their home countries, and they’re just not able to plug and play into the system as it’s set up.”

That’s left doctors such as Sussy Obando, a 29-year-old from Colombia, jumping through hoops to become physicians in the U.S. In 2013, she graduated after six years of medical school in Colombia, then spent a year treating patients in underserved communities. But when Obando arrived in the U.S., her credentials and experience weren’t enough.

While licensure guidelines vary by state, foreign-trained doctors typically must pass a medical licensing exam costing more than $3,500, and then complete at least a year of on-the-job training, known as a residency, in the U.S. For many, including Obando, that means brushing up on their English and learning the relevant medical terminology. She also needed U.S. clinical experience to qualify for a residency, something U.S.-trained doctors achieve through rotations during medical school.

“If you don’t know anyone in this field, you have to go door to door to find somebody to give you the opportunity to rotate,” Obando said.

She tried emailing Hispanic doctors she found online to ask if she could complete a rotation with one of them. She ended up paying $750 to enter a psychiatry rotation at the University of Texas McGovern Medical School in Houston.

“I tried to go into internal medicine,” Obando said. “But because psychiatry was less expensive, I have to go for that.”

She also worked for almost a year as a volunteer at Houston’s MD Anderson Cancer Center, and is now assisting with clinical trials for covid vaccines at the Texas Center for Drug Development. She’s applied for a residency through a national program that matches medical school graduates with residency slots. But it’s difficult for foreign-trained physicians to secure a spot, because many are earmarked for U.S. med school graduates. And many residency programs are open only to recent graduates, not those who finished medical school years ago.

“It’s competitive for people who trained in the United States to get into a residency program. If you’re trained outside the United States, it’s even harder,” said Jacki Esposito, director of U.S. policy and advocacy for World Education Services, a nonprofit that helps immigrants find jobs in the U.S. and Canada.

That’s why states such as Colorado have eased the requirement for a residency during the pandemic. Early on, Colorado officials realized they couldn’t license doctors and other health workers because covid lockdowns had canceled required licensing exams. Under an executive order from Democratic Gov. Jared Polis in April, state officials created a temporary licensing program allowing medical school graduates to begin practicing under supervision for six months, and then extended it through June 2021.

Officials created a similar pathway to temporary licensure for foreign medical school graduates who lacked the minimum year of residency.

Colorado also created temporary licenses for foreign-trained nurses, certified nurse’s aides, physician assistants and many other health professionals. All of those licenses require supervision from a licensed professional and are valid only as long as the governor’s public health emergency declaration remains in effect.

The state relaxed the scope-of-practice rules for those health workers, too, allowing them to perform any task their supervisors assign to them.

“So if you’re an occupational therapist, you can give vaccinations as long as they are delegating to you and they’re confident you have the skill and knowledge,” said Karen McGovern, deputy director of legal affairs for the professions and occupations division at the Colorado Department of Regulatory Agencies. “You can exceed your statutory skill and practice to what needs to be done during the pandemic.”

Through mid-December, the state had received 36 applications from foreign-trained doctors seeking temporary licenses, although only one applicant met all the criteria. New Jersey, on the other hand, received more than 1,100 applications for temporary medical licenses last year. (Michigan also issued an executive order allowing temporary licenses, but it was later rescinded.)

Many of the medical professionals stuck on the sidelines have unique skills and experience that would be invaluable during the pandemic. Victor Ladele, 44, finished medical school in Nigeria and treated patients during a drought in Niger in 2005, in the midst of the Darfur genocide in Sudan in 2007 and after a civil war in Liberia in 2010. His family moved to the U.S. a few years later, but Ladele was recruited to help with the Ebola outbreak in West Africa in 2014. What he thought would be a three-month stay turned into a two-year mission.

Now back in Edmond, Oklahoma, working with a U.N. program that helps new business ventures get off the ground, Ladele has found that the challenges of the covid pandemic parallel many of his past experiences. He saw how a program for Ebola contact tracing told people with a cough or fever to call a hotline, which would direct them to a care center. But as soon as the initiative went live, rumors began to spread on social media that European doctors at the care centers were harvesting organs. It took months of outreach to tribal and religious leaders to instill confidence in the system.

He’s seen similar misinformation spread about covid and masks.

“If, in Oklahoma, the public health officials had done outreach to all the pastors in the churches and gained their support for masking, would there be more people using masks?” Ladele said.

Ideally, he said, he would like to spend about half his time seeing patients, but the licensing process remains a challenge.

“It’s not unsurmountable,” he said. But “when I think of all the hurdles to credentialing here, I’m not really sure it’s worth the effort.”

Upwardly Global helps health professionals navigate that unfamiliar application and credentialing system. Many foreign-trained health workers have never had to write résumés or interview for jobs.

While the pandemic has temporarily eased entry in five states, Krause-Vilmar and others believe it could be a model to address workforce shortages in underserved areas across the country. As of September, the federal Health Resources and Services Administration had designated more than 7,300 health care shortage areas, requiring an additional 15,000 health care practitioners.

“We’ve had a crisis in access to health care, especially in rural areas, in this country for a long time,” she said. “How do we start imagining what that would look like in terms of more permanent licenses for these folks who are helping us recover and rebuild?”

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

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Vaccine Ramp-Up Squeezes Covid Testing and Tracing


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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Yurts, Igloos and Pop-Up Domes: How Safe Is ‘Outside’ Restaurant Dining This Winter?

With the arrival of winter and the U.S. coronavirus outbreak in full swing, the restaurant industry — looking at losses of $235 billion in 2020 — is clinging to techniques for sustaining outdoor dining even through the cold and vagaries of a U.S. winter.

Yurts, greenhouses, igloos, tents and all kinds of partly open outdoor structures have popped up at restaurants around the country. Owners have turned to these as a lifeline to help fill some tables by offering the possibility at least of a safer dining experience.

“We’re trying to do everything we can to expand the outdoor dining season for as long as possible,” said Mike Whatley with the National Restaurant Association.

Dire times have forced the industry to find ways to survive. Whatley said more than 100,000 restaurants are either “completely closed or not open for business in any capacity.”

“It’s going to be a hard and tough winter,” Whatley said. “As you see outdoor dining not being feasible from a cold-weather perspective or, unfortunately, from a government regulations perspective, you are going to see more operators going out of business.”

In recent months, many cities and states have imposed a raft of restrictions on indoor dining, given the high risk of spreading the virus in these crowded settings.

Many have capped occupancy for dine-in restaurants. Some halted indoor dining altogether, including Michigan and Illinois. Others have gone even further. Los Angeles and Baltimore have halted indoor and outdoor dining. Only carryout is allowed.

Those who can serve customers outdoors, on patios or sidewalks, are coming up with creative adaptations that can make dining possible in the frigid depths of winter.

Embrace the ‘Yurtiness’

Washington state shut down indoor dining in mid-November and has kept that ban in place as coronavirus cases continue to surge.

On a blustery December evening, servers at the high-end Seattle restaurant Canlis huddled together in the parking lot, clad in flannel and puffy vests, while their boss Mark Canlis gave a pep talk ahead of a busy night.

“The hospitality out here is exactly the same as it is in there,” Canlis said, gesturing to his restaurant, which overlooks Lake Union. “But that looks really different, so try to invite them into the ‘yurtiness’ of what we are doing.”

Canlis has erected an elaborate yurt village in the parking lot next to his family’s storied restaurant.

It includes an outdoor fireplace and wood-paneled walkways winding between small pine trees and the circular tents. The assemblage of yurts, with their open window flaps, is the Canlis family’s best effort to keep fine dining alive during the pandemic and a typically long and wet Seattle winter (referred to locally as the “Big Dark”).

Arriving guests are greeted with a forehead thermometer to take their temperature and a cup of hot cider.

“It gives us an excuse to think differently,” Canlis said of the outdoor dining restrictions.

The yurts are meant to shield diners from the elements and from infectious airborne particles that might otherwise spread from table to table.

Dining inside such structures is not risk free: Guests could still catch the virus from a dining companion as they sit near each other, without masks, for a prolonged period. But Canlis said there is no easy way to determine whether every member of a dining group is from the same household.

“I’m not the governor or the CDC,” he said. “I’m assuming if you are there at the table, you’re taking your health into your own hands.”

New rules for outdoor dining structures in Washington require Canlis to consider issues such as how to ventilate the yurts properly and sanitize the expensive furniture.

“What is the square inch of yurt volume space? What is the size of the door and the windows? How many minutes will we allow the yurt to ‘breathe?’” Canlis said.

The structures get cleaned after each dining party finishes a meal and leaves; during the meal service the waiters enter and leave quickly, wearing N95 masks.

Igloos, Domes, Tents: Just How Safe Are They?

Another, more modern-looking take on outdoor dining involves transparent igloos and other domelike structures that have become popular with restaurant owners all over the country.

Tim Baker, who owns the Italian restaurant San Fermo in Seattle, had to order his igloos from Lithuania and assemble them with the help of his son.

His restaurant’s policy is that only two people are allowed in an igloo at a time, to cut down on the risk of those from different households gathering together.

“You’re completely enclosed in your own space with somebody in your own household. These domes protect you from all the people walking by on the sidewalk, and the server doesn’t go in with you,” he said.

Baker said he consulted with experts in airflow and decided to use an industrial hot air cannon after each party of diners leaves the igloo and before the next set enters — aiming to clear the air inside the structure of any lingering infectious particles.

“You fire this cannon up, and it just pushes the air through really aggressively,” quickly dispersing the particles, Baker said.

His restaurant’s igloos have become a big attraction.

“I’m particularly proud of anything that we can do to get people excited right now, because we need it,” he said. “We’re all getting crushed by this emotionally.”

Not all outdoor dining structures are created equally, said Richard Corsi, an air quality expert and dean of engineering and computer science at Portland State University in Oregon.

“There’s a wide spectrum,” Corsi said. “The safest that we’re talking about is no walls — a roof. And then the worst is fully enclosed — which is essentially an indoor tent — especially if it doesn’t have really good ventilation and good physical distancing.”

In fact, Corsi said, some outdoor dining structures that are enclosed and have lots of tables near each other end up being more dangerous than being indoors, because the ventilation is worse.

Dining that is truly outdoors, with no temporary shelter at all, is much safer because there are “higher air speeds, more dispersion and more mixing than indoors,” Corsi said, which means respiratory droplets harboring the virus don’t accumulate and are less concentrated when people are close to one another.

“If they have heaters, then you’re going to actually have pretty good ventilation,” Corsi said. “The air will rise up when it’s heated, and then cool air will come in.”

He said private “pods” or “domes” can be fairly safe if they are properly ventilated and cleaned between diners. That also assumes that everyone eating inside the structure lives together, so they have already been exposed to one another’s germs.

But Corsi said he is still not going out for a meal in one of the many new outdoor dining creations — “even though I know they’ve got a much lower risk” of spreading covid-19 than most indoor alternatives.

This story comes from NPR’s health reporting partnership with 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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Door to Door in Miami’s Little Havana to Build Trust in Testing, Vaccination


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Little Havana is a neighborhood in Miami that, until the pandemic, was known for its active street life along Calle Ocho, including live music venues, ventanitas serving Cuban coffee and a historic park where men gather to play dominoes.

But during the pandemic, a group called Healthy Little Havana is zeroing in on this area with a very specific assignment: persuading residents to get a coronavirus test.

The nonprofit has lots of outreach experience. It helped with the 2020 census, for example, and because of the pandemic did most of that work by phone. But this new challenge, community leaders say, needs a face-to-face approach.

The group’s outreach workers have been heading out almost daily to walk the quiet residential streets, to persuade as many people as possible to get tested for covid-19. On a recent afternoon, a group of three — Elvis Mendes, María Elena González and Alejandro Díaz — knocked on door after door at a two-story apartment building. Many people here have jobs in the service industry, retail or construction; most of them aren’t home when visitors come calling.

Lisette Mejía did answer her door, holding a baby in her arms and flanked by two small children.

“Not everyone has easy access to the internet or the ability to look for appointments,” Mejía replied, after being asked why she hadn’t gotten a test. She added that she hasn’t had any symptoms, either.

The Healthy Little Havana team gave her some cotton masks and told her about pop-up testing planned for that weekend at an elementary school just a short walk away. They explained that people might lack symptoms but still have the virus.

Testing Is Still Too Difficult

The nonprofit organization is one of several receiving funding from the Health Foundation of South Florida. The foundation is spending $1.5 million on these outreach efforts, in part to help make coronavirus testing as accessible and convenient as possible.

A number of social and economic reasons make it difficult for some Miamians to get tested or treated, or isolate themselves if they are sick with covid. One big problem is that many people say they can’t afford to stay home when they’re sick.

“People usually rather go to work than actually treat themselves — because they have to pay rent, they have to pay school expenses, food,” said Mendes.

This part of Miami is home to many Cuban exiles, as well as people from all over Latin America. Some lack health insurance, while others are undocumented immigrants.

So Mendes and his team try to spread the word among residents here about programs like Ready Responders, a group of paramedics that now has foundation funding to give free coronavirus tests at home in areas like this one, regardless of immigration status.

“Our mission is for all these people to get tested — regardless if they have a symptom or not — so we can diminish the level of people getting covid-19,” Mendes said. According to the Centers for Disease Control and Prevention, people who are infected but presymptomatic or asymptomatic account for more than 50% of transmissions.

The Health Foundation of South Florida’s coronavirus-related grants have ranged from $35,000 to $160,000; other recipients include the South Florida chapter of the National Medical Association, Centro Campesino and the YMCA of South Florida.

The foundation is focusing on low-income neighborhoods where some residents might not have access to a car or be able to afford a coronavirus test at a pharmacy. Their focus includes residential areas near agriculture work sites. In Miami-Dade County, the foundation is working with county officials directly to increase testing. In neighboring Broward County, the foundation is collaborating with public housing authorities to bring more testing into people’s homes.

Soothing Fears, Offering Options in Spanish

It’s time-consuming to go door to door, but worthwhile: Residents respond when outreach teams speak their language and make a personal connection.

Little Havana resident Gloria Carvajal told the outreach group that she felt anxious about whether the PCR test is painful.

“What about that stick they put all the way up?” Carvajal asked, laughing nervously.

González jumped in to reassure her it’s not so bad: “I’ve done it many times, because obviously we’re out and about in public and so we have to get the test done.”

Another outreach effort is happening at Faith Community Baptist Church in Miami. The church hosted a day of free testing back in October, with help from the foundation.

“You know us. You know who we are,” said pastor Richard Dunn II. “You know we wouldn’t allow anybody to do anything to hurt you.”

Dunn spoke recently in nearby Liberty City, a historically Black neighborhood, at an outdoor memorial service for Black residents who have died of covid. To convey the magnitude of the community’s losses, hundreds of white plastic tombstones were set up behind the podium. They filled an entire field in the park.

“Thousands upon thousands have died, and so we’re saying to the Lord here today, we’re not going to let their deaths be in vain,” Dunn said.

Dunn is also helping with a newly launched effort to build trust in the covid vaccines among Black residents, by participating in online meetings during which Black church members can hear directly from Black medical experts. The message of the meetings is that the vaccines are safe and vital.

“It’s taken over 300,000 lives in the United States of America,” Dunn said at the end of the meeting. “And I believe to do nothing would be more of a tragedy than to at least try to do something to prevent it and to stop the spreading of the coronavirus.”

Churches will play a big role in the ongoing outreach efforts, and Dunn is committed to doing his part. He knows covid is an extremely contagious and serious disease — this past summer, he caught it himself.

This story comes from a reporting partnership that includes WLRN, 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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Biden Takes the Reins, Calls for a United Front Against Covid and Other Threats

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Joe Biden on Wednesday took the oath to become the 46th president of the United States, vowing to bring the nation together in the midst of an ongoing pandemic that has claimed more than 400,000 lives, enormous economic dislocation and civil unrest so serious that the U.S. Capitol steps where he took his oath were surrounded not by cheering crowds, but by tens of thousands of armed police and National Guard troops.

In his inaugural address, given outside despite concerns for his physical security, Biden emphasized unity, the driving theme of his campaign. “My whole soul is in this, bringing America together, uniting our nation,” he said. “And I ask every American to join me in this cause.”

On health care, Biden made it clear that combating the covid-19 pandemic will be his top priority. “We must set aside politics and finally face this pandemic as one nation,” he said. “We will get through this together.”

Last week, Biden unveiled a covid plan that includes using the Defense Production Act to speed the manufacture of syringes and other supplies needed to administer vaccines; creating federal vaccination centers and mobilizing the Federal Emergency Management Agency, the National Guard and others to administer the vaccines, and launching a communications campaign to convince reluctant members of the public that the vaccine is safe. Details on his vaccination plan followed his unveiling the day before of a $1.9 trillion covid emergency relief package.

Biden got a separate boost earlier in the day with the swearing in of two new Democratic senators from Georgia, fresh off their victories in a Jan. 5 runoff election. The additions of Sen. Jon Ossoff and Raphael Warnock, plus a tie-breaking vote from new Vice President Kamala Harris, gives Democrats 51 votes in the Senate and effective control of both chambers of Congress for the first time since 2010.

With such narrow majorities in the House and Senate, it seems unlikely Biden will be able to make good on some of his more sweeping health-related campaign promises, including creating a “public option” to help expand insurance coverage and lowering the Medicare eligibility age from 65 to 60.

But even the barest of control will make it substantially easier for Biden to get his appointees confirmed in the Senate, and the possibility is open to use a fast-track process called budget reconciliation to make health-related budget changes, perhaps including modifications of the Affordable Care Act that might make coverage less expensive for some families.

Beyond covid, health is likely to take a back seat in the early going of the administration as officials deal with more pressing problems like the economy, immigration and climate change.

Biden health aides are expected to begin to unwind many of the changes made by Trump that do not require legislation, such as restoring anti-discrimination protections for transgender people and reversing the Trump administration’s decision to allow some states to implement work requirements for adults covered by Medicaid. But even that could take weeks or months.

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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Biden prometió 100 millones de vacunas de covid en 100 días. No será fácil de cumplir

Está en la naturaleza de los candidatos presidenciales y de los flamantes presidentes: prometer grandes cosas. Apenas unos meses antes de su juramentación en 1961, el presidente John F. Kennedy prometió que iba a enviar un hombre a la luna antes de que terminara la década.

Esa promesa se cumplió, pero muchas otras no, como la de Bill Clinton de lograr una atención médica universal o la George H.W. Bush de no generar nuevos impuestos.

Ahora, durante una pandemia que ocurre una vez en un siglo, Joe Biden ha prometido proporcionar 100 millones de dosis de vacunas contra covid-19 en sus primeros 100 días de mandato.

“Este equipo ayudará a que 100 millones de dosis lleguen a los brazos de los estadounidenses en los primeros 100 días”, dijo Biden en la conferencia de prensa del 8 de diciembre en la que presentó a su equipo de salud.

Luego de esa afirmación, la campaña de Biden aclaró que se había referido a que 50 millones de personas recibirían sus dos dosis. Más tarde aclararon que distribuirían las dosis a medida que estuvieran disponibles, en vez de retener suministros para las segundas dosis.

De cualquier manera, la meta de Biden parece difícil de alcanzar.

“Creo que es un objetivo posible. Pero también un gran desafío”, dijo Claire Hannan, directora ejecutiva de la Association of Immunization Managers.

“Mientras que el ritmo de 1 millón de dosis al día es en alguna medida un aumento con respecto a lo que estamos haciendo ahora, será necesaria una tasa mucho más alta de vacunación para frenar la pandemia”, dijo Larry Levitt, vicepresidente ejecutivo para políticas de salud de la Kaiser Family Foundation (KFF).

“La administración Biden planea racionalizar la distribución de vacunas, pero aumentar el suministro rápidamente podría ser una tarea difícil”, agregó.

Bajo la administración Trump, el despliegue de vacunas ha sido mucho más lento que el plan de Biden. El lanzamiento comenzó el 14 de diciembre. Desde entonces, se han administrado 12 millones de dosis y se han distribuido 31 millones, según el monitoreo de vacunación de los Centros para el Control y Prevención de Enfermedades (CDC).

Esta lentitud se ha atribuido a la falta de comunicación entre el gobierno federal y los departamentos de salud estatales y locales. También a la falta de fondos para una vacunación a gran escala, y a la confusa orientación del gobierno federal sobre la distribución.

La administración Biden podría tener los mismos problemas, según expertos. Los estados aun no están seguros de cuántas vacunas recibirán y si habrá un suministro suficiente, dijo el doctor Marcus Plescia, director médico de la Association of State and Territorial Health Officials, que representa a las agencias de salud pública estatales.

“Se nos ha proporcionado poca información sobre la cantidad de vacunas que recibirán los estados en el futuro cercano y puede que no haya un millón de dosis disponibles cada día en los primeros 100 días de la administración”, dijo Plescia.

Otro problema ha sido la falta de dinero: los estados han tenido que iniciar campañas de vacunación con presupuestos esqueléticos a causa de la pandemia. “Los estados deben pagar por crear los sistemas, identificar al personal y capacitarlos, el rastreo de contactos, las campañas de información, todo lo que necesitan para terminar vacunando a una persona”, explicó Jennifer Kates, directora de política global y VIH de KFF. “Tienen que crear un programa de vacunación masiva si precedentes sobre una base inestable”, observó.

El último estímulo para covid, promulgado en diciembre, asignó $9 mil millones en fondos a los CDC para esfuerzos de vacunación. Se supone que la mitad, unos $45 mil millones se destinarán a estados, territorios y reservas indígenas.

Pero cuando la vacunación se amplíe a más grupos, no está claro si las campañas se puedan sostener con ese nivel de financiamiento.

La semana del 11 de enero, Biden lanzó un plan de $1.9 mil millones para abordar los problemas de la economía y covid. Incluye dinero para crear programas nacionales de vacunación y pruebas, pero también para asistencia financiera a individuos, ayuda a gobiernos locales,  extensión del seguro de desempleo y dinero para que las escuelas reabran de manera segura.

Aunque el Congreso tardó casi ocho meses en aprobar el último proyecto de ley de ayuda tras las objeciones republicanas, Biden parece optimista de que logrará que algunos republicanos se unan a su plan. Pero aún no está claro que funcione. También está la cuestión de si el juicio político del presidente saliente Donald Trump se interpondrá en el camino de las prioridades legislativas de Biden.

Además, los estados se han quejado de la falta de orientación e instrucciones confusas sobre a qué grupos se les debe dar prioridad para la vacunación, un tema que la administración Biden deberá abordar.

El 3 de diciembre, los CDC recomendaron que el personal de atención médica, los residentes de centros de atención a largo plazo, las personas de 75 años o más y los trabajadores esenciales de primera línea se vacunaran primero.

Pero el 12 de enero, los CDC cambiaron de rumbo y recomendaron que todas las personas mayores de 65 años debían vacunarse. Biden dijo que seguiría esta recomendación.

El secretario saliente de Salud y Servicios Humanos, Alex Azar, también dijo el 12 de enero que los estados que muevan su suministro de vacunas más rápido tendrán prioridad para recibir más envíos.

Aún no se sabe si los CDC de la administración de Biden se apegarán a esta guía. Los críticos han dicho que podría hacer que la distribución de vacunas sea menos equitativa. En general, asumir el control con una visión sólida y una comunicación clara será clave para aumentar la distribución de vacunas, dijo Hannan.

“Todos deben comprender cuál es el objetivo y cómo va a funcionar”, agregó.

Un desafío para Biden será frenar las expectativas de que la vacuna es todo lo que se necesita para poner fin a la pandemia. En todo el país, hay más casos de covid que nunca y en muchos lugares los funcionarios no pueden controlar la propagación.

Los expertos en salud pública dijeron que Biden debe intensificar los esfuerzos para aumentar las pruebas en todo el país, como ha sugerido que hará al prometer establecer una junta nacional de pruebas de pandemias.

Con el fuerte enfoque en la distribución de vacunas, es importante que esta parte de la ecuación no se pierda.

En este momento, “está en todo el mapa”, dijo Kates de KFF, y agregó que el gobierno federal necesitará tener un claro sentido de las áreas del país en donde se están haciendo las pruebas y en las que no, para “arreglar” esa capacidad de salud pública.

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Biden’s Covid Challenge: 100 Million Vaccinations in the First 100 Days. It Won’t Be Easy.


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

It’s in the nature of presidential candidates and new presidents to promise big things. Just months after his 1961 inauguration, President John F. Kennedy vowed to send a man to the moon by the end of the decade. That pledge was kept, but many others haven’t been, such as candidate Bill Clinton’s promise to provide universal health care and presidential hopeful George H.W. Bush’s guarantee of no new taxes.

Now, during a once-in-a-century pandemic, incoming President Joe Biden has promised to provide 100 million covid-19 vaccinations in his first 100 days in office.

“This team will help get … at least 100 million covid vaccine shots into the arms of the American people in the first 100 days,” Biden said during a Dec. 8 news conference introducing key members of his health team.

When first asked about his pledge, the Biden team said the president-elect meant 50 million people would get their two-dose regimen. The incoming administration has since updated this plan, saying it will release vaccine doses as soon as they’re available instead of holding back some of that supply for second doses.

Either way, Biden may run into difficulty meeting that 100 million mark.

“I think it’s an attainable goal. I think it’s going to be extremely challenging,” said Claire Hannan, executive director of the Association of Immunization Managers.

While a pace of 1 million doses a day is “somewhat of an increase over what we’re already doing,” a much higher rate of vaccinations will be necessary to stem the pandemic, said Larry Levitt, executive vice president for health policy at KFF. (KHN is an editorially independent program of KFF.) “The Biden administration has plans to rationalize vaccine distribution, but increasing the supply quickly” could be a difficult task.

Under the Trump administration, vaccine deployment has been much slower than Biden’s plan. The rollout began more than a month ago, on Dec. 14. Since then, 12 million shots have been given and 31 million doses have been shipped out, according to the Centers for Disease Control and Prevention’s vaccine tracker.

This sluggishness has been attributed to a lack of communication between the federal government and state and local health departments, not enough funding for large-scale vaccination efforts, and confusing federal guidance on distribution of the vaccines.

The same problems could plague the Biden administration, said experts.

States still aren’t sure how much vaccine they’ll get and whether there will be a sufficient supply, said Dr. Marcus Plescia, chief medical officer for the Association of State and Territorial Health Officials, which represents state public health agencies.

“We have been given little information about the amount of vaccine the states will receive in the near future and are of the impression that there may not be 1 million doses available per day in the first 100 days of the Biden administration,” said Plescia. “Or at least not in the early stages of the 100 days.”

Another challenge has been a lack of funding. Public health departments have had to start vaccination campaigns while also operating testing centers and conducting contact tracing efforts with budgets that have been critically underfunded for years.

“States have to pay for creating the systems, identifying the personnel, training, staffing, tracking people, information campaigns — all the things that go into getting a shot in someone’s arm,” said Jennifer Kates, director of global health & HIV policy at KFF. “They’re having to create an unprecedented mass vaccination program on a shaky foundation.”

The latest covid stimulus bill, signed into law in December, allocates almost $9 billion in funding to the CDC for vaccination efforts. About $4.5 billion is supposed to go to states, territories and tribal organizations, and $3 billion of that is slated to arrive soon.

But it’s not clear that level of funding can sustain mass vaccination campaigns as more groups become eligible for the vaccine.

Biden released a $1.9 trillion plan last week to address covid and the struggling economy. It includes $160 billion to create national vaccination and testing programs, but also earmarks funds for $1,400 stimulus payments to individuals, state and local government aid, extension of unemployment insurance, and financial assistance for schools to reopen safely.

Though it took Congress almost eight months to pass the last covid relief bill after Republican objections to the cost, Biden seems optimistic he’ll get some Republicans on board for his plan. But it’s not yet clear that will work.

There’s also the question of whether outgoing President Donald Trump’s impeachment trial will get in the way of Biden’s legislative priorities.

In addition, states have complained about a lack of guidance and confusing instructions on which groups should be given priority status for vaccination, an issue the Biden administration will need to address.

On Dec. 3, the CDC recommended health care personnel, residents of long-term care facilities, those 75 and older, and front-line essential workers should be immunized first. But on Jan. 12, the CDC shifted course and recommended that everyone over age 65 should be immunized. In a speech Biden gave last week detailing his vaccination plan, he said he would stick to the CDC’s recommendation to prioritize those over 65.

Outgoing Health and Human Services Secretary Alex Azar also said Jan. 12 that states that moved their vaccine supply fastest would be prioritized in getting more shipments. It’s not known yet whether the Biden administration’s CDC will stick to this guidance. Critics have said it could make vaccine distribution less equitable.

In general, taking over with a strong vision and clear communication will be key to ramping up vaccine distribution, said Hannan.

“Everyone needs to understand what the goal is and how it’s going to work,” she said.

A challenge for Biden will be tamping expectations that the vaccine is all that is needed to end the pandemic. Across the country, covid cases are higher than ever, and in many locations officials cannot control the spread.

Public health experts said Biden must amp up efforts to increase testing across the country, as he has suggested he will do by promising to establish a national pandemic testing board.

With so much focus on vaccine distribution, it’s important that this part of the equation not be lost. Right now, “it’s completely all over the map,” said KFF’s Kates, adding that the federal government will need a “good sense” of who is and is not being tested in different areas in order to “fix” public health capacity.

Today marks the launch of The Biden Promise Tracker, which monitors the 100 most important campaign promises of President Joseph R. Biden. Biden listed the coronavirus and a variety of other health-related issues among his top priorities. You can see the entire list – including improving the economy, responding to calls for racial justice and combating climate change – here. As part of KHN’s partnership with PolitiFact, we will follow the health-related issues and then rate them on whether the promise was achieved: Promise Kept, Promise Broken, Compromise, Stalled, In the Works or Not Yet Rated. We rate the promise not on the president’s intentions or effort, but on verifiable outcomes. PolitiFact previously tracked the promises of President Donald Trump and President Barack Obama

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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Advocates View Health Care as Key to Driving LGBTQ Rights Conversation

When Allison Scott came out as a trans woman in 2013, she told not only family and friends, but also her primary care physician.

She didn’t need his help with hormone therapy. She had another doctor for that. But she wanted to share the information with her doctor of more than 10 years in case it affected other aspects of her health.

She was shocked when he told her he would no longer treat her.

“It was humiliating,” said Scott, now director of policy and programs for the Campaign for Southern Equality, an LGBTQ advocacy organization based in North Carolina. “It’s not because the provider doesn’t have the knowledge they need, but because the provider isn’t comfortable with who you are.”

Surveys in North Carolina and across the nation show that about one-third of transgender people have been refused treatment or suffered verbal or physical abuse from a medical provider.

Such concerns have become more worrisome during the covid-19 pandemic, when being denied health care — or avoiding it due to fear of discrimination and previous negative experiences — can have deadly consequences.

But Scott and other advocates in North Carolina now see an opening to push for city and county laws prohibiting this type of treatment. A state ban preventing local governments from enacting nondiscrimination ordinances expired on Dec. 1.

The ban was a remnant of the controversial 2016 “bathroom bill,” which catapulted North Carolina into the national spotlight by making it the first state to require transgender people to use the bathroom of the gender on their birth certificate. Although public backlash and economic repercussions forced the state to repeal that law, the legislature replaced it with one that blocked local governments from passing nondiscrimination ordinances.

Now new laws could address discrimination in employment, housing, public places and more. Scott said health care should be among the top considerations, whether that means banning discrimination on the basis of gender identity and sexual orientation in hospitals and clinics or preventing someone from being fired for their identity and losing health insurance as a result.

So far, the towns of Carrboro, Hillsborough and Chapel Hill, along with Orange County, jointly announced this month new nondiscrimination ordinances that will protect LGBTQ individuals in workplaces and in public. At least two other cities are drafting ordinances and plan to vote on them later this month.

These local actions take on added significance in view of efforts during the past four years to roll back federal protections for LGBTQ people. The Trump administration has tried to expand the interpretation of religious liberty and civil rights laws to protect medical providers who refuse to provide services for religious or moral reasons. Last summer, the administration reinterpreted the Affordable Care Act’s nondiscrimination requirements to remove Obama-era protections for LGBTQ people. This month, it removed explicit provisions that prohibited social service providers who receive Department of Health and Human Services grants from discriminating on the basis of sexual orientation and gender identity, among other characteristics. Sasha Buchert, a senior attorney with Lambda Legal, said the change affects a wide array of programs, from Meals on Wheels to child welfare agencies, HIV/AIDS services and more.

Although many of these actions have been blocked by courts, and the incoming Biden administration has promised to reverse several of Trump’s policies, LGBTQ advocates and legal experts say those processes take time and are not guaranteed.

“To put it plainly, having protections at the local level sometimes offers more protection, particularly as laws are being contested at the federal level,” said Lindsey Dawson, a researcher who studies LGBTQ issues at KFF. (KHN is an editorially independent program of KFF.)

A Path Forward

In recent decades, protections for LGBTQ Americans have emerged as a cultural flashpoint, often triggering debates about religious liberties versus civil rights and involving anything from marriage and parenting to offices and bakeries.

Critics of nondiscrimination laws say they squash valid debate in health care about what constitutes ethical treatment.

Ryan Anderson, a senior research fellow with the conservative think tank the Heritage Foundation, said no one should be turned away from medical care because of their identity, but laws need to distinguish between that type of discrimination and medical providers who disagree on a certain treatment plan.

“If there’s an adult who wants to transition and a doctor and health care plan who want to support that, they can do that,” Anderson said. “But if the doctor or health plan don’t want to support that, they should also be free not to do that.”

For advocates who work with LGBTQ people daily, the need for nondiscrimination laws is clear. Ames Simmons, policy director for Equality NC, recounted the experiences of people he knows: One trans woman was threatened with arrest if she didn’t leave a hospital in the western part of the state, while another was denied care at a dialysis clinic in eastern North Carolina after she complained about harassment.

Research shows that LGBTQ people in states with nondiscrimination laws experience fewer disparities in employment, education and health care than those living in states without such laws. And city- and county-level actions may provide a road map for broader efforts. Christy Mallory, legal director at the Williams Institute at UCLA, pointed to the example of Utah, where a series of local ordinances eventually led the traditionally conservative state to pass a nondiscrimination law in 2015.

The laws don’t automatically change people’s beliefs, Mallory said, but they provide a starting point to build momentum toward statewide and cultural changes.

Pandemic Urgency

Advocates cite an added imperative to protect LGBTQ rights because the covid pandemic has highlighted shortcomings and disparities in the nation’s health care system. A report by the Movement Advancement Project, a Colorado-based think tank, found 1 in 8 LGBTQ people have lost insurance coverage during the pandemic — twice the rate of non-LGBTQ people. Many are unable to afford hormone therapy or counseling. In some parts of the country, transgender people have reported mistreatment at covid testing sites.

Even before covid, transgender patients who came to Dr. Jennifer Abbott, a family physician at Western North Carolina Community Health Services in Asheville, often told her they had called as many as 10 other providers before finding someone willing to treat them. Abbott, who heads the clinic’s transgender health program, said about one-third of its approximately 400 patients come from rural areas across the western part of the state.

For some, the promise of nondiscrimination laws reaches beyond questions of access. The laws can also temper discriminatory behavior by sending a clear message about what is acceptable in a community, said Michael Hoeben, who coordinates services for transgender and HIV patients at the clinic and is a transgender man.

Once, when Hoeben was having a cervical polyp removed, the doctor asked him what it meant to be transgender. The doctor and nurse proceeded to laugh at Hoeben’s response while performing the procedure, he said. Hoeben was so mortified that he avoided seeing a doctor for the next seven years.

A law may not have prevented that experience, Hoeben said, “but without the law, it’s like open season.”

“For your local government to pass a law that says we see you, we recognize you and we include you,” Hoeben said, “that is a level of safety you’re constantly seeking as a trans person.”

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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Patients Fend for Themselves to Access Highly Touted Covid Antibody Treatments

By the time he tested positive for covid-19 on Jan. 12, Gary Herritz was feeling pretty sick. He suspects he was infected a week earlier, during a medical appointment in which he saw health workers who were wearing masks beneath their noses or who had removed them entirely.

His scratchy throat had turned to a dry cough, headache, joint pain and fever — all warning signs to Herritz, who underwent liver transplant surgery in 2012, followed by a rejection scare in 2018. He knew his compromised immune system left him especially vulnerable to a potentially deadly case of covid.

“The thing with transplant patients is we can crash in a heartbeat,” said Herritz, 39. “The outcome for transplant patients [with covid] is not good.”

On Twitter, Herritz had read about monoclonal antibody therapy, the treatment famously given to President Donald Trump and other high-profile politicians and authorized by the Food and Drug Administration for emergency use in high-risk covid patients. But as his symptoms worsened, Herritz found himself very much on his own as he scrambled for access.

His primary care doctor wasn’t sure he qualified for treatment. His transplant team in Wisconsin, where he’d had the liver surgery, wasn’t calling back. No one was sure exactly where he should go to get it. From bed in Pascagoula, Mississippi, he spent two days punching in phone numbers, reaching out to health officials in four states, before he finally landed an appointment to receive a treatment aimed at keeping patients like him out of the hospital — and, perhaps, the morgue.

“I am not rich, I am not special, I am not a political figure,” Herritz, a former community service officer, wrote on Twitter. “I just called until someone would listen.”

Months after Trump emphatically credited an experimental antibody therapy for his quick recovery from covid and even as drugmakers ramp up supplies, only a trickle of the product has found its way into regular people. While hundreds of thousands of vials sit unused, sick patients who, research indicates, could benefit from early treatment — available for free — have largely been fending for themselves.

Federal officials have allocated more than 785,000 doses of two antibody treatments authorized for emergency use during the pandemic, and more than 550,000 doses have been delivered to sites across the nation. The federal government has contracted for nearly 2.5 million doses of the products from drugmakers Eli Lilly and Co. and Regeneron Pharmaceuticals at a cost of more than $4.4 billion.

So far, however, only about 30% of the available doses have been administered to patients, federal Department of Health and Human Services officials said.

Scores of high-risk covid patients who are eligible remain unaware or have not been offered the option. Research has shown the therapy is most effective if given early in the illness, within 10 days of a positive covid test. But many would-be recipients have missed this crucial window because of a patchwork system in the U.S. that can delay testing and diagnosis.

“The bottleneck here in the funnel is administration, not availability of the product,” said Dr. Janet Woodcock, a veteran FDA official in charge of therapeutics for the federal Operation Warp Speed effort.

Among the daunting hurdles: Until this week, there has been no nationwide system to tell people where they could obtain the drugs, which are delivered through IV infusions that require hours to administer and monitor. Finding space to keep covid-infected patients separate from others has been difficult in some health centers slammed by the pandemic.

“The health care system is crashing,” Woodcock told reporters. “What we’ve heard around the country is the No. 1 barrier is staffing.”

At the same time, many hospitals have refused to offer the therapy because doctors were unimpressed with the research federal officials used to justify its use.

Monoclonal antibodies are lab-produced molecules that act as substitutes for the body’s own antibodies that fight infection. The covid treatments are designed to block the SARS-CoV-2 virus that causes infection from attaching to and entering human cells. Such treatments are usually prohibitively expensive, but for the time being the federal government is footing the bulk of the bill, though patients likely will be charged administrative fees.

Nationwide, nearly 4,000 sites offer the infusion therapies. But for patients and families of people most at risk — those 65 and older or with underlying health conditions — finding the sites and gaining access has been almost impossible, said Brian Nyquist, chief executive officer of the National Infusion Center Association, which is tracking supplies of the antibody products. Like Herritz, many seeking information about monoclonals find themselves on a lone crusade.

“If they’re not hammering the phones and advocating for access for their loved ones, others often won’t,” he said. “Tenacity is critical.”

Regeneron officials said they’re fielding calls about covid treatments daily to the company’s medical information line. More than 3,500 people have flooded Eli Lilly’s covid hotline with questions about access.

As of this week, all states are required to list on a federal locator map sites that have received the monoclonal antibody products, HHS officials said. The updated map shows wide distribution, but a listing doesn’t guarantee availability or access; patients still need to check. It’s best to confer with a primary care provider before reaching out to the centers. For best results, treatment should occur as soon as possible after a positive covid test.

Some health systems have refused to offer the monoclonal antibody therapies because of doubts about the data used to authorize them. Early studies suggested that Lilly’s therapy, bamlanivimab, reduced the need for hospitalization or emergency treatment in outpatient covid cases by about 70%, while Regeneron’s antibody cocktail of casirivimab plus imdevimab reduced the need by about 50%.

But those studies were small, just a few hundred subjects, and the results were limited. “A lot of doctors, actually, they’re not impressed with the data,” said Dr. Daniel Griffin, an infectious disease expert at Columbia University who co-hosts the podcast “This Week in Virology.” “There really is still that question of, ‘Does this stuff really work?’”

As more patients are treated, however, there’s growing evidence that the therapies can keep high-risk patients out of the hospital, not only easing their recovery but also decreasing the burden on health systems struggling with record numbers of patients.

Dr. Raymund Razonable, an infectious disease expert at the Mayo Clinic in Minnesota, said he has treated more than 2,500 covid patients with monoclonal antibody therapy with promising results. “It’s looking good,” he said, declining to provide details because they’re embargoed for publication. “We are seeing reductions in hospitalizations; we’re seeing reductions in ICU care; we’re also seeing reductions in mortality.”

Banking on observations from Mayo experts and others, federal officials have been pushing for wider use of antibody therapies. HHS officials have partnered with hospitals in three hard-hit states — California, Arizona and Nevada — to set up infusion centers that are treating dozens of covid patients each day.

One of those sites went up in late December at El Centro Regional Medical Center in California’s Imperial County, an impoverished farming region on the state’s southern border that has recorded among the highest covid infection rates in the state. For months, the medical center strained to absorb the overwhelming influx of patients, but chief executive Dr. Adolphe Edward said a new walk-up infusion site has already put a dent in the covid load.

More than 130 people have been treated, all patients who were able to get the two-hour infusions and then recuperate at home. “If those folks would not have had the treatment, they would have come through the emergency department and we would have had to admit the lion’s share of them,” he said.

It’s important to make sure people in high-risk groups know to seek out the therapy and to get it early, Edward said. He and his staff have been working with area doctors’ offices and nonprofit groups and relying on word-of-mouth.

“On multiple levels, we’re saying, ‘If you’ve tested positive for the virus, come and let us see if you are eligible,’” Edward said.

Greater awareness is a goal of the HHS effort, said Dr. John Redd, chief medical officer for the assistant secretary for preparedness and response. “These antibodies are meant for everyone,” he said. “Everyone across the country should have equal access to these products.”

For now, patients like Herritz, the Mississippi liver transplant recipient, say reality is falling well short of that goal. If he hadn’t continued to call in search of a referral, he wouldn’t have been treated. And without the therapy, Herritz believes, he was just days away from hospitalization.

“I think it’s horrible that if I didn’t have Twitter, I wouldn’t know anything about this,” he said. “I think about all the people who have died not knowing this was an option for high-risk individuals.”

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On Trump’s Last Full Day, Nation Records 400,000 Covid Deaths

While millions wait for a lifesaving shot, the U.S. death count from covid-19 continues to soar upward with horrifying speed. On Tuesday, the last full day of Donald Trump’s presidency, the death toll reached 400,000 — a once-unthinkable number. More than 100,000 Americans have perished in the pandemic in just the past five weeks.

In the U.S., someone now dies of covid every 26 seconds. And the disease is claiming more American lives each week than any other condition, ahead of heart disease and cancer, according to the Institute for Health Metrics and Evaluation at the University of Washington.

“It didn’t have to be like this, and it shouldn’t still be like this,” said Kristin Urquiza, whose father, Mark, died of covid in June, as the virus was sweeping through Phoenix.

Urquiza described it as “watching a slow-moving hurricane” tear apart her childhood neighborhood, where many people have no choice but to keep going to work and risking their health.

“I talk to dozens of strangers a day who are going through what I did in June, but the magnitude and the haunting similarities between our stories six months later is really hard,” said Urquiza, who addressed the Democratic National Convention in August. She co-founded Marked By COVID, to organize grieving families and supporters. The group calls for a faster government response and a national memorial for pandemic victims.

Given its large population, the U.S. death rate from covid remains lower than the rate in many other countries. But the death toll of 400,000 now exceeds any other country’s count — close to double what Brazil has recorded, and four times the toll in the United Kingdom.

“It’s very hard to wrap your mind around a number that is so large, particularly when we’ve had 10 months of large numbers assaulting our senses and really, really horrific images coming out of our hospitals and our morgues,” said Dr. Kirsten Bibbins-Domingo, chair of epidemiology at the University of California-San Francisco.

Scientists had long expected that wintertime could plunge the country into the deadliest months yet, but even Bibbins-Domingo wasn’t ready for the sheer pace of deaths, or the scale of the accumulated losses. The mortality burden has fallen heavily on her own state of California, which was averaging fewer than 100 deaths a day for long stretches of the pandemic, but has ranged up to more than 500 in recent days.

She said California followed the science with its handling of the pandemic, yet the devastation unfolding in places like Los Angeles reveals just how fragile any community can be.

“It’s important to understand virology. It’s important to understand epidemiology. But ultimately, what we’ve learned is that human behavior and psychology is a major force in this pandemic,” she said.

The U.S. in mid-January has averaged more than 3,300 deaths a day — well above the most devastating days of the early spring surge, when daily average deaths hovered around 2,000.

“At this point, looking at the numbers, for me the question is: Is there any way we can avoid half a million deaths before the end of February?” said Dr. Ashish Jha, dean of the Brown University School of Public Health.

“I think of how much suffering as a nation we seem to be willing to accept that we have this number of people getting infected and dying every day.”

How Did U.S. Go From 300,000 Deaths to 400,000?

The path to 400,000 deaths was painfully familiar, with patterns of sickness and death repeating themselves from earlier in the pandemic.

A shocking number of people in nursing homes and assisted living facilities continue to die each week — more than 6,000 in the first week of January.

Deaths linked to long-term care account for more than a third of all covid deaths in the U.S. since the beginning of the pandemic. In a handful of states, long-term care contributed to half the total deaths.

Certain parts of the country have a disproportionately high death rate. Alabama and Arizona, in particular, have experienced high rates, given their populations. The virus continues to kill Black and Indigenous Americans at much higher rates than whites.

The chance of dying of covid remains much higher in rural America than in the urban centers.

People over 65 make up the overwhelming majority of deaths, but Jha said more young people are dying than earlier in the pandemic, simply because the virus is so widespread.

In this newest and grimmest chapter of the pandemic, the virus has preyed upon a public weary of restrictions and rules, and eager to mix with family and friends over the holiday season.

Like many other health workers, Dr. Panagis Galiatsatos at Johns Hopkins Hospital is now witnessing the tragic consequences in his daily rounds.

“My heart breaks, because we could have prevented this,” said Galiatsatos, an assistant professor of medicine who cares for covid patients in the intensive care unit.

“A lot of what we saw during the holiday travel was the inability to reach our loved ones or family members — not like a public service announcement, but one on one, talking to them [about the exposure risks]. … I really felt like we failed.”

Galiatsatos still recalls a grandmother who was transported six hours from her home to his hospital — because there were no beds anywhere closer. On the phone, he heard her family’s shock at her sudden passing.

“They said, ‘But she was so healthy. She cooked us all Thanksgiving dinner and we had all the family over,’” he said. “They were saying it with sincerity, but that’s probably where she got it.”

Light at the End of a Very Long Tunnel

The enormous loss of life this winter has happened, paradoxically, at a time that many hope marks the start of the final chapter of the pandemic.

A quarter of all covid deaths have happened during the five weeks since the Food and Drug Administration authorized the first vaccine.

“The trickle of vaccine is so tragically scant. What we need is more of a river of it,” said Dr. Howard Markel, who directs the University of Michigan’s Center for the History of Medicine.

Markel, who has written about the 1918-19 flu pandemic, said it’s estimated it killed upward of 700,000 Americans.

Of the covid pandemic, he said, “I hope we’re not talking … 600,000 or more.”

At this point, about 3 in 100 people have been vaccinated, placing America ahead of many other countries but behind the optimistic promises made in the early days of the rollout. Given the current pace of vaccination, experts warn, Americans cannot depend solely on the vaccine to prevent a crushing number of additional deaths in the coming months.

UCSF’s Bibbins-Domingo worries that the relief of knowing a vaccine will eventually be widely available — the light at the end of the tunnel — may actually lull millions more Americans into a false sense of safety.

“This tunnel is actually a very long tunnel, and the next few months, as the last few months have been, are going to be very dark times,” she said.

The emergence of more contagious variants of SARS-CoV-2, the covid virus, complicates the picture and makes it all the more imperative that Americans spend the coming months doubling down on the very same tactics — masks and physical distancing — that have kept many people safe so far.

But Jha, of Brown University, says the country now faces a different task from that of the fall, when “big behavioral changes and large economic costs” were required to prevent deaths.

“Right now what is required is getting people vaccinated with vaccines we already have,” he said. “The fact that’s going super slow still is incredibly frustrating.”

It is this dichotomy — the advent of lifesaving vaccines as hospitals are filled with more dying patients than ever before — that makes this moment in the pandemic so confounding.

“I can’t help but feel this immense somberness,” said Kristin Urquiza. “I know that a vaccine isn’t going to make a difference for the people that are in the hospital right now or who will be in the hospital next week or even next month.”

This story is from a reporting partnership with NPR.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Black Americans Are Getting Vaccinated at Lower Rates Than White Americans

Black Americans are receiving covid vaccinations at dramatically lower rates than white Americans in the first weeks of the chaotic rollout, according to a new KHN analysis.

About 3% of Americans have received at least one dose of a coronavirus vaccine so far. But in 16 states that have released data by race, white residents are being vaccinated at significantly higher rates than Black residents, according to the analysis — in many cases two to three times higher.

In the most dramatic case, 1.2% of white Pennsylvanians had been vaccinated as of Jan. 14, compared with 0.3% of Black Pennsylvanians.

The vast majority of the initial round of vaccines has gone to health care workers and staffers on the front lines of the pandemic — a workforce that’s typically racially diverse made up of physicians, hospital cafeteria workers, nurses and janitorial staffers.

If the rollout were reaching people of all races equally, the shares of people vaccinated whose race is known should loosely align with the demographics of health care workers. But in every state, Black Americans were significantly underrepresented among people vaccinated so far.

Access issues and mistrust rooted in structural racism appear to be the major factors leaving Black health care workers behind in the quest to vaccinate the nation. The unbalanced uptake among what might seem like a relatively easy-to-vaccinate workforce doesn’t bode well for the rest of the country’s dispersed population.

Black, Hispanic and Native Americans are dying from covid at nearly three times the rate of white Americans, according to a Centers for Disease Control and Prevention analysis. And non-Hispanic Black and Asian health care workers are more likely to contract covid and to die from it than white workers. (Hispanics can be of any race.)

“My concern now is if we don’t vaccinate the population that’s highest-risk, we’re going to see even more disproportional deaths in Black and brown communities,” said Dr. Fola May, a UCLA physician and health equity researcher. “It breaks my heart.”

Dr. Taison Bell, a University of Virginia Health System physician who serves on its vaccination distribution committee, stressed that the hesitancy among some Blacks about getting vaccinated is not monolithic. Nurses he spoke with were concerned it could damage their fertility, while a Black co-worker asked him about the safety of the Moderna vaccine since it was the company’s first such product on the market. Some floated conspiracy theories, while other Black co-workers just wanted to talk to someone they trust like Bell, who is also Black.

Dose 2 is in! Just some mild arm soreness that will probably be worse tomorrow. I’ll check in tomorrow to give an update. h/t: @gradydoctor for the T-shirt idea#RightToBareArms 💪🏾 💉 #ShotOfHope#BlackMenInMedicine pic.twitter.com/56jAu0V5zy

— Dr. Taison Bell (@TaisonBell) January 5, 2021

But access issues persist, even in hospital systems. Bell was horrified to discover that members of environmental services — the janitorial staff — did not have access to hospital email. The vaccine registration information sent out to the hospital staff was not reaching them.

“That’s what structural racism looks like,” said Dr. Georges Benjamin, executive director of the American Public Health Association. “Those groups were seen and not heard — nobody thought about it.”

UVA Health spokesperson Eric Swenson said some of the janitorial crew were among the first to get vaccines and officials took additional steps to reach those not typically on email. He said more than 50% of the environmental services team has been vaccinated so far.

A Failure of Federal Response

As the public health commissioner of Columbus, Ohio, and a Black physician, Dr. Mysheika Roberts has a test for any new doctor she sees for care: She makes a point of not telling them she’s a physician. Then she sees if she’s talked down to or treated with dignity.

That’s the level of mistrust she says public health officials must overcome to vaccinate Black Americans — one that’s rooted in generations of mistreatment and the legacy of the infamous Tuskegee syphilis study and Henrietta Lacks’ experience.

A high-profile Black religious group, the Nation of Islam, for example, is urging its members via its website not to get vaccinated because of what Minister Louis Farrakhan calls the “treacherous history of experimentation.” The group, classified as a hate group by the Southern Poverty Law Center, is well known for spreading conspiracy theories.

Public health messaging has been slow to stop the spread of misinformation about the vaccine on social media. The choice of name for the vaccine development, “Operation Warp Speed,” didn’t help; it left many feeling this was all done too fast.

Benjamin noted that while the nonprofit Ad Council has raised over $37 million for a marketing blitz to encourage Americans to get vaccinated, a government ad campaign from the Health and Human Services Department never materialized after being decried as too political during an election year.

“We were late to start the planning process,” Benjamin said. “We should have started this in April and May.”

And experts are clear: It shouldn’t merely be ads of famous athletes or celebrities getting the shots.

“We have to dig deep, go the old-fashioned way with flyers, with neighbors talking to neighbors, with pastors talking to their church members,” Roberts said.

Speed vs. Equity

Mississippi state Health Officer Dr. Thomas Dobbs said that the shift announced Tuesday by the Trump administration to reward states that distribute vaccines quickly with more shots makes the rollout a “Darwinian process.”

Dobbs worries Black populations who may need more time for outreach will be left behind. Only 18% of those vaccinated in Mississippi so far are Black, in a state that’s 38% Black.

It might be faster to administer 100 vaccinations in a drive-thru location than in a rural clinic, but that doesn’t ensure equitable access, Dobbs said.

“Those with time, computer systems and transportation are going to get vaccines more than other folks — that’s just the reality of it,” Dobbs said.

In Washington, D.C, a digital divide is already evident, said Dr. Jessica Boyd, the chief medical officer of Unity Health Care, which runs several community health centers. After the city opened vaccine appointments to those 65 and older, slots were gone in a day. And Boyd’s staffers couldn’t get eligible patients into the system that fast. Most of those patients don’t have easy access to the internet or need technical assistance.

“If we’re going to solve the issues of inequity, we need to think differently,” Boyd said.

Dr. Marcus Plescia, chief medical officer at the Association of State and Territorial Health Officials, said the limited supply of vaccine must also be considered.

“We are missing the boat on equity,” he said. “If we don’t step back and address that, it’s going to get worse.”

While Plescia is heartened by President-elect Joe Biden’s vow to administer 100 million doses in 100 days, he worries the Biden administration could fall into the same trap.

And the lack of public data makes it difficult to spot such racial inequities in real time. Fifteen states provided race data publicly, Missouri did so upon request, and eight other states declined or did not respond. Several do not report vaccination numbers separately for Native Americans and other groups, and some are missing race data for many of those vaccinated. The CDC plans to add race and ethnicity data to its public dashboard, but CDC spokesperson Kristen Nordlund said it could not give a timeline for when.

Historical Hesitation

One-third of Black adults in the U.S. said they don’t plan to get vaccinated, citing the newness of the vaccine and fears about safety as the top deterrents, according to a December poll from KFF. (KHN is an editorially independent program of KFF.) Half of them said they were concerned about getting covid from the vaccine itself, which is not possible.

Experts say this kind of misinformation is a growing problem. Inaccurate conspiracy theories that the vaccines contain government tracking chips have gained ground on social media.

Just over half of Black Americans who plan to get the vaccine said they’d wait to see how well it’s working in others before getting it themselves, compared with 36% of white Americans. That hesitation can even be found in the health care workforce.

“We shouldn’t make the assumption that just because someone works in health care that they somehow will have better information or better understanding,” Bell said.

In Colorado, Black workers at Centura Health were 44% less likely to get the vaccine than their white counterparts. Latino workers were 22% less likely. The hospital system of more than 21,000 workers is developing messaging campaigns to reduce the gap.

“To reach the people we really want to reach, we have to do things in a different way, we can’t just offer the vaccine,” said Dr. Ozzie Grenardo, a senior vice president and chief diversity and inclusion officer at Centura. “We have to go deeper and provide more depth to the resources and who is delivering the message.”

That takes time and personal connections. It takes people of all ethnicities within those communities, like Willy Nuyens.

Nuyens, who identifies as Hispanic, has worked for Kaiser Permanente Los Angeles Medical Center for 33 years. Working on the environmental services staff, he’s now cleaning covid patients’ rooms. (KHN is not affiliated with Kaiser Permanente.)

In Los Angeles County, 92% of health care workers and first responders who have died of covid were nonwhite. Nuyens has seen too many of his co-workers lose family to the disease. He jumped at the chance to get the vaccine but was surprised to hear only 20% of his 315-person department was doing the same.

So he went to work persuading his co-workers, reassuring them that the vaccine would protect them and their families, not kill them.

“I take two employees, encourage them and ask them to encourage another two each,” he said.

So far, uptake in his department has more than doubled to 45%. He hopes it will be over 70% soon.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Bringing in Vaccinators

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

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

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

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

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

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

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

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

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

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

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

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

Bureaucratic Delays

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

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

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

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

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

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

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

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

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

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

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

KHN correspondent Rachana Pradhan contributed to this report.

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

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

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Geography Is Destiny: Dentists’ Access to Covid Shots Depends on Where They Live

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Dr. Monte Junker, an Oregon dentist, is waiting for his turn to get vaccinated for covid even though he considers himself a front-line health worker.

“If they offered it to me today, I would be there,” he said.

In December, just before the first vaccines were cleared for emergency use, the Centers for Disease Control and Prevention immunization advisory board recommended that health care workers — as well as nursing home residents and staff members — be the first to be inoculated because of their high risks of infection.

But Oregon is one of a handful of states, including Colorado, North Carolina and Texas, that have put dentists lower in priority order than other health professionals who treat patients — even though they have their hands in people’s mouths and are exposed to aerosols that spray germs in their faces during procedures.

As a result, dentists in those states must wait while many of their peers got their shots in December.

Dr. Tam Le, president of the Connecticut State Dental Association, was vaccinated in December along with employees at his practice in Cheshire. He said he lobbied the state to include dentists with other front-line hospital and health workers.

“In Connecticut, we are doing really well,” he said, noting that the state set up an online registration system for eligible health workers and then contacted them about when and where they could get the vaccine. Le said he and his staff went to a nearby community health center for their shots.

Dentists gained goodwill from state officials last spring by donating gloves and masks to hospitals, Le said. They also offered to help administer the shots since they have experience with that.

States are increasingly diverging from CDC guidance in their vaccination plans, according to an analysis by KFF. “Timelines vary significantly across states, regardless of priority group, resulting in a vaccine rollout labyrinth across the country,” the report said. (KHN is an editorially independent program of KFF.)

The American Dental Association said it’s aware that the lack of a national immunization strategy has meant that dentists and their staffs are not being treated equally across the country.

The CDC advisory board included dentists when it recommended that front-line health workers get priority.

“Each state government’s approach to vaccination will be different based on populations and need, but all dental team members should be prioritized in the first-tier distribution as the vaccines roll out by the different state and county public health departments,” said Daniel Klemmedson, the ADA president. An oral surgeon in Arizona, he has been vaccinated.

In Florida, dentists and their staffs are included among front-line workers eligible for vaccines in the first wave, but a lack of supply has hindered some from getting their shots, according to Drew Eason, CEO of the Florida Dental Association. Some county health departments have also incorrectly turned dentists away, he added.

Dr. Cindy Roark, a Boca Raton dentist and chief clinical officer of Sage Dental, which has 15 offices in Florida and Georgia, said she has no idea when she’ll get vaccinated. She said Georgia dentists in her company have been vaccinated, while those in Florida must wait. The only exceptions appear to be the relatively few dentists affiliated with hospitals. “We are equally vulnerable,” she said.

Still, Roark said she is not upset. “I know I can protect myself,” she said, adding that her office staffers wear N95 masks, face shields and gloves to protect themselves and patients. “Most dentists feel completely safe running their practice and preventing transmission.”

Junker, regional dental director at Advantage Dental in The Dalles, Oregon, said he understands that intensive care staff members, emergency department workers and the elderly in nursing homes need the vaccine first.

“But we are definitely up there for the copious quantities of aerosol in our faces each day,” he said. “The atmosphere is highly concentrated” with virus.

He’s upset at the poor planning and coordination between states and the federal government to make dentists a priority.

In cases where hospital staffers are declining the vaccine because they don’t trust it, Junker said, hospitals should offer shots to dentists and others who are eager for them.

“I don’t think it’s fair for them to sit on the vaccine for a month or two. It needs to get used, and if the hospital workers later decide to get vaccinated, they can get back in line,” he said.

Dr. Stan Hardesty, a Raleigh, North Carolina, dentist and president of the state dental society, said it’s disappointing to see dentists in other states get the vaccine while he and his colleagues have been told to wait.

“We have been advocating on behalf of our members to have dentists and our team members included in phase 1a as recommended by the CDC,” he said. “Unfortunately, the decision-makers [in the state government] have decided to utilize a different prioritization in their vaccine implementation.”

North Carolina dentists will be in “phase 1b,” which includes adults 75 and older, essential workers such as police officers and firefighters.

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

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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Delicate Covid Vaccines Slow Rollout — Leading to Shots Given Out of Turn or, Worse, Wasted

For Heather Suri, a registered nurse in Virginia, the race to vaccinate Americans against covid has thrown up some unprecedented obstacles.

The vaccines themselves are delicate and require a fair bit of focus over time. Consider Moderna’s instructions for preparing its doses: Select the number of shots that will be given. Thaw the vials for 2.5 hours in a refrigerator set between 36 and 46 degrees. Then rest them at room temperature for 15 minutes. Do not refreeze. Swirl gently between each withdrawal. Do not shake. Inspect each vial for particulate matter or discoloration. Store any unused vaccine in refrigeration.

And then there’s this: Once open, a vial is good for only six hours. As vaccines go, that’s not very long. Some flu vaccine keeps almost a month.

“This is very different, administering this vaccine. The process, it takes a whole lot longer than any mass vaccination event that I’ve been involved with,” said Suri, a member of the Loudoun Medical Reserve Corps who joined her first clinic Dec. 28, to vaccinate first responders.

Of the first two covid vaccines on the market, Moderna’s is considered more user-friendly. Pfizer-BioNTech’s shot must be stored in specialized freezers at 94 degrees below zero. Once out of deep freeze, it lasts just five days, compared with 30 days for Moderna’s.

One thing the shots have in common: They last a paltry six hours once the first dose is removed from a vial. That short shelf life raises the stakes for the largest vaccination effort in U.S. history by forcing clinicians to anticipate the exact number of doses they’ll need each day. If they don’t get it right, precious stores of vaccine may go to waste.

During one recent clinic over several hours, Suri estimated she gave “maybe 25” shots, many fewer than the number of flu shots she’s given during similar clinics over the years.

With covid, she said, “the vaccine itself slows things down.”

The slow rollout has frustrated people who at Thanksgiving imagined millions of vaccines in arms by Christmas. Promises that 20 million would be vaccinated by New Year’s fell well short: Just 2.8 million had the first of two required shots by the end of December, according to data from the Centers for Disease Control and Prevention.

Public health officials say many factors are at play, including a shortage of workers trained to administer shots, covid protocols that require physical distancing at clinics and vaccine allocation numbers from the federal government that fluctuate by the week.

And then there are the logistics of the first covid vaccines, which are complex and make hyper-vigilant practitioners wary of opening too many vials over the course of each day, for fear that anything unused will have to be tossed. Vaccine providers also report wasted or spoiled doses to public health authorities.

“If you get to the end of your clinic and every nurse has half a vial left, what are you going to do with that vaccine?” Suri said. “The clock is ticking. You don’t want to waste those doses.”

That impulse has led some health personnel to make dramatic decisions at the end of a day: calling non-front-line health workers or offering shots to whoever is at hand in, say, a grocery store, instead of scrambling to find the health workers and residents of nursing homes in the government’s first tier for injections.

“We jumped and ran and got the vaccine,” said Dr. Mark Hathaway, an OB-GYN in the District of Columbia who received the first dose of a Moderna vaccine on Dec. 26 along with his wife, a registered nurse specializing in nutrition. Both clinicians received vaccines faster than anticipated at a Unity Health Care clinic when there were extra doses because fewer front-line health care workers than expected showed up.

“Health care workers have been priority 1a, so our first attempt has always been our staff,” said Dr. Jessica Boyd, Unity Health Care’s chief medical officer. Since then, the community health center network has broadened its criteria for extra doses to include staff members or high-risk patients visiting a clinic, she said.

Health officials encourage using the doses to get as many Americans vaccinated as quickly as possible. Public health experts say the need to vaccinate people is especially urgent as a new and more contagious variant of the virus first detected in the United Kingdom is showing up in multiple states. Some states, including New York and California, have loosened their guidelines on who can get vaccinated after an outcry over health care providers throwing away doses that didn’t meet officials’ strict criteria.

The tiers “are simply recommendations, and they should never stand in the way of getting shots in arms instead of keeping vaccine in the freezer or wasting vaccine in the vial,” Health and Human Services Secretary Alex Azar said Jan. 6, referring to CDC guidelines saying health care workers and residents and staff of long-term care facilities should be first in line, then people at least 75 years old. The Trump administration this week also said it would make more shots available by releasing second doses and urged states to broaden rules to allow anyone 65 or older and any resident with a serious medical condition to get a shot.

Pfizer-BioNTech’s ultra-cold storage requirements have made it less ideal for local public health departments and rural areas.

Both of the available vaccines arrive in multidose vials — Pfizer-BioNTech’s contains about five doses, Moderna’s 10. Neither contains preservatives and they are viable for only six months frozen. By contrast, during the H1N1 pandemic roughly a decade ago, the swine flu vaccines lasted 18 weeks to 18 months, Sen. Chuck Grassley (R-Iowa) wrote in a May 2010 letter to then-HHS Secretary Kathleen Sebelius.

“We can’t get the vaccine out fast enough; we have people dying. But, at the same time, we have to get it right,” said Claire Hannan, executive director of the Association of Immunization Managers.

The added risk of losing doses due to quick expiration is another thing “causing angst,” Hannan said. “You can’t just draw it up and let it sit. It can’t just sit out like that.”

The Trump administration fell significantly short of its promise that 20 million Americans would be vaccinated by the end of December, partly the result of a disjointed and underfunded public health system that has received limited guidance from federal officials. As of Jan. 11, 25.5 million vaccine doses had been distributed nationwide but only 9 million administered, according to the CDC.

Federal officials have released sparse data about who is getting vaccinated, but state information has shown significant variation in vaccination rates depending on the facility. New York Gov. Andrew Cuomo on Jan. 4 said New York City’s public hospital system had used only 31% of its allocated vaccines, while private health systems NewYork-Presbyterian and Northwell Health had used 99% and 62%, respectively.

“When you target a priority group, it’s inefficient. When you open it up to a larger group, it’s efficient … but you’re not going to have enough supply,” Hannan said. “You still have the challenge of getting those health care workers vaccinated and no matter any way you slice it, you still have limited supply. You can’t please everyone.”

While Pfizer’s vaccine has largely been earmarked for large institutions like hospitals and nursing homes, Moderna’s has been more widely distributed to smaller sites like public health departments and clinics run by volunteers. State and local officials have begun or will soon vaccinate other priority populations, including police officers, teachers and other K-12 school employees, and seniors overall.

Unlike the covid vaccines, many flu vaccines come in prefilled syringes — each syringe’s cap is removed only when a shot is given, which speeds the process and eases some concerns about storage. However, relying on prefilled syringes during a pandemic has its own complications, according to Michael Watson, former president of Valera, a Moderna subsidiary: They take up more fridge space. They’re more expensive. And they can’t be used for frozen products, he said.

“For all these reasons, a vial was the best and only option,” he said.

In Ohio, Eric Zgodzinski, health commissioner for Toledo-Lucas County, said two-thirds of first responders the county surveyed said they would get the vaccine. Still, he said, his department has encountered situations in which a covid vaccine dose is left over in an open vial and officials have turned to a waiting list to find someone who can arrive within minutes to get a jab.

His department also has an internal running list of potential vaccine takers, including health department staffers, people in congregate care settings or those who had scheduled vaccination appointments for later on.

“We’re not going to open up a vial for one individual and figure out nine other people right away,” said Zgodzinski, whose department planned to distribute 2,200 doses of the Moderna vaccine the week of Jan. 4.

“If I have one dose left, who can I give it to?” he added. “A shot in the arm for anybody is better than it being wasted.”

San Francisco editor Arthur Allen and senior correspondent JoNel Aleccia contributed to this report.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Hospitals’ Rocky Rollout of Covid Vaccine Sparks Questions of Fairness

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Last week, after finishing inoculations of some front-line hospital staff, Jupiter Medical Center was left with 40 doses of precious covid vaccine. So, officials offered shots to the South Florida hospital’s board of directors and their spouses over age 65.

But that decision sparked outrage among workers left unvaccinated, including those at one of the hospital’s urgent care clinics, or who believe the hospital was currying favor with wealthy insiders before getting all its staffers protected, according to a hospital employee who spoke on the condition of not being named.

The move also prompted dozens of calls from donors looking to get vaccinated.

The hospital received 1,000 doses of the Moderna vaccine two days before Christmas, fewer than half of what it requested from the state to cover its workforce. Officials prioritized delivering the vaccine to front-line medical workers who requested it, performing inoculations on Christmas Eve or the holiday weekends.

Patti Patrick, a hospital vice president, said the hospital acted appropriately in its offerings of the vaccine, which has a short shelf life once vials are opened. Neither she nor other administrators who don’t work directly with patients were included in this first round of shots.

“This was a simple way to move 40 doses very quickly” before it spoiled, she said.

She added that all front-line staff from the health system, including the clinics, were given the opportunity to get the shots.

Jupiter is not the only hospital in the nation facing questions about its handling of the vaccines. The initial rollout — aimed at health care workers and nursing home residents — has been uneven at best because of a lack of a federal strategy on how it should work, with states, hospitals, nursing homes and pharmacies often making decisions on their own about who gets vaccinated and when.

In some hospitals, administrators and other personnel who have no contact with patients or face no risk at work from the virus are getting shots, while patients — and even front-line staff — who are at heightened risk for covid complications are being passed by. Some administrators who have been working remotely throughout the pandemic have been vaccinated, especially at hospitals that decided to allocate doses by age group rather than exposure risk.

Although states and federal health groups laid out broad guidelines on how to prioritize who gets the vaccine, in practice what’s mattered most was who controlled the vaccine and where the vaccine distribution was handled.

Stanford Health Care in California was forced to rework its priority list after protests from front-line doctors in training who said they had been unfairly overlooked while the vaccine was given to faculty who don’t regularly see patients. (Age was the important factor in the university’s algorithm.)

Members of Congress have called for an investigation following media reports that MorseLife Health System, a nonprofit that operates a nursing home and assisted living facility in West Palm Beach, Florida, vaccinated donors and members of a country club who donated thousands of dollars to the health company.

At least three other South Florida hospital systems — Jackson Health, Mount Sinai Medical Center and Baptist Health — have offered vaccines to donors in advance of the general public, while administering the shots to front-line employees, The Miami Herald reported.

Like Jupiter Medical, the hospitals insist that those offered shots were 65 and older, as prioritized by state officials.

Staffing Problems at Hospitals

An advisory board to the Centers for Disease Control and Prevention designated hospitals and nursing homes to get covid vaccines first because their workers and residents were considered at highest risk, and most states have followed that recommendation. But in many cases, the health institutions have found demand from staffers, some of whom are leery of the voluntary shot, is less than anticipated.

In addition, the arrival of promised shipments has been unpredictable. While the federal government approved the first covid vaccine on Dec. 14, some hospitals did not receive allotments until after Christmas.

That was the case at Hendry Regional Medical Center in Clewiston, Florida, which got 300 doses from the state. The hospital vaccinated 30 of its 285 employees between Dec. 28 and Jan. 5, said R.D. Williams, its chief executive officer. Some employees preferred to wait until after New Year’s weekend out of concern about side effects, he said.

The vaccine has been reported to commonly cause pain at the injection site and sometimes produce fever, lethargy or headache. The reactions generally last no more than a few days.

“I’m happy with how it’s going so far,” Williams said. “I know many of our employees want to be vaccinated, but I don’t see it as a panacea that they have to have it today,” he said, noting that staffers already have masks and gloves to protect themselves from the virus.

The hospital is also trying to coordinate vaccination schedules so 10 people at a time get the shot to ensure none of the medication is wasted after the multidose vials are thawed. Once vaccine is thawed, it must be used within hours to retain its effectiveness.

As of Jan. 6, Howard University Hospital in Washington, D.C., had vaccinated slightly more than 900 health workers since its first doses arrived Dec. 14. It has received 3,000 doses.

Success has been limited by reluctance among workers to get a vaccine and a lack of personnel trained to administer it, CEO Anita Jenkins said.

“We still have a hospital to run and have patients in the hospital with heart attacks and other conditions, and we don’t have additional staff to run the vaccine clinics,” she said.

While some hospitals offer the vaccine only to front-line workers who interact with patients, Howard makes it available to everyone, including public relations staff, cafeteria workers and administrators. Jenkins defended the move because, she said, it’s the best way to protect the entire hospital.

She noted such employees as information technology personnel who don’t see patients may be around doctors and nurses who do. “Working in a hospital, almost everyone runs into patients just walking down the hallway,” she said.

At Eisenhower Health, a nonprofit hospital based in Rancho Mirage, California, 2,300 of the 5,000 employees have been vaccinated.

“Our greatest challenge has been managing the current patient surge and staffing demands in our acute and critical care areas while also trying to ensure we have adequate staffing resources to operate the vaccine clinics,” said spokesperson Lee Rice.

A Non-System of Inequitable Distribution

Arthur Caplan, a bioethicist at NYU Langone Medical Center in New York City, said hospitals should not be inoculating board members ahead of hospital workers unless those people have a crucial role in running the hospital.

“That seems, to me, jostling to the head of the line and trying to reward those who may be potential donors,” he said. But he acknowledged that the hospitals’ vaccination systems are not always rational or equitable.

Covid vaccines need to get out as quickly as possible, he added, but hospitals can give them only to people they are connected with.

Caplan noted he was vaccinated at an NYU outpatient site last week, even though his primary care doctor hadn’t yet gotten the vaccine because his clinic had not received any doses.

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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Are You Old Enough to Get Vaccinated? In Tennessee, They’re Using the Honor System

In December, all states began vaccinating only health care workers and residents and staffers of nursing homes in the “phase 1A” priority group. But, since the new year began, some states have also started giving shots to — or booking appointments for — other categories of seniors and essential workers.

As states widen eligibility requirements for who can get a covid-19 vaccine, health officials are often taking people’s word that they qualify, thereby prioritizing efficiency over strict adherence to distribution plans.


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“We are doing everything possible to vaccinate only those ‘in phase,’ but we won’t turn away someone who has scheduled their vaccine appointment and tells us that they are in phase if they do not have proof or ID,” said Bill Christian, spokesperson for the Tennessee Department of Health.

Among the states pivoting to vaccinating all seniors, timelines and strategies vary. Tennessee started offering shots to people 75 and older on Jan. 1. So, Frank Bargatze of Murfreesboro, Tennessee, snagged an appointment online for his father — and then went ahead and put his own name in, though he’s only 63.

“He’s 88,” Bargatze said, pointing to his father in the passenger seat after they both received their initial shots at a drive-thru vaccination site in Murfreesboro, a large city outside Nashville. “I jumped on his bandwagon,” he added with a laugh. “I’m going to blame it on him.”

Bargatze does work a few days a week with people in recovery from addiction, he added, so in a way, he might qualify as a health care worker.

Some departments are trying more than others, but overwhelmed public health departments don’t have time to do much vetting.

Dr. Lorraine MacDonald is the medical examiner in Rutherford County, Tennessee, where she’s been staffing the vaccination site. If people seeking the vaccine make it through the sign-up process online, MacDonald said, and show up for their appointment, health officials are not going to ask any more questions — as long as they’re on the list from the online sign-up.

“That’s a difficult one,” MacDonald acknowledged, when asked about people just under the age cutoff joining with older family members and putting themselves down for a dose, too. “It’s pretty much the honor system.”

People getting vaccinated in several Tennessee counties told a reporter they did not have to show ID or proof of qualifying employment when they arrived at a vaccination site. Tennessee’s health departments are generally erring on the side of simply giving the shot, even if the person is not a local resident or is not in the country legally.

The loose enforcement of the distribution phases extends to other parts of the country, including Los Angeles. In response, New York’s governor is considering making line-skipping a punishable offense.

Still, many people who don’t qualify on paper believe they might need the vaccine as much as those who do qualify in the initial phases.

Gayle Boyd of Murfreesboro is 74, meaning she didn’t quite make the cutoff in Tennessee, which is 75. But she’s also in remission from lung cancer, and so eager to get the vaccine and start getting back to a more normal life, that she joined her slightly older husband at the Murfreesboro vaccination site this week.

“Nobody’s really challenged me on it,” she said, noting she made sure to tell vaccination staffers about her medical issues. “Everybody’s been exceptionally nice.”

Technically, in the state’s current vaccine plan, having a respiratory risk factor like lung cancer doesn’t leapfrog anyone who doesn’t otherwise qualify. But in some neighboring states such as Georgia, where the minimum age limit is 65, Boyd would qualify.

Even for those who sympathize with such situations, anecdotes about line-skipping enrage many trying to wait their turn.

“We try to be responsible,” said 57-year-old Gina Kay Reid of Eagleville, Tennessee.

Reid was also at the Murfreesboro vaccination site, sitting in the back seat as she accompanied her older husband and her mother. She said she didn’t think about trying to join them in getting their first doses of vaccine. “If you take one and don’t necessarily need it, you’re knocking out somebody else that is in that higher-risk group.”

But there is a way for younger, healthier people to get the vaccine sooner than later — and not take a dose away from anyone more deserving.

A growing number of jurisdictions are realizing they have leftover doses at the end of every day. And the shots can’t be stored overnight once they’re thawed. So some pharmacists, such as some in Washington, D.C., are offering them to anyone nearby.

Jackson, Tennesse, has established a “rapid response” list for anyone willing to make it down to the health department within 30 minutes. Dr. Lisa Piercey, the state’s health commissioner, said her own aunt and uncle received a call at 8 p.m. and rushed to the county vaccination site to get their doses.

Piercey called it a “best practice” that she hopes other jurisdictions will adopt, offering a way for people eager for the vaccine to get it, while also helping states avoid wasting precious doses.

This story is part of a partnership that include WPLN, 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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Only a Smokescreen? Big Tobacco Stands Down as Colorado and Oregon Hike Cigarette Taxes


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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

But not all voters get a say.

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

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

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

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

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

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An Urban Hospital on the Brink Vs. the Officials Sworn to Save It

Illinois and Chicago officials are trying to figure out how to stop a private company from closing a money-losing urban hospital in a poor, underserved Chicago neighborhood.

Trinity Health, a national Catholic tax-exempt chain, wants to close Mercy Hospital and Medical Center on Chicago’s Near South Side by May 31. Last month, in an unusual move, the Illinois Health Facilities & Services Review Board unanimously denied Trinity permission to close the 412-bed facility, which predominantly serves Black and other minority patients on Medicaid.

The board members said they feared the closure would limit access to care for nearly 60,000 South Side residents, forcing them to travel nearly 7 miles to the closest facility with an emergency room, intensive care unit and birthing center. It also would cost the community about 2,000 hospital jobs.

Urban hospitals in low-income areas of Los Angeles, Philadelphia, San Francisco, Washington, D.C., and other cities and suburbs face similar financial squeezes. Inner-city facilities like Mercy struggle to survive on lean payment rates from Medicaid and to compete with financially robust hospitals that mostly serve well-paying, privately insured patients.

So far, no one has come up with a politically and financially viable solution for strengthening safety-net health providers in low-income urban communities. “The sad fact is market location is everything,” said Lawton Robert Burns, a professor of health care management at the University of Pennsylvania, who studied the controversial closure of Hahnemann University Hospital in Philadelphia in 2019. “No offense to poor people, but there are economic factors that hospitals can’t control.”

But it is far from clear that a government board can stop a hospital from going out of business. “It’s really difficult in a capitalist country to tell a private company you have to continue to lose money,” said Dr. Linda Rae Murray, a member of the health facilities board and former Trinity Health board member who teaches health policy at the University of Illinois-Chicago.

Trinity, which operates 92 hospitals in 22 states, seems determined to push forward with its plans to close the hospital. It has deep pockets, with $31.9 billion in total assets. It reported revenue of $18.8 billion last year, and a profit of 2.3% in the most recent quarter. Trinity executives told the health facilities board in December that Mercy loses nearly $39 million a year and that they could not find any buyers for the hospital — Chicago’s oldest, chartered in 1852. They also reminded the board that state lawmakers rejected Mercy’s 2019 $1 billion proposal to merge with three other South Side hospitals and build a new hospital facility and several new clinics with $520 million in state aid.

Trinity declined to make anyone available for an interview for this article.

Trinity has said it will try again to get approval to shut Mercy at the facilities review board’s Jan. 26 meeting. It has offered to replace the hospital with a $13 million clinic offering just diagnostic and urgent care — but no primary care physician services. Critics of that proposal say the clinic, while helpful, would not be an adequate replacement for the hospital because it would not provide access to the full range of needed services.

“We can’t have these mega-hospital companies that are getting a property tax exemption for providing charity care closing a safety-net hospital in the middle of a pandemic,” said former Illinois Gov. Pat Quinn, a Democrat who spearheaded a 2013 deal to save Roseland Hospital, another embattled facility on Chicago’s South Side. “I’d tell the Trinity executives, ‘You’re not doing this to Chicago. We’ll work with you to put together a bigger deal.’”

The obvious long-term solution is richer Medicaid funding for safety-net hospitals, effective partnerships between public and private providers and firm commitments by financially strong hospital companies, including academic medical centers, to expand services in low-income communities. For instance, some say state and local officials should prod Trinity to use the resources of its Loyola University Medical Center in west suburban Chicago to bolster Mercy.

Hospitals are required to get a certificate of need for closure from the facilities review board, according to a new state law. But state officials’ actions are limited when seeking to enforce a decision to keep a facility open.

The state could levy a fine of up to $10,000 for not complying with the board’s decision, plus an additional $10,000 a month while the hospital continues to operate. But that’s a trivial amount for a big company like Trinity.

The state also could halt Medicaid and other public payments to Mercy. But that would be counterproductive, hastening the hospital’s demise since nearly half of Mercy’s inpatient revenue and 35% of its outpatient revenue comes from Medicaid, according to state data.

A final source of leverage is in Trinity’s ownership of three other hospitals in the Chicago area: Loyola, Gottlieb Memorial Hospital and MacNeal Hospital. The state could threaten Trinity’s property-tax exemption as a charitable organization. That’s an approach favored by Quinn, who cited a previous legal challenge to the tax-exempt status of the Carle Foundation Hospital in Urbana, Illinois.

No matter what the state does, Trinity can find ways to shut down Mercy. It could argue that even as Mercy is meeting the state requirement to continue to treat patients, it must close critical services like the emergency department or the birthing center because it lacks funding or staff to maintain adequate quality of care, said Juan Morado Jr., a Chicago health care lawyer who formerly served as general counsel for the facilities review board. The new law permits closing only one hospital department every six months.

While the state presses to keep the hospital open, Mercy also could suffer from attrition. When there’s talk of closing a hospital, physicians, nurses and other staffers may start leaving for other jobs. Whether Trinity seeks to refill positions is critical.

“There are things the owner can do to trickle the hospital down to nothing,” said Dr. David Ansell, senior vice president for community health equity at Rush University Medical Center in Chicago, who opposes shuttering Mercy. “There is a drip, drip, drip of negativity, and at some point people vote with their feet.”

The Chicago area has been through a similar battle recently. Pipeline Health, a private-equity investment firm, bought Westlake Hospital in suburban Melrose Park and two other local hospitals from hospital chain Tenet Healthcare in 2019. Pipeline quickly announced it was closing Westlake, a 230-bed hospital — even though it had promised the state it would keep it open for at least two years.

That controversial move prompted the Illinois legislature to give the facilities review board new authority to deny permission for future hospital closures, which the board lacked for Westlake.

Yet, the Westlake saga may point to a better solution for Mercy. In early 2020, the state and federal governments renovated the Westlake facility so it could be used as an overflow site for covid-19 patients. It wasn’t needed, but the updates led to strong interest from companies in purchasing and reopening the hospital, particularly for behavioral health inpatient services.

State Rep. Kathleen Willis, a Democrat who co-sponsored the 2019 bill to let the facilities review board say no to hospital closures, said a deal to buy and reopen Westlake likely will be announced within the next few weeks.

Any deal to save Mercy likely will require more money from Trinity, more commitment from other providers to offer a full range of hospital and medical services in the area, and significant increases in state and federal funding.

“Every hospital CEO has to worry about the bottom line of their business,” Ansell said. “But big organizations like Trinity need to come up with a better solution than the wholesale shutdown of an anchor institution that will leave communities bereft.”

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

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Trump Administration Approves First Medicaid Block Grant, in Tennessee

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With just a dozen days left in power, the Trump administration on Friday approved a radically different Medicaid financing system in Tennessee that for the first time would give the state broad authority in running the health insurance program for the poor in exchange for capping its annual federal funding.

The approval is a 10-year “experiment.” Instead of the open-ended federal funding that rises with higher enrollment and health costs, Tennessee will instead get an annual block grant. The approach has been pushed for decades by conservatives who say states too often chafe under strict federal guidelines about enrollment and coverage and can find ways to provide care more efficiently.

The approval, however, faces an uncertain future because the incoming Biden administration is likely to oppose such a move. But to unravel it, officials would need to set up a review that includes a public hearing.

Meanwhile, the changes in Tennessee will take months to implement because they need final legislative approval, and state officials must negotiate quality of care targets with the administration.

TennCare, the state’s Medicaid program, said the block grant system would give it unprecedented flexibility to decide who is covered and what services it will pay for.

It said the new arrangement would allow the state to keep part of the money it saves from operating the program more efficiently. Trump administration officials said the approach adds incentive for the state to save money, unlike the current system, in which increased state spending is matched with more federal dollars. If Medicaid enrollment grows, the state can secure additional federal funding. If enrollment drops, it will get less money.

“This groundbreaking waiver puts guardrails in place to ensure appropriate oversight and protections for beneficiaries, while also creating incentives for states to manage costs while holding them accountable for improving access, quality and health outcomes,” said Seema Verma, administrator of the Centers for Medicare & Medicaid Services. “It’s no exaggeration to say that this carefully crafted demonstration could be a national model moving forward.”

Opponents, including most advocates for low-income Americans, say the approach will threaten care for the 1.4 million people in TennCare, which includes children, pregnant women and the disabled. Federal funding covers two-thirds of the cost of the program.

Michele Johnson, executive director of the Tennessee Justice Center, said the block grant approval is a step backward for the state’s Medicaid program.

“No other state has sought a block grant, and for good reason. It gives state officials a blank check and creates financial incentives to cut health care to vulnerable families,” she said.

Democrats have fought back block grant Medicaid proposals since the Reagan administration and most recently in 2018 as part of Republicans’ failed effort to repeal and replace major parts of the Affordable Care Act. Even some key Republicans opposed the idea because it would cut billions in funding to states that would make it harder to help the poor.

Implementing block grants via an executive branch action rather than getting Congress to amend Medicaid law is also likely to be met with court challenges.

The block grant approval comes as Medicaid enrollment is at its highest ever level.

More than 76 million Americans are covered by the state-federal health program, a million more than when the Trump administration took charge in 2017. Enrollment has jumped by more than 5 million in the past year as the economy slumped with the pandemic.

Medicaid, part of President Lyndon B. Johnson’s “Great Society” initiative of the 1960s, is an entitlement program in which the government pays each state a certain percentage of the cost of care for anyone eligible for the health coverage. As a result, the more money states spend on Medicaid, the more they get from Washington.

Under the approved demonstration, CMS will work with Tennessee to set spending targets that will increase at a fixed amount each year.

The plan includes a “safety valve” to increase federal funding due to unexpected increases in enrollment.

“The safety valve will maintain Tennessee’s commitment to enroll all eligible Tennesseans with no reduction in today’s benefits for beneficiaries,” CMS said in a statement.

Tennessee has committed to maintaining coverage for eligible beneficiaries and existing services.

In exchange for taking on this financing approach, the state will receive a range of operating flexibilities from the federal government, as well as up to 55% of the savings generated on an annual basis when spending falls below the aggregate spending cap and the state meets certain quality targets, yet to be determined.

The state can spend that money on various health programs for residents, including areas that Medicaid funding typically doesn’t cover, such as improving transportation and education and employment.

The 10-year waiver is unusual, but the Trump administration has approved such long-term experiments in recent years to give states more flexibility.

Tennessee is one of 12 states that have not approved expanding Medicaid under the Affordable Care Act that’s left tens of thousands of working adults without health insurance.

“The block grant is just another example of putting politics ahead of health care during this pandemic,” said Johnson of the Tennessee Justice Center. “Now is absolutely not the time to waste our energy and resources limiting who can access health care.”

State officials applauded the approval.

“It’s a legacy accomplishment,” said Tennessee Gov. Bill Lee, a Republican. “This new flexibility means we can work toward improving maternal health coverage and clearing the waiting list for developmentally disabled.”

“This means we will be able to make additional investments in TennCare without reduction in services and provider cuts.”

KHN chief Washington correspondent Julie Rovner contributed to this report.

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

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

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

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

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

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

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

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

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

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

Pero algunos cuestionan esta razón.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Políticos de otros estados han hecho lo opuesto.

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

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

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

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

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

La corresponsal de Montana, Katheryn Houghton, la corresponsal de California Healthline, Angela Hart y los corresponsales Markian Hawlyruk y JoNel Aleccia colaboraron con esta historia.

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

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Do-It-Yourself Contact Tracing Is a ‘Last Resort’ in Communities Besieged by Covid

The contact tracers of Washtenaw County in Michigan have been deluged with work and, to cope, the overburdened health department has a new tactic: It is asking residents who test positive for covid-19 to do their own contact tracing.


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Washtenaw is a county of nearly 350,000 residents who live in and around the city of Ann Arbor, about 45 minutes from Detroit. Until mid-October, a county team of 15 contact tracers was managing the workload. But by Thanksgiving, more than 1,000 residents were testing positive for the coronavirus every week, and the tracers could not keep pace.

In Washtenaw County, the process starts with people called case investigators, who receive lab reports of positive coronavirus tests. Their job is to call anyone who has tested positive, tell them they need to isolate and ask them for the names of people with whom they have had close contact. After creating a list of potentially exposed “contacts,” investigators pass it to a new team to start the actual contact tracing. As the number of positive cases builds, the number of calls tracers must make swells.

But in recent weeks, it’s not just the number of positive cases that has increased, overwhelming the capacity of case investigators — so has the number of contacts that each infected person has, said contact tracer Madeline Bacolor.

“There’s just so many more people that are gathering and that are exposed,” she said. “It used to be, we had a case, and maybe that person had seen two people, and now it’s a whole classroom full of day care students or a whole workplace.”

The work to keep people who have been exposed to the virus away from people who have not is crucial, said public health professor Angela Beck, because it breaks viral transmission chains and prevents the virus from spreading unchecked through a community.

Beck teaches at the University of Michigan and runs the campus program for tracing coronavirus exposures among students.

When you’re trying to contain an infectious disease, she said, running out of contact tracers is “not a situation that you want to be in.”

But it’s happening now in health departments in Michigan and around the U.S. where contact tracing workforces have grown, but not fast enough to keep pace with the pandemic’s spread.

As a result, health departments are asking some residents with covid to reach out to their contacts on their own.

Trying ‘a Compromised Strategy’

Once billed as one of the fundamental tools for stemming the spread of the virus, contact tracing has fallen apart in many regions of the country. It’s a systematic breakdown that Lawrence Gostin, a professor of global health law at Georgetown University, said hasn’t happened since the spread and stigma of HIV and AIDS in the 1980s and ’90s.

In Michigan’s rural Upper Peninsula, a public health district spanning five counties warned residents that its tracers were overwhelmed and that they might not receive a call at all, despite testing positive. Health workers would need to focus their efforts on residents 65 and older, teens and children attending school in person, and people living in group settings.

In Michigan’s southwestern corner, contact tracers in Van Buren and Cass counties can no longer keep up with their calls. It’s the same situation in Berrien County: “If you test positive, take action immediately by isolating and notifying close contacts,” the county health officer urged residents in a press release.

Health officials have taken similar actions in all regions of the country, including Oregon, North Dakota, Ohio and Virginia.

Within many health departments, the shortage of contact tracers has been exacerbated by the communications challenge of relaying a recent change in quarantine guidance from the Centers for Disease Control and Prevention — it reduced the quarantine period from 14 days to 10 for some individuals exposed to the virus.

The idea behind the change was that the risk of transmission after 10 days of quarantine was low, and shorter quarantine periods might increase people’s willingness to comply with the orders. But the shift also meant that contact tracers had to spend time learning and explaining the new procedures just when caseloads were exploding.

“It makes things more confusing,” said Bacolor, the contact tracer in Washtenaw County. “People might be hearing something different from their job or school than they are from the health department.”

Asking infected people, some of whom might be sick, to call their own friends and families — in effect, conduct their own contact-tracing operation — is far from ideal, public health experts said.

“It is a last-resort tool,” said Beck, the University of Michigan professor. “It is the best that we can do in the situation that we’re in, but it’s a compromised strategy.”

Contact tracing is more than just alerting people to a potential exposure so they can quarantine. Part of the process is to conduct carefully structured interviews with those exposed, to determine if they’ve developed symptoms of covid-19. If so, contacts of those people also need to be traced and told to quarantine, to prevent the virus from proliferating through successive chains of people in the community.

Trained contact tracers also often ask valuable questions to learn more about how the virus was transmitted from person to person so that local health officials can piece together an understanding about which settings and activities seem particularly likely to promote spread — in-person choir rehearsals and crowded bars, for example — and which are unlikely to generate outbreaks.

Contact tracing is a key part of a tried-and-true strategy known as “test, trace and isolate.” Public health professor Beck said the strategy has been used all over the world and it works — when there are enough people and enough time to do it properly.

And she said effective contact tracing can help mitigate the economic pain of a pandemic because it means that only people with known exposures to the virus must stay away from workplaces and school and refrain from other activities.

But success requires significant investment in public health infrastructure, something that Beck and other researchers said has been lacking for decades in the U.S.

This story is part of a partnership that includes 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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As the Vulnerable Wait, Some Political Leaders’ Spouses Get Covid Vaccines

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Politicians in other states have taken the opposite tack.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Oxygen as Cold as Neptune

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

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

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

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

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

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

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

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

The Oxygen Shortage Doom Loop

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

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

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

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

‘Extreme Rurality’

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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


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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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La pandemia de covid-19 está devastando a los profesionales de salud de color

La primavera pasada, Maritza Beniquez, enfermera de una sala de emergencias de Nueva Jersey, fue testigo de “una oleada tras otra” de pacientes enfermos, cada uno con una mirada aterrada que se volvió familiar a medida que pasaban las semanas.

Pronto, fueron sus colegas del Hospital Universitario de Newark, enfermeras, técnicos y médicos con los que había estado trabajando codo con codo, quienes se presentaban en la emergencia luchando por respirar. “Muchos de nuestros propios compañeros de trabajo se enfermaron, especialmente al principio; literalmente diezmó a nuestro personal”, contó.

A fines de junio, 11 de los colegas de Beniquez habían muerto. Como los pacientes que habían estado tratando, la mayoría eran de raza negra y latinos (que pueden ser de cualquier raza).

“Nos vimos afectados de manera desproporcionada por la forma en que nuestras comunidades se han visto afectadas de manera desproporcionada en cada [parte de] nuestras vidas, desde las escuelas hasta los trabajos y los hogares”, dijo.

El 14 de diciembre, Beniquez se convirtió en la primera persona en Nueva Jersey en recibir la vacuna contra el coronavirus, y fue una de los muchos trabajadores médicos de color destacados en los titulares.

Fue una ocasión alegre, que reavivó la posibilidad de volver a ver a sus padres y a su abuela de 96 años, quienes viven en Puerto Rico. Pero esas imágenes transmitidas a nivel nacional también fueron un recordatorio de aquéllos para quienes la vacuna llegó demasiado tarde.

Covid-19 se ha cobrado un precio enorme entre los afroamericanos y los hispanounidenses. Y esas disparidades se extienden a los trabajadores médicos que los intubaron, limpiaron sus sábanas y tomaron sus manos en sus últimos días, halló una investigación de KHN/The Guardian.

Las personas de color representan aproximadamente el 65% de las muertes en los casos en los que hay datos de raza y etnia.

Un estudio reciente encontró que los trabajadores de salud de color tienen más del doble de probabilidades que sus contrapartes caucásicas de dar positivo para el virus. Son más propensos a tratar a pacientes diagnosticados con covid, y a trabajar en hogares de adultos mayores, los principales focos de coronavirus; y también a reportar un suministro inadecuado de equipo de protección personal, según el informe.

En una muestra nacional de 100 casos recopilados por KHN/The Guardian en los que un trabajador de salud expresó su preocupación por la insuficiencia de EPP antes de morir por covid, tres cuartas partes de las víctimas fueron identificadas como negras, hispanas, nativas americanas o asiáticas.

“Es más probable que los trabajadores de salud de raza negra quieran ir a atenderse al sector público donde saben que tratarán de manera desproporcionada a las comunidades de color”, dijo Adia Wingfield, socióloga de la Universidad de Washington en St. Louis, quien ha estudiado la desigualdad racial en el industria del cuidado de salud. “Pero también es más probable que estén en sintonía con las necesidades y desafíos particulares que puedan tener las comunidades de color”, dijo.

Wingfield agregó que muchos miembros del personal de atención médica afroamericanos no solo trabajan en centros de salud de bajos recursos, sino que también son más propensos a sufrir muchas de las mismas comorbilidades que se encuentran en la población negra en general, un legado de décadas de inequidades sistémicas.

Y pueden ser víctimas de estándares de atención más bajos, agregó la doctora Susan Moore, pediatra de raza negra de 52 años de Indiana, quien fue hospitalizada con covid en noviembre y, según un video publicado en su cuenta de Facebook, tuvo que pedir repetidamente pruebas, remdesivir y analgésicos. Dijo que su médico (caucásico) desestimó sus quejas de dolor y fue dada de alta, solo para ser internada en otro hospital 12 horas después.

Numerosos estudios han encontrado que los afroamericanos a menudo reciben peor atención médica que sus contrapartes blancas: en marzo, una empresa de biotecnología de Boston publicó un análisis que mostraba que era menos probable que los médicos remitieran a pacientes negros sintomáticos para pruebas de coronavirus que a los blancos sintomáticos.

Los médicos también son menos propensos a recetar analgésicos a pacientes negros.

“Si fuera blanca, no tendría que pasar por eso”, dijo Moore en el video publicado desde su cama de hospital. “Así es como matan a los negros, cuando los envías a casa, y no saben cómo luchar por sí mismos”. Moore murió el 20 de diciembre por complicaciones de covid, dijo su hijo Henry Muhammad a los medios de comunicación.

Junto con las personas de color, los trabajadores de salud inmigrantes han sufrido pérdidas desproporcionadas a causa de covid-19. Más de un tercio de los trabajadores de salud que mueren por covid en el país nacieron en el extranjero, desde Filipinas y Haití, hasta Nigeria y México, según un análisis de KHN/The Guardian de casos registrados. Representan el 20% del total de trabajadores de salud de los Estados Unidos.

El doctor Ramon Tallaj, médico y presidente de Somos, una red sin fines de lucro de proveedores de atención médica en Nueva York, dijo que los médicos y enfermeras inmigrantes a menudo ven a pacientes de sus propias comunidades, y muchas comunidades inmigrantes de clase trabajadora han sido devastadas por covid.

“Nuestra comunidad son trabajadores esenciales. Tuvieron que ir a trabajar al comienzo de la pandemia, y cuando se enfermaban, iban a ver al médico de la comunidad”, dijo. Doce médicos y enfermeras de la red Somos han muerto por covid, dijo.

El doctor Eriberto Lozada era médico de familia de 83 años en Long Island, Nueva York. Todavía estaba viendo pacientes fuera de su consulta cuando los casos comenzaron a aumentar la primavera pasada. Originario de Filipinas, un país con un historial de envío de trabajadores médicos calificados a los Estados Unidos, estaba orgulloso de ser médico y “de haber sido un inmigrante próspero”, dijo su hijo James Lozada.

Los miembros de la familia de Lozada lo recuerdan como estricto y de voluntad fuerte; lo llamaban cariñosamente “el rey”. Inculcó a sus hijos la importancia de una buena educación. Murió en abril.

Dos de sus cuatro hijos, John y James Lozada, son médicos. Ambos fueron vacunados el mes pasado. Considerando todo lo que habían pasado, dijo John, fue una ocasión “agridulce”. Pero pensó que era importante por otra razón: ser un ejemplo para sus pacientes.

Las desigualdades en las infecciones, y las muertes, por covid podrían alimentar la desconfianza en la vacuna. En un estudio reciente del Pew Research Center, alrededor del 42% de los encuestados de raza negra dijeron que “definitivamente o probablemente” recibirían la vacuna en comparación con el 60% de la población general.

Esto tiene sentido para Patricia Gardner, enfermera nacida en Jamaica y gerenta en el Centro Médico de la Universidad de Hackensack, en Nueva Jersey, quien contrajo el coronavirus junto con familiares y colegas. “Mucho de lo que escucho es, ‘¿Cómo es que no fuimos los primeros en recibir atención, pero ahora somos los primeros en vacunarnos?’”, dijo.

Al igual que Beniquez, se vacunó el 14 de diciembre. “Para mí, dar un paso al frente y decir: ‘Quiero estar en el primer grupo’, espero que eso envíe un mensaje”, dijo.

Beniquez dijo que sintió el peso de esa responsabilidad cuando se inscribió para ser la primera persona en su estado en recibir la vacuna. Muchos de sus pacientes han expresado escepticismo, impulsado, opinó, por un sistema de salud que les ha fallado durante años.

“Recordamos los juicios de Tuskegee. Recordamos las ‘apendicectomías’ ”: informes de mujeres que fueron esterilizadas a la fuerza en un centro de detención del Servicio de Inmigración y Control de Aduanas de Georgia. “Estas son cosas que le han sucedido a esta comunidad, a las comunidades negras y latinas durante el último siglo. Como trabajadora de salud, tengo que reconocer que sus temores son legítimos y explicarles ‘Esto no es lo mismo’”, dijo.

Beniquez dijo que su alegría y alivio por recibir la vacuna se ven atenuados por la realidad del aumento de casos en la sala de emergencias. La adrenalina que ella y sus colegas sintieron la primavera pasada se ha ido, reemplazada por la fatiga y la cautela de los meses venideros.

Su hospital colocó 11 árboles en el vestíbulo, uno por cada empleado que murió de covid; han sido adornados con recuerdos y obsequios de sus colegas.

Hay uno para Kim King-Smith, de 53 años, el amable técnico de EKG, que visitaba a amigos de amigos, o a familiares cada vez que terminaba en el hospital.

Uno para Danilo Bolima, 54, el enfermero de Filipinas que se convirtió en profesor y era el jefe de servicios de atención al paciente.

Otro para Obinna Chibueze Eke, de 42 años, asistente de enfermería nigeriano, que pidió a sus amigos y familiares que oraran cuando estuvo hospitalizado con covid.

“Cada día, recordamos a nuestros colegas y amigos caídos como los héroes que nos ayudaron a seguir adelante durante esta pandemia y más allá”, dijo el doctor Shereef Elnahal presidente y director ejecutivo del hospital, en un comunicado. “Nunca olvidaremos sus contribuciones y su pasión colectiva por esta comunidad y por los demás”.

Justo afuera del edificio, está el árbol número 12. “Será para otro u otra que perdamos en esta batalla”, dijo Beniquez.

Esta historia es parte de “Lost on the Frontline”, un proyecto en curso de The Guardian y Kaiser Health News que tiene como objetivo documentar las vidas de los trabajadores de  salud de los Estados Unidos que mueren a causa de COVID-19, e investigar por qué tantos son víctimas de la enfermedad. Si tienes un colega o un ser querido que deberíamos incluir, por favor comparte su historia.

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

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Covid ‘Decimated Our Staff’ as the Pandemic Ravages Health Workers of Color in US


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

Last spring, New Jersey emergency room nurse Maritza Beniquez saw “wave after wave” of sick patients, each wearing a look of fear that grew increasingly familiar as the weeks wore on.

Soon, it was her colleagues at Newark’s University Hospital — the nurses, techs and doctors with whom she had been working side by side — who turned up in the ER, themselves struggling to breathe. “So many of our own co-workers got sick, especially toward the beginning; it literally decimated our staff,” she said.

By the end of June, 11 of Beniquez’s colleagues were dead. Like the patients they had been treating, most were Black and Latino.

“We were disproportionately affected because of the way that Blacks and Latinos in this country have been disproportionately affected across every [part of] our lives — from schools to jobs to homes,” she said.

Now Beniquez feels like a vanguard of another kind. On Dec. 14, she became the first person in New Jersey to receive the coronavirus vaccine — and was one of many medical workers of color featured prominently next to headlines heralding the vaccine’s arrival at U.S. hospitals.

It was a joyous occasion, one that kindled the possibility of again seeing her parents and her 96-year-old grandmother, who live in Puerto Rico. But those nationally broadcast images were also a reminder of those for whom the vaccine came too late.

Covid-19 has taken an outsize toll on Black and Hispanic Americans. And those disparities extend to the medical workers who have intubated them, cleaned their bedsheets and held their hands in their final days, a KHN/Guardian investigation has found. People of color account for about 65% of fatalities in cases in which there is race and ethnicity data.

One recent study found health care workers of color were more than twice as likely as their white counterparts to test positive for the virus. They were more likely to treat patients diagnosed with covid, more likely to work in nursing homes — major coronavirus hotbeds — and more likely to cite an inadequate supply of personal protective equipment, according to the report.

In a national sample of 100 cases gathered by KHN/The Guardian in which a health care worker expressed concerns over insufficient PPE before they died of covid, three-quarters of the victims were identified as Black, Hispanic, Native American or Asian.

“Black health care workers are more likely to want to go into public-sector care where they know that they will disproportionately treat communities of color,” said Adia Wingfield, a sociologist at Washington University in St. Louis who has studied racial inequality in the health care industry. “But they also are more likely to be attuned to the particular needs and challenges that communities of color may have,” she said.

Not only do many Black health care staffers work in lower-resourced health centers, she said, they are also more likely to suffer from many of the same co-morbidities found in the general Black population, a legacy of systemic inequities.

And they may fall victim to lower standards of care. Dr. Susan Moore, a 52-year-old Black pediatrician in Indiana, was hospitalized with covid in November and, according to a video posted to her Facebook account, had to ask repeatedly for tests, remdesivir and pain medication. She said her white doctor dismissed her complaints of pain and she was discharged, only to be admitted to another hospital 12 hours later.

Numerous studies have found Black Americans often receive worse medical care than their white counterparts: In March, a Boston biotech firm published an analysis showing physicians were less likely to refer symptomatic Black patients for coronavirus tests than symptomatic whites. Doctors are also less likely to prescribe painkillers to Black patients.

“If I was white, I wouldn’t have to go through that,” Moore said in the video posted from her hospital bed. “This is how Black people get killed, when you send them home, and they don’t know how to fight for themselves.” She died on Dec. 20 of covid complications, her son Henry Muhammad told news outlets.

Along with people of color, immigrant health workers have suffered disproportionate losses to covid-19. More than one-third of health care workers to die of covid in the U.S. were born abroad, from the Philippines to Haiti, Nigeria and Mexico, according to a KHN/Guardian analysis of cases for which there is data. They account for 20% of health care workers in the U.S. overall.

Dr. Ramon Tallaj, a physician and chairman of Somos, a nonprofit network of health care providers in New York, said immigrant doctors and nurses often see patients from their own communities — and many working-class, immigrant communities have been devastated by covid.

“Our community is essential workers. They had to go to work at the beginning of the pandemic, and when they got sick, they would come and see the doctor in the community,” he said. Twelve doctors and nurses in the Somos network have died of covid, he said.

Dr. Eriberto Lozada was an 83-year-old family physician in Long Island, New York. He was still seeing patients out of his practice when cases began to climb last spring. Originally from the Philippines, a country with a history of sending skilled medical workers to the United States, he was proud to be a doctor and “proud to have been an immigrant who made good,” his son James Lozada said.

Lozada’s family members remember him as strict and strong-willed — they affectionately called him “the king.” He instilled in his children the importance of a good education. He died in April.

Two of his four sons, John and James Lozada, are doctors. Both were vaccinated last month. Considering all they had been through, John said, it was a “bittersweet” occasion. But he thought it was important for another reason — to set an example for his patients.

The inequities in covid infections and deaths risk fueling distrust in the vaccine. In a recent Pew study, around 42% of Black respondents said they would “definitely or probably” get the vaccine compared with 60% of the general population.

This makes sense to Patricia Gardner, a Black, Jamaican-born nursing manager at Hackensack University Medical Center in New Jersey who has been infected with the coronavirus along with family members and colleagues. “A lot of what I hear is, ‘How is it that we weren’t the first to get the care, but now we’re the first to get vaccinated?’” she said.

Like Beniquez, the nurse in Newark, she was vaccinated on Dec. 14. “For me to step up to say, ‘I want to be in the first group’ — I’m hoping that sends a message,” she said.

Beniquez said she felt the weight of that responsibility when she signed on to be the first person in her state to receive the vaccine. Many of her patients have expressed skepticism over the vaccine, fueled, she said, by a health system that has failed them for years.

“We remember the Tuskegee trials. We remember the ‘appendectomies’” — reports that women were forcibly sterilized in a U.S. Immigration and Customs Enforcement detention center in Georgia. “These are things that have happened to this community to the Black and Latino communities over the last century. As a health care worker, I have to recognize that their fears are legitimate and explain ‘This is not that,’” she said.

Beniquez said her joy and relief over receiving the vaccine are tempered by the reality of rising cases in the ER. The adrenaline she and her colleagues felt last spring is gone, replaced by fatigue and wariness of the months ahead.

Her hospital placed 11 trees in the lobby, one for each employee who has died of covid; they have been adorned with remembrances and gifts from their colleagues.

There is one for Kim King-Smith, 53, the friendly EKG technician, who visited friends of friends or family whenever they ended up in the hospital.

One for Danilo Bolima, 54, the nurse from the Philippines who became a professor and was the head of patient care services.

One for Obinna Chibueze Eke, 42, the Nigerian nursing assistant, who asked friends and family to pray for him when he was hospitalized with covid.

“Each day, we remember our fallen colleagues and friends as the heroes who helped keep us going throughout this pandemic and beyond,” hospital president and CEO Dr. Shereef Elnahal said in a statement. “We can never forget their contributions and their collective passion for this community, and each other.”

Just outside the building, stands a 12th tree. “It’s going to be for whoever else we lose in this battle,” Beniquez said.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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In Fast-Moving Pandemic, Health Officials Try to Change Minds at Warp Speed

Nine months into the pandemic that has killed more than 320,000 people in the U.S., Kim Larson is still trying to convince others in her northern Montana county that COVID-19 is dangerous.

As Hill County Health Department director and county health officer, Larson continues to hear people say the coronavirus is just like a bad case of the flu. Around the time Montana’s governor mandated face coverings in July, her staffers saw notices taped in several businesses’ windows spurning the state’s right to issue such emergency orders.

For a while, the county with a population of 16,000 along the Canadian border didn’t see much evidence of the pandemic. It had only one known COVID case until July. But that changed as the nation moved into its third surge of the virus this fall. By mid-December, Hill County had recorded more than 1,500 cases — the vast majority since Oct. 1 — and 33 people there had died.

When Larson hears people say pandemic safety rules should end, she talks about how contagious the COVID virus is, how some people experience lasting effects and how hospitals are so full that care for any ailment could face delays.

“In public health, we’ve seen the battle before, but you typically have the time to build your evidence, research showing that this really does save lives,” Larson said. “In the middle of a pandemic, you have no time.”

Public health laws typically come long after social norms shift, affirming a widespread acceptance that a change in habits is worth the public good and that it’s time for stragglers to fall in line. But even when decades of evidence show a rule can save lives — such as wearing seat belts or not smoking indoors — the debate continues in some places with the familiar argument that public restraints violate personal freedoms. This fast-moving pandemic, however, doesn’t afford society the luxury of time. State mandates have put local officials in charge of changing behavior while general understanding catches up.

Earlier this month, U.S. Surgeon General Jerome Adams stood next to Montana’s governor in Helena and said he hopes people wear masks because it’s the right thing to do — especially as COVID hospitalizations rise.

“You don’t want to be the reason that a woman in labor can’t get a hospital bed,” Adams said, adding a vaccine is on the way. “It’s just for a little bit longer.”

He spoke days after state lawmakers clashed over masks as a majority of Republican lawmakers arrived for a committee meeting barefaced and at least one touted false information on the dangers of masks. As of Dec. 15, the Republican majority hadn’t required masks for the upcoming legislative session, set to begin Jan. 4.

And now a group opposed to masks from Gallatin and Flathead counties has filed a lawsuit asking a Montana judge to block the state’s pandemic-related safety rules.

Public health laws typically spark political battles. Changing people’s habits is hard, said Lindsay Wiley, director of the health law and policy program at American University in Washington, D.C. Despite the misconception that there was universal buy-in for masks during the 1918 pandemic, Wiley said, some protesters intentionally built rap sheets of arrests for going maskless in the name of liberty.

She said health officials realize any health restrictions amid a pandemic require the public’s trust and cooperation for success.

“We don’t have enough police to walk around and force everyone to wear a mask,” she said. “And I’m not sure we want them to do it.”

Local officials have the best chance to win over that support, Wiley said. And seeing elected leaders such as President Donald Trump rebuff his own federal health guidelines makes that harder. Meanwhile, public shaming like calling unmasked people selfish or stupid can backfire, Wiley said, because if they were to give in to mask-wearing, they would essentially be accepting those labels.

In the history of public health laws, even rules that have had time to build widely accepted evidence weren’t guaranteed support.

It’s illegal in Montana to go without a seat belt in a moving car. But, as in 13 other states, authorities aren’t allowed to pull people over for being unbuckled. Every few years, a Montana lawmaker, backed by a collection of public health and law enforcement organizations, proposes a law to allow seat belt traffic stops, arguing it would save lives. In 2019, that request didn’t even make it out of committee, squelched by the arguments of personal choice and not giving too much power to the government.

Main opposition points against public health laws — whether it’s masks, seat belts, motorcycle helmets or smoking — can sound alike.

When Missoula County became the first place in Montana to ban indoor smoking in public spaces in 1999, opponents said the change would destroy businesses, be impossible to enforce and violate people’s freedom of choice.

“They are the same arguments in a lot of ways,” said Ellen Leahy, director of the Missoula City-County Health Department. “Public health was right at that intersection between what’s good for the whole community and the rights and responsibilities of the individual.”

Montana adopted an indoor smoking ban in 2005, but many bars and taverns were given until 2009 to fall in line. And, in some places, debate and court battles continued for a decade more on how the ban could be enforced.

Amid the COVID pandemic, Missoula County was again ahead of much of the state when it passed its own mask ordinance. The county has two hospitals and a university that swells its population with students and commuters.

“If you have to see it to believe it, you’re going to see the impact of a pandemic first in a city, most likely,” Leahy said.

Compliance hasn’t been perfect and she said the need for strict enforcement has been limited. As of early December, out of the more than 1,500 complaints the Missoula health department followed up on since July, it sent closure notices to four businesses that flouted the rules.

In Hill County, when the health department gets complaints that a business is violating pandemic mandates, two part-time health sanitarians, who perform health inspections of businesses, talk with the owners about why the rules exist and how to live by them. Often it works. Other times the complaints keep coming.

County attorney Karen Alley said the local health officials have reached out to her office with complaints of noncompliance on COVID safety measures, but she has not seen enough evidence to bring a civil case against a business. Unlike other health laws, she said, mask rules have no case studies yet to offer a framework for enforcing them through the Montana courts. (A handful of cases against businesses skirting COVID rules were still playing out as of mid-December.)

“Somebody has to be the test case, but you never want to be the test case,” said Alley, who is part of a team of three. “It’s a lot of resources, a lot of time.”

Larson, with the Hill County Health Department, said her focus is still on winning over the community. And she’s excited about some progress. The town’s annual live Nativity scene, which typically draws crowds with hot cocoa, turned into a drive-by event this year.

She doesn’t expect everyone to follow the rules — that’s never the case in public health. But Larson hopes enough people will to slow down the virus. That could be happening. By mid-December, the county’s tally of daily active cases was declining for the first time since its spike began in October.

“You just try to figure out the best way for your community and to get their input,” Larson said. “Because we need the community’s help to stop it.”

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

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Analysis: Some Said the Vaccine Rollout Would Be a ‘Nightmare.’ They Were Right.


This story also ran on The New York Times. It can be republished for free.

WASHINGTON — Even before there was a vaccine, some seasoned doctors and public health experts warned, Cassandra-like, that its distribution would be “a logistical nightmare.

After Week 1 of the rollout, “nightmare” sounds like an apt description.

Dozens of states say they didn’t receive nearly the number of promised doses. Pfizer says millions of doses sat in its storerooms, because no one from President Donald Trump’s Operation Warp Speed task force told them where to ship them. A number of states have few sites that can handle the ultra-cold storage required for the Pfizer product, so, for example, front-line workers in Georgia have had to travel 40 minutes to get a shot. At some hospitals, residents treating COVID patients protested that they had not received the vaccine while administrators did, even though they work from home and don’t treat patients.

The potential for more chaos is high. Dr. Vivek Murthy, named as the next surgeon general under President-elect Joe Biden, said this week that the Trump administration’s prediction — that the general population would get the vaccine in April — was realistic only if everything went smoothly. He instead predicted wide distribution by summer or fall.

The Trump administration had expressed confidence that the rollout would be smooth, because it was being overseen by a four-star general, Gustave Perna, an expert in logistics. But it turns out that getting fuel, tanks and tents into war-torn mountainous Afghanistan is in many ways simpler than passing out a vaccine in our privatized, profit-focused and highly fragmented medical system. Gen. Perna apologized this week, saying he wanted to “take personal responsibility.” It’s really mostly not his fault.

Throughout the COVID pandemic, the U.S. health care system has shown that it is not built for a coordinated pandemic response (among many other things). States took wildly different COVID prevention measures; individual hospitals varied in their ability to face this kind of national disaster; and there were huge regional disparities in test availability — with a slow ramp-up in availability due, at least in some part, because no payment or billing mechanism was established.

Why should vaccine distribution be any different?

In World War II, toymakers were conscripted to make needed military hardware airplane parts, and commercial shipyards to make military transport vessels. The Trump administration has been averse to invoking the Defense Production Act, which could help speed and coordinate the process of vaccine manufacture and distribution. On Tuesday, it indicated it might do so, but only to help Pfizer obtain raw materials that are in short supply, so that the drugmaker could produce — and sell — more vaccines in the United States.

Instead of a central health-directed strategy, we have multiple companies competing to capture their financial piece of the pandemic health care pie, each with its patent-protected product as well as its own supply chain and shipping methods.

Add to this bedlam the current decision-tree governing distribution: The Centers for Disease Control and Prevention has made official recommendations about who should get the vaccine first — but throughout the pandemic, many states have felt free to ignore the agency’s suggestions.

Instead, Operation Warp Speed allocated initial doses to the states, depending on population. From there, an inscrutable mix of state officials, public health agencies and lobbyists seem to be determining where the vaccine should go. In some states, counties requested an allotment from the state, and then they tried to accommodate requests from hospitals, which made their individual algorithms for how to dole out the precious cargo. Once it became clear there wasn’t enough vaccine to go around, each entity made its own adjustments.

Some doses are being shipped by FedEx or UPS. But Pfizer — which did not fully participate in Operation Warp Speed — is shipping much of the vaccine itself. In nursing homes, some vaccines will be delivered and administered by employees of CVS and Walgreens, though issues of staffing and consent remain there.

The Moderna vaccine, rolling out this week, will be packaged by the “pharmaceutical services provider” Catalent in Bloomington, Indiana, and then sent to McKesson, a large pharmaceutical logistics and distribution outfit. It has offices in places like Memphis, Tennessee, and Louisville, which are near air hubs for FedEx and UPS, which will ship them out.

Is your head spinning yet?

Looking forward, basic questions remain for 2021: How will essential workers at some risk (transit workers, teachers, grocery store employees) know when it’s their turn? (And it will matter which city you work in.) What about people with chronic illness — and then everyone else? And who administers the vaccine — doctors or the local drugstore?

In Belgium, where many hospitals and doctors are private but work within a significant central organization, residents will get an invitation letter “when it’s their turn.” In Britain, the National Joint Committee on Vaccination has settled on a priority list for vaccinations — those over 80, those who live or work in nursing homes, and health care workers at high risk. The National Health Service will let everyone else “know when it’s your turn to get the vaccine ” from the government-run health system.

In the United States, I dread a mad scramble — as in, “Did you hear the CVS on P Street got a shipment?” But this time, it’s not toilet paper.

Combine this vision of disorder with the nation’s high death toll, and it’s not surprising that there is intense jockeying and lobbying — by schools, unions, even people with different types of preexisting diseases — over who should get the vaccine first, second and third. It’s hard to “wait your turn” in a country where there are 200,000 new cases and as many as 2,000 new daily COVID deaths — a tragic per capita order of magnitude higher than in many other developed countries.

So kudos and thanks to the science and the scientists who made the vaccine in record time. I’ll eagerly hold out my arm — so I can see the family and friends and colleagues I’ve missed all these months. If only I can figure out when I’m eligible, and where to go to get it.

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

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More Than 2,900 Health Care Workers Died This Year — And the Government Barely Kept Track


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

More than 2,900 U.S. health care workers have died in the COVID-19 pandemic since March, a far higher number than that reported by the government, according to a new analysis by KHN and The Guardian.

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

Many of the deaths — about 680 — occurred in New York and New Jersey, which were hit hard early in the pandemic. Significant numbers also died in Southern and Western states in the ensuing months.

The findings are part of “Lost on the Frontline,” a nine-month data and investigative project by KHN and The Guardian to track every health care worker who dies of COVID-19.

One of those lost, Vincent DeJesus, 39, told his brother Neil that he’d be in deep trouble if he spent much time with a COVID-positive patient while wearing the surgical mask provided to him by the Las Vegas hospital where he worked. DeJesus died on Aug. 15.

Another fatality was Sue Williams-Ward, a 68-year-old home health aide who earned $13 an hour in Indianapolis, and bathed, dressed and fed clients without wearing any PPE, her husband said. She was intubated for six weeks before she died May 2.

“Lost on the Frontline” is prompting new government action to explore the root cause of health care worker deaths and take steps to track them better. Officials at the Department of Health and Human Services recently asked the National Academy of Sciences for a “rapid expert consultation” on why so many health care workers are dying in the U.S., citing the count of fallen workers by The Guardian and KHN.

“The question is, where are they becoming infected?” asked Michael Osterholm, a member of President-elect Joe Biden’s COVID-19 advisory team and director of the Center for Infectious Disease Research and Policy at the University of Minnesota. “That is clearly a critical issue we need to answer and we don’t have that.”

The Dec. 10 report by the national academies suggests a new federal tracking system and specially trained contact tracers who would take PPE policies and availability into consideration.

Doing so would add critical knowledge that could inform generations to come and give meaning to the lives lost.

“Those [health care workers] are people who walked into places of work every day because they cared about patients, putting food on the table for families, and every single one of those lives matter,” said Sue Anne Bell, a University of Michigan assistant professor of nursing and co-author of the national academies report.

The recommendations come at a fraught moment for health care workers, as some are getting the COVID-19 vaccine while others are fighting for their lives amid the highest levels of infection the nation has seen.

The toll continues to mount. In Indianapolis, for example, 41-year-old nurse practitioner Kindra Irons died Dec. 1. She saw seven or eight home health patients per week while wearing full PPE, including an N95 mask and a face shield, according to her husband, Marcus Irons.

The virus destroyed her lungs so badly that six weeks on the most aggressive life support equipment, ECMO, couldn’t save her, he said.

Marcus Irons said he is now struggling financially to support their two youngest children, ages 12 and 15. “Nobody should have to go through what we’re going through,” he said.

In Massachusetts, 43-year-old Mike “Flynnie” Flynn oversaw transportation and laundry services at North Shore Medical Center, a hospital in Salem, Massachusetts. He and his wife were also raising young children, ages 8, 10 and 11.

Flynn, who shone at father-daughter dances, fell ill in late November and died Dec. 8. He had a heart attack at home on the couch, according to his father, Paul Flynn. A hospital spokesperson said he had full access to PPE and free testing on-site.

Since the first months of the pandemic, more than 70 reporters at The Guardian and KHN have scrutinized numerous governmental and public data sources, interviewed the bereaved and spoken with health care experts to build a count.

The total number includes fatalities identified by labor unions, obituaries and news outlets and in online postings by the bereaved, as well as by relatives of the deceased. The previous total announced by The Guardian and KHN was approximately 1,450 health care worker deaths. The new number reflects the inclusion of data reported by nursing homes and health facilities to the federal and state governments. These deaths include the facility names but not worker names. Reporters cross-checked each record to ensure fatalities did not appear in the database twice.

The tally has been widely cited by other media as well as by members of Congress.

Rep. Norma Torres (D-Calif.) referenced the data citing the need for a pending bill that would provide compensation to the families of health care workers who died or sustained long-term disabilities from COVID-19.

Sen. Ron Wyden (D-Ore.) mentioned the tally in a Senate Finance Committee hearing about the medical supply chain. “The fact is,” he said, “the shortages of PPE have put our doctors and nurses and caregivers in grave danger.”

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

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

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


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

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

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

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

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

Few felt safe.

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

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

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

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

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

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

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

New York’s Warning for the Nation

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

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

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

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

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

The personal risks paramedics faced were also grave.

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

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

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

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

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

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

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

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

Neither was the rest of the country.

An Elusive Enemy

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

More ‘Lost on the Frontline’ Stories

Desperate for Safety Gear

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Nursing Homes Devastated

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

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

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

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

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

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

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

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

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

The Vaccine Arrives

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

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

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

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

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

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

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

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

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

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

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

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

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This story can be republished for free (details).

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

“We’re just holding our breath, hoping we can get all the humans vaccinated in the country. That will give us all a sigh of relief.”

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

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Health Officials Fear Pandemic-Related Suicide Spike Among Native Youth

WOLF POINT, Mont. — Fallen pine cones covered 16-year-old Leslie Keiser’s fresh grave at the edge of Wolf Point, a small community on the Fort Peck Indian Reservation on the eastern Montana plains.

Leslie, whose father is a member of the Fort Peck Assiniboine and Sioux Tribes, is one of at least two teenagers on the reservation who died by suicide this summer. A third teen’s death is under investigation, authorities said.

Leslie’s mother, Natalie Keiser, was standing beside the grave recently when she received a text with a photo of the headstone she had ordered.

She looked at her phone and then back at the grave of the girl who took her own life in September.

“I wish she would have reached out and let us know what was wrong,” she said.

In a typical year, Native American youth die by suicide at nearly twice the rate of their white peers in the U.S. Mental health experts worry that the isolation and shutdowns caused by the COVID-19 pandemic could make things worse.

“It has put a really heavy spirit on them, being isolated and depressed and at home with nothing to do,” said Carrie Manning, a project coordinator at the Fort Peck Tribes’ Spotted Bull Recovery Resource Center.

It’s not clear what connection the pandemic has to the youth suicides on the Fort Peck reservation. Leslie had attempted suicide once before several years ago, but she had been in counseling and seemed to be feeling better, her mother said.

Keiser noted that Leslie’s therapist canceled her counseling sessions before the pandemic hit.

“Probably with the virus it would have been discontinued anyway,” Keiser said. “It seems like things that were important were kind of set to the wayside.”

Tribal members typically lean on one another in times of crisis, but this time is different. The reservation is a COVID hot spot. In remote Roosevelt County, which encompasses most of the reservation, more than 10% of the population has been infected with the coronavirus. The resulting social distancing has led tribal officials to worry the community will fail to see warning signs among at-risk youth.

So tribal officials are focusing their suicide prevention efforts on finding ways to help those kids remotely.

“Our people have been through hardships and they’re still here, and they’ll still be here after this one as well,” said Don Wetzel, tribal liaison for the Montana Office of Public Instruction and a member of the Blackfeet Nation. “I think if you want to look at resiliency in this country, you look at our Native Americans.”

Poverty, high rates of substance abuse, limited health care and crowded households elevate both physical and mental health risks for residents of reservations.

“It’s those conditions where things like suicide and pandemics like COVID are able to just decimate tribal people,” said Teresa Brockie, a public health researcher at Johns Hopkins University and a member of the White Clay Nation from Fort Belknap, Montana.

Montana has seen 231 suicides this year, with the highest rates occurring in rural counties. Those numbers aren’t much different from a typical year, said Karl Rosston, suicide prevention coordinator for the state’s Department of Public Health and Human Services. The state has had one of the highest suicide rates in the country each year for decades.

As physical distancing drags on, fatality numbers climb and the economic impacts of the pandemic start to take hold of families, Rosston said, and he expected to see more suicide attempts in December and January.

“We’re hoping we’re wrong in this, of course,” he said.

For rural teenagers, in particular, the isolation caused by school closures and curtailed or canceled sports seasons can tax their mental health.

“Peers are a huge factor for kids. If they’re cut off, they’re more at risk,” Rosston said.

Furthermore, teen suicides tend to cluster, especially in rural areas. Every suicide triples the risk that a surviving loved one will follow suit, Rosston said.

On average, every person who dies by suicide has six survivors. “When talking about small tribal communities, that jumps to 25 to 30,” he said.

Maria Vega, a 22-year-old member of the Fort Peck Tribes, knows this kind of contagious grief. In 2015, after finding the body of a close friend who had died by suicide, Vega attempted suicide as well. She is now a youth representative for a state-run suicide prevention committee that organizes conferences and other events for young people.

Vega is a nursing student who lives six hours away from her family, making it difficult to travel home. She contracted COVID-19 in October and was forced to isolate, increasing her sense of removal from family. While isolated, Vega was able to attend therapy sessions through a telehealth system set up by her university.

“I really do think therapy is something that would help people while they’re alone,” she said.

But Vega points out that this is not an option for many people on rural reservations who don’t have computers or reliable internet access. The therapists who offer telehealth services have long waitlists.

Other prevention programs are having difficulties operating during the pandemic. Brockie, who studies health delivery in disadvantaged populations, has twice had to delay the launch of an experimental training program for Native parents of young children. She hopes the program will lower the risk of substance abuse and suicide by teaching resiliency and parenting skills.

At Fort Peck, the reservation’s mental health center has had to scale down its youth events that teach leadership skills and traditional practices like horseback riding and archery, as well as workshops on topics like coping with grief. The events, which Manning said usually draw 200 people or more, are intended to take teenagers’ minds away from depression and allow them to have conversations about suicide, a taboo topic in many Native cultures. The few events that can go forward are limited now to a handful of people at a time.

Tribes, rural states and other organizations running youth suicide intervention and prevention initiatives are struggling to sustain the same level of services. Using money from the federal CARES Act and other sources, Montana’s Office of Public Instruction ramped up online prevention training for teachers, while Rosston’s office has beefed up counseling resources people can access by phone.

On the national level, the Center for Native American Youth in Washington, D.C., hosts biweekly webinars for young people to talk about their hopes and concerns. Executive Director Nikki Pitre said that on average around 10,000 young people log in each week. In the CARES Act, the federal government allocated $425 million for mental health programs, $15 million of which was set aside for Native health organizations.

Pitre hopes the pandemic will bring attention to the historical inequities that led to lack of health care and resources on reservations, and how they enable the twin epidemics of COVID-19 and suicide.

“This pandemic has really opened up those wounds,” she said. “We’re clinging even more to the resiliency of culture.”

In Wolf Point, Natalie Keiser experienced that resiliency and support firsthand. The Fort Peck community has come together to pay for Leslie’s funeral.

“That’s a miracle in itself,” 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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California’s COVID Enforcement Strategy: Education Over Citations

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

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

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

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

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

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

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

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

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

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

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

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

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

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

As ICUs run out of capacity, this Huntington Beach, CA scene was posted by a resident noting that today’s Green Bay/ Detroit game can be seen on overhead TVs. pic.twitter.com/Dcr3IlOOaS

— Margot Roosevelt (@margotroosevelt) December 14, 2020

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Democrats Are Running Hard on Health Care in Georgia’s Senate Runoffs. Republicans? Not So Much.


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

Vice President Mike Pence was the clear celebrity draw at a Nov. 20 campaign event for Georgia’s two incumbent U.S. senators, Kelly Loeffler and David Perdue. Both Republicans are fighting to keep their seats against two Democratic challengers in the runoff election set for Jan. 5.

People were so eager to see Pence at the rally in Canton, Georgia, that parking spots were scarce and a long line of cars snaked through the parking lot of a community college. Some drivers jumped the curb and parked in the grass.

Hundreds of people, many unmasked, were given temperature checks before boarding large coach buses for a short ride to the rally site. The venue was a large, open space outside the conference center, but few attendees maintained physical distance

The runoff in Georgia was triggered when no candidate in either Senate race won more than 50% of the vote in the general election on Nov. 3.

In the midst of the coronavirus pandemic and with the fate of the Affordable Care Act in question, Republicans hope the two incumbents will win reelection, thus preserving their party’s 50-48 control of the Senate.

But if the two challengers, Raphael Warnock and Jon Ossoff, win their runoffs, Democrats will gain narrow control of the Senate, with Vice President-elect Kamala Harris serving as the designated tie-breaker.

Yana De Moraes came to the rally from another Atlanta suburb, Buford. She is uninsured and, after a recent hospital stay, said the high cost of medical care was weighing on her mind.

“We would like our health care costs lowered, so it could be more affordable,” she said, with a rueful laugh. “So you don’t get another heart attack while you’re getting a bill!”

De Moraes added she’d also like to see better price controls on prescription drugs to stop pharmaceutical companies from “robbing American people.”

Others on their way to the rally said they were looking for any kind of change, ideally one that minimizes government involvement in health care.

Barry Brown made the 40-mile drive from his home in Atlanta for the rally. He’s retired but too young to qualify for Medicare, so he has ACA insurance, which he affords with the help of a federal subsidy.

“It sort of works. It’s better than nothing,” Brown said. “I would like to see an improved health care situation. I don’t know what that will be, so maybe they’ll mention that today. I’m hoping so.”

But at the rally, Loeffler only briefly mentioned her health care plan, which focuses on reducing drug prices and giving people access to insurance options that cost less but offer fewer benefits.

When it was his turn to speak, Perdue didn’t talk much about health care either, though he did take a shot at Obamacare, which he’s voted multiple times to overturn.

“Remember a little thing called the Affordable Care Act? You think that was done bipartisan?” Perdue asked the crowd. “No! It was done with a supermajority! Can you imagine what they’re gonna do if they get control of the Senate?”

As the two Republicans have campaigned throughout the state, they have consistently stoked fears about what Democrats will do, and health care policy has not led their messaging.

Their Democratic challengers, however, have been all over health care in their own speeches.

Warnock opened his runoff campaign to unseat Loeffler with a modestly attended Nov. 12 event devoted to health care. That’s also been a focus for Ossoff in his bid to win Perdue’s seat.

“This is why these Senate runoffs are so vital,” Ossoff explained at a small, physically distanced event in the shadow of the Georgia Capitol building in Atlanta on Nov. 10.

Ossoff and Warnock support adding a public insurance option to the Affordable Care Act. They also have emphasized the role Democrats will play in resurrecting key parts of the law if the U.S. Supreme Court decides to overturn it. The justices are set to make a ruling next year.

“If the Supreme Court strikes down the Affordable Care Act, it will be up to Congress to decide how to legislate such that preexisting conditions remain covered,” Ossoff said.

Voters like Janel Green, a Democrat, connect with that message. She’s from the nearby suburb of Decatur and is fighting breast cancer — for the second time. Green wondered whether her private health insurance might try to deny her coverage if the protections in the ACA disappear.

“I have to worry about whether or not next year in open enrollment that I won’t be discriminated against, that I won’t have limits that would then potentially end my life,” she said.

More than one-quarter of Georgians have preexisting conditions that could make it hard to get coverage if the ACA is struck down, according to an analysis by KFF. (KHN is an editorially independent program of KFF.)

That possibility also drove Atlanta resident Herschel Jones to support the runoff. On a recent weekday morning, he dropped by an Ossoff campaign office to pick up a yard sign.

Jones, who has diabetes, is insured through the Veterans Health Administration. He said everyone deserves access to health care.

“It’s a main issue, because the Affordable Care Act benefits all those individuals who might have preexisting conditions,” Jones said.

One likely reason Ossoff and Warnock are running so much harder on health care than Perdue and Loeffler is because that strategy paid off for Democrats in the general election, said Ken Thorpe, a health policy professor at Emory University.

President-elect Joe Biden can thank independent voters for his win in Georgia, Thorpe said, and they were drawn to him because of his promise to uphold Obamacare.

“The threat of potentially losing health insurance in the midst of this pandemic turned out to be probably the major defining issue in the election,” Thorpe said.

Polling in the days leading up to the Nov. 3 election showed Democrats were motivated on the issues of health care and the coronavirus pandemic.

For Democrats to win Georgia’s Senate seats, Thorpe said, they’ll need to stay focused on those issues. That emphasis could help them attract additional moderate voters, as well as entice those in the party base to cast ballots a second time.

“The health care issue is the probably main motivating factor that’s gonna get Democrats and independents to the polls,” he said.

Still, no Democrat has ever won a statewide runoff race in Georgia. That means that even with a strong health care message, it’ll be tough for Ossoff and Warnock to break that trend and unseat the Republicans, Thorpe said.

This story is from a reporting partnership that includes WABENPR 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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Inside the First Chaotic Days of the Effort to Vaccinate America

One tray of COVID-19 vaccine from pharmaceutical giant Pfizer contains 975 doses — way too many for a rural hospital in Arkansas.

But with the logistical gymnastics required to safely get the Pfizer vaccine to rural health care workers, splitting the trays into smaller shipments has its own dangers. Once out of the freezer that keeps it at 94 degrees below zero, the vaccine lasts only five days and must be refrigerated in transit.

In Arkansas — where over 40% of its counties are rural and COVID infections are climbing — solving this distribution puzzle is urgently critical, said Dr. Jennifer Dillaha, the state’s epidemiologist.

“If their providers come down with COVID-19,” Dillaha said, “there’s no one there to take care of the patients.”

Such quandaries resonate with officials in Georgia, Kentucky, Utah, Indiana, Wisconsin and Colorado. The first push of the nation’s mass COVID vaccination effort has been chaotic, marked by a lack of guidance and miscommunication from the federal level.

With Washington punting most vaccination decisions, each state and county is left to weigh where to send vaccines first and which of two vaccines authorized by the Food and Drug Administration for emergency use makes the most sense for each nursing home, hospital, local health department and even school. And after warning for months that they lacked the resources to distribute vaccines, state officials are only now set to receive a major bump in funding — $8.75 billion in Congress’ latest relief bill, which lawmakers are likely to pass this week.

The feat facing public health officials has “absolutely no comparison” in recent history, said Claire Hannan, executive director of the Association of Immunization Managers.

Officials who thought the H1N1 swine flu shot in 2009 was a logistical nightmare say it now looks simple in comparison. “It was a flu vaccine. It was one dose. It came at refrigerator-stable temperatures,” Hannan said. “It was nothing like this.”

Within just a few days, the logistical barriers of the vaccine made by Pfizer and BioNTech were laid bare. Many officials now hang their hopes on Moderna, whose vaccine comes in containers of 100 doses, doesn’t require deep freezing and is good for 30 days from the time it’s shipped.

The federal government had divvied up nearly 8 million doses of Pfizer and Moderna’s vaccines to distribute this week, on top of roughly 3 million Pfizer shots that were sent last week, said Army Gen. Gustave Perna, chief operating officer of the Trump administration’s Operation Warp Speed effort.

Perna said he took “personal responsibility” for overstating how many Pfizer doses states would receive.

Federal delays have led to confusion, Dillaha said: “Sometimes we don’t have information from CDC or Operation Warp Speed until right before a decision needs to be made.”

Officials in other states painted a mixed picture of the rollout.

Georgia’s Coastal Health District, which oversees public health for eight counties and has offices in Savannah and Brunswick, spent more than $27,000 on two ultra-cold freezers for the Pfizer vaccine, which it’s treating “like gold,” said Dr. Lawton Davis, its health director. Health care workers are being asked to travel, some up to 40 minutes, to get their vaccinations, because shipping them would risk wasting doses, he said. Vaccination uptake has been lower than Davis would like to see. “It’s sort of a jigsaw puzzle and balancing act,” he said. “We’re kind of learning as we go.”

In Utah, sites to vaccinate teachers and first responders starting in January had no capability to store the Pfizer vaccine, although officials are trying to secure some ultra-cold storage, a state department of health spokesperson said. Very few of Kentucky’s local health offices could store the Pfizer shots, because of refrigeration requirements and the size of shipments, said Sara Jo Best, public health director of the Lincoln Trail District. Indiana’s state health department had to identify alternative cold storage options for 17 hospitals following changes in guidance for the vaccine thermal shippers.

And in New Hampshire, where the National Guard will help administer vaccines, officials last week were still finalizing details for 13 community-based sites where first responders and health care workers are due to get vaccinated later this month. Jake Leon, a state Health and Human Services spokesperson, said that while the sites will be able to administer both companies’ vaccines, most likely they’ll get Moderna’s because of its easier transport. Even as the earliest vaccines are injected, much remains up in the air.

“It’s day to day and even then hour by hour or minute by minute — what we know and how we plan for it,” Leon said Friday. “We’re building the plane while flying it.”

In all, the Trump administration has bought 900 million COVID vaccine doses from six companies, but most of the vaccines are still in clinical studies. Even the front-runners whose shots have received FDA emergency authorization— Pfizer and BioNTech on Dec. 11, Moderna on Dec. 18 — will require months to manufacture at that scale. The Trump administration plans to distribute 20 million vaccine doses to states by early January, Perna said Saturday.

By spring, officials hope to stage broader vaccine deployment beyond top-priority populations of health care workers, nursing home residents and staff, as well as first responders.

During the effort to vaccinate Americans against H1N1, Dillaha said, health departments set up mass vaccination clinics in their counties and delivered doses to schools. But hospitals are taking charge of parts of the initial COVID immunization campaign, both because health care workers are at highest risk of illness or death from COVID-19, and to pick up the slack from health departments overwhelmed by case investigations and contact tracing from an unending stream of new infections.

Best said her workforce is struggling to keep up with COVID infections alone, much less flu season and upcoming COVID vaccinations. Public health department personnel in Kentucky shrank by 49% from 2009 to 2019, according to state data she supplied. Across the country, 38,000 state and local health positions have disappeared since the 2008 recession. Per capita spending for local health departments has dropped by 18% since 2010.

Nationally, Pfizer and Moderna have signed contracts with the federal government to each provide 100 million vaccine doses by the end of March; Moderna is set to deliver a second tranche of 100 million doses by June. States were playing it safe last week, directing Pfizer vials mainly to facilities with ultra-cold freezers, Hannan said.

“A lot of that vaccine is destined for institutional facilities,” Sean Dickson, director of health policy for West Health Policy Center, said of the Pfizer shots. The center, with the University of Pittsburgh School of Pharmacy, found that 35% of counties have two or fewer facilities to administer COVID vaccines.

The analysis found tremendous variation in how far people would need to drive for the vaccine. Residents of North Dakota, South Dakota, Montana, Wyoming, Nebraska and Kansas face the longest drives, with more than 10% living more than 10 miles from the closest facility that could administer a shot.

Counties with long driving distances between sites and a low number of sites overall “are going to be the hardest ones to reach,” said Inmaculada Hernandez, an assistant professor at the University of Pittsburgh School of Pharmacy and lead author of the analysis.

Certain vaccines could be better suited for such places, including Johnson & Johnson’s potential offering, which is a single shot, and health departments could distribute in rural areas through mobile units, she said. The company is expected to apply for FDA emergency authorization in February, Operation Warp Speed chief scientific adviser Moncef Slaoui said this month.

Until then, Pfizer and Moderna are the companies supplying doses for the country, and they’re not considered equal even though each is more than 90% effective at reducing disease.

In Wisconsin, the Moderna vaccine “gives us many more options” and “allows for us to get doses to those smaller clinics, more-rural clinics, in a way that reduces the number of logistics” needed for ultra-cold storage, Dr. Stephanie Schauer, the state’s immunization program manager, told reporters Wednesday.

Alan Morgan, head of the National Rural Health Association, echoed that the Moderna vaccine is being looked to as a “rural solution.” But he said states including Kansas have shown that a Pfizer rural rollout can be done.

“It’s where these states put a priority — either they prioritize rural or they don’t,” he said. “It’s a cautionary tale of what we may see this spring, of rural populations perhaps being second-tier when it comes to vaccination.”

Virginia, too, has a plan for getting the Pfizer vaccine to far-flung places. It’s shipping the vaccines to 18 health facilities with ultra-cold freezers across the state. The hubs are distributed widely enough so vaccinators can bring shots from there to health workers even in thinly populated areas before they spoil, said Brookie Crawford, spokesperson for the Virginia Department of Health’s central region.

Washington, on the other hand, allows hospitals without ultra-cold freezers to temporarily store Pfizer vaccines in the thermal boxes they arrive in, said Franji Mayes, spokesperson for the state’s health department. That means a box needs to be used quickly, before doses expire. “We are also working on a policy that will allow hospitals who don’t expect to vaccinate 975 people to transfer extra vaccine to other enrolled facilities,” she said. “This will reduce wasted 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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Surprise! Congress Takes Steps to Curb Unexpected Medical Bills

Most Americans tell pollsters they’re worried about being able to afford an unexpected medical bill.

Late Monday, Congress passed a bill to allay some of those fears. The measure is included in a nearly 5,600-page package providing coronavirus economic relief and government funding for the rest of the fiscal year.

Specifically, the legislation addresses those charges that result from a long-running practice in which out-of-network medical providers — from doctors to air ambulance companies — send insured Americans “surprise bills,” sometimes for tens of thousands of dollars.

The legislation itself was a bit of a surprise, coming after two years of debate that featured high-stakes lobbying by all who stood to gain or lose: hospitals, insurers, patient advocacy groups, physicians, air ambulance companies and private equity firms, which own a growing number of doctor practices. A similar effort failed at the last minute a year ago after intense pressure from a range of interests, including those private equity groups.

This time around, no group got everything it wanted. Lawmakers compromised — mainly over how to determine how much providers will ultimately be paid for their services.

“No law is perfect,” said Zack Cooper, an associate professor of public health and economics at Yale who studies health care pricing. “But it fundamentally protects patients from being balance-billed,” he said, referring to out-of-network medical providers billing patients for amounts their insurer did not cover. “That’s a remarkable achievement.”

The bottom line: Patients may still be surprised by the high cost of health care overall. But they will now be protected against unexpected bills from out-of-network providers.

Here’s a rundown on what this legislation means for consumers:

Fewer Surprise Bills

Starting in 2022, when the law goes into effect, consumers won’t get balance bills when they seek emergency care, when they are transported by an air ambulance, or when they receive nonemergency care at an in-network hospital but are unknowingly treated by an out-of-network physician or laboratory.

Patients will pay only the deductibles and copayment amounts that they would under the in-network terms of their insurance plans.

Medical providers won’t be allowed to hold patients responsible for the difference between those amounts and the higher fees they might like to charge. Instead, those providers will have to work out with insurers acceptable payments. For the uninsured, for whom everything is out of network, the bill requires the secretary of Health and Human Services to create a provider-patient bill dispute resolution process.

The measure takes aim at situations in which patients have little choice about whether they are in network, including emergencies. A recent survey found 18% of emergency room visits, on average, resulted in at least one surprise bill. (A growing number of emergency rooms are staffed by private equity-owned agencies that sign few in-network agreements.)

The legislative agreement also applies to nonemergency care provided at in-network facilities, where patients receive care and services from out-of-network providers, such as anesthesiologists and laboratories.

Also included in the bar on balance billing is air ambulance transportation, which is among the most expensive medical services, often costing tens of thousands of dollars.

Still, the bill does not extend its consumer protections to the far more commonly used ground ambulance services. But it does call for an advisory committee to recommend how to take this step.

An Option for Consumers to Agree to Balance Billing

In some cases, physicians can balance-bill their patients, but they must get consent in advance.

This part of the bill is aimed at patients who want to see an out-of-network physician, perhaps a surgeon or obstetrician recommended by a friend.

In those cases, physicians must provide a cost estimate and get patient consent at least 72 hours before treatment. For shorter-turnaround situations, the bill requires that patients receive the consent information the day the appointment is made.

In a sense, though, this provision allows consumers to forfeit protection.

Health providers “have to give you a good-faith cost estimate. If you sign that, then you can be billed whatever that physician wants to bill you,” said Jack Hoadley, research professor emeritus in the Health Policy Institute at Georgetown University.

The legislation allows this only in nonemergency circumstances and bars many types of physicians from the practice. Anesthesiologists, for example, can’t seek consent to balance-bill for their services, nor can radiologists, pathologists, neonatologists, assistant surgeons or laboratories.

Payment Will Be Sorted Out in Negotiations

While lawmakers agreed that patients will be held harmless, the real fight was over how to decide what amounts providers would be paid by insurers.

Some groups — including hospitals and physicians — opposed any kind of benchmark or standard to which all bills would be held. On the other side, insurers, employers and consumer groups argued for a benchmark, warning that, without one, providers would angle for much higher payments.

The legislation carves out some middle ground.

It gives insurers and providers 30 days to try to negotiate payment of out-of-network bills. If that fails, the claims would go through an independent dispute resolution process with an arbitrator, who would have the final say.

The bill does not specify a benchmark, but it bars physicians and hospitals from using their “billed charges” during arbitration. Such charges are generally far higher than negotiated rates and bear little or no relation to the actual cost of providing the care.

That was considered a win for insurers, employers and consumer advocates, who argued that allowing billed charges would mean higher prices — potentially driving up premiums — in cases sent to arbitration.

Billed charges “are totally made up” by providers, said Cooper, at Yale. “So, the big deal is that arbitrators are not considering charges.”

But hospitals and doctors won a limit they sought, too.

In last-minute changes over the weekend, they succeeded in barring consideration of Medicare or Medicaid prices during arbitration. Those government payments are often far lower than the negotiated rates paid by insurers and self-insured employers.

Instead, the bill says negotiators can consider the median in-network prices paid by each insurer for the services in dispute. Other factors, too, can come into play, including whether the medical provider tried to join the insurers’ network, and how sick the patient was compared with others. It also allows consideration of network rates a provider may have agreed to during the previous four years, which might help some high-priced services, such as air ambulances, remain costly even in arbitration.

Overall, the legislation “did include some wins for provider groups,” said Loren Adler, associate director at the USC-Brookings Schaeffer Initiative for Health Policy.

Even so, he expects the legislation will help insurers contain some prices and provide “some downward pressure on premiums, even if relatively minor at the end of the day.”

State Laws May Change

More than 30 states have enacted some type of surprise billing protections, but only 17 are considered comprehensive, according to the Commonwealth Fund.

Comprehensive states — California, New York and New Mexico, for example — extend protections to cover nonemergency situations at in-network hospitals, but that isn’t the case in less comprehensive states, the fund noted.

And state laws have another limitation: They apply only to certain types of insurance, and often do not cover Americans who get their health insurance through self-insured employers, which tend to be midsize to large companies because they fall under federal rules.

But the new federal rules will cover most types of insurance plans, including those offered by self-insured employers.

“States can’t fully deal with these situations, but this covers it,” said Hoadley, at Georgetown.

Still, some provisions in state law, such as how to determine a payment, differ from the federal law. In such cases, the federal law defers to states.

Statehouse lawmakers may eventually alter their legislation or adopt new proposals to avoid confusion, said policy experts. If they don’t, they could be left with rules that affect people differently depending on whether their insurance comes through a large self-insured employer or directly from an insurance plan subject to state law. “I would be surprised if, over time, states don’t just glom onto the federal law,” said Adler.

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

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

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

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

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

Q: How are you doing at UCSF right now? 

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Montana’s Mask Mandate in Doubt With Incoming Governor

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HELENA, Mont. — Incoming Montana Gov. Greg Gianforte signaled he won’t continue a statewide mask mandate in place since July, though he said he plans to wear a mask himself and get vaccinated against COVID-19.

If Gianforte, a Republican, reverses outgoing Democratic Gov. Steve Bullock’s mask order, Montana will be just the second state after Mississippi to lift its mandate. Thirty-eight states now have statewide mandates.

“I trust Montanans with their health and the health of their loved ones,” Gianforte said in a recent interview with KHN. “The state has a role in clearly communicating the risks of who is most vulnerable, what the potential consequences are, but then I do trust Montanans to make the right decisions for themselves and their family.”

The Centers for Disease Control and Prevention says masks help prevent transmission of COVID-19. At least one study has found that states with mask requirements have had slower COVID growth rates compared with those without mandates.

“We’re going to encourage people to wear masks,” Gianforte said. “I’m personally going to lead by example, wearing a mask in the Capitol.”

Montana is the only state where control of the governor’s office is changing parties as a result of November’s election. Also, among the 11 governors being sworn in this January, Gianforte will be the only one new to managing his state’s response to the pandemic.

Nine of the others are incumbents starting second terms. The 10th, Spencer Cox, is Utah’s lieutenant governor in the current administration and has played a central role in his state’s COVID response.

Montana alone will have wholly new leadership next year as states try to keep hospitals from overflowing amid the surging virus, while adjusting to a new presidential administration and executing vaccine distribution plans.

Gianforte doesn’t plan to scrap everything the outgoing administration has done to fight the pandemic. For example, he said he and Bullock are “on the same page” when it comes to prioritizing distribution of the vaccine to health care workers and vulnerable residents.

Gianforte also said he plans to take the vaccine when it’s his turn.

“When my name comes up on the list, I will raise my hand and I am going to get vaccinated,” Gianforte said. “It’s very important that I lead by example because I think this vaccine is a critical part of us getting back to normal.”

Gianforte, a businessman who sold his software company, RightNow Technologies, to Oracle for $1.8 billion in 2011, has long coveted Montana’s governor’s office, spending nearly $12 million of his personal fortune over four years and two campaigns to win the seat.

He ran against Bullock and lost in 2016, then won Montana’s congressional seat in a 2017 special election infamous for Gianforte’s misdemeanor assault against a reporter trying to ask him questions.

Gianforte won a second term in Congress in 2018 and defeated Bullock’s lieutenant governor, Mike Cooney, by more than 12 percentage points in November’s election.

Gianforte will be the first Republican in the governor’s office in 16 years. Republican lawmakers, who control the Montana Legislature, cheered Gianforte’s election and have high expectations for the session that begins the day of his inauguration.

Republican lawmakers will likely seek budget cuts after unsuccessfully asking Bullock to preemptively cut state spending during the pandemic. Bullock has said the state is in good financial shape and that any decision to cut spending would be made for ideological reasons, not out of necessity.

Gianforte has declined to indicate whether he plans to support spending cuts, saying his incoming team is still reviewing Bullock’s proposed two-year budget. That budget proposal includes spending increases to Medicaid, support for children and families, senior and long-term care and treatment for addiction and mental disorders.

John Doran, vice president of external affairs for Blue Cross and Blue Shield of Montana, said he hopes lawmakers spare health services used by at-risk residents if they plan to reduce spending to balance the budget.

“These are critical services and the need for them has only increased since the start of the pandemic,” Doran said.

The structure of Montana’s Medicaid expansion program could emerge as one of the more contentious health issues this session. The federal and state health insurance program for people with low incomes or disabilities extended eligibility to Montana adults who make 138% of the federal poverty level in 2015, and it now enrolls more than 90,000 low-income adults.

At least a half-dozen bill requests have been made by Republican lawmakers ahead of the session to revise the Medicaid expansion program, alarming some health care industry officials. Rich Rasmussen, president and CEO of the Montana Hospital Association, said Medicaid expansion has helped small, rural hospitals maintain financial stability, particularly during the COVID crisis.

“We will adamantly oppose any effort to dismantle the program,” Rasmussen said. “We will share with lawmakers how devastating it will be to employers.”

Gianforte said he supports continuing Medicaid expansion but would be willing to revise the program to increase safeguards against fraud. There hasn’t been evidence of widespread fraud in the state’s Medicaid expansion program.

“If we let people sign up for it who are not qualified, the benefits may not be there for the people who really need it,” he said. “So I am open to additional accountability components.”

Gianforte also is expected to be drawn into a legislative debate about changing or limiting the powers of county public health officials. Local conservative leaders and business owners complain that many health officials have overstepped their authority during the pandemic, while at least seven local health leaders have left their positions amid complaints about a lack of support by some county leaders and law enforcement officials in enforcing directives.

Republican Rep. David Bedey is proposing a measure that would require county commissioners to ratify any decisions made by a local public health officer or panel. He said his proposal isn’t meant to take power away from public health officials, but rather to shift the accountability of such decisions to elected officials.

“I do not wish to punish public health officials,” Bedey said. I think they need political cover to do their jobs.”

Bedey’s proposal is one of a handful of bill requests seeking changes in the powers of local health officials. Some health industry officials and lobbyists worry about any infringement on the ability to respond to a public health emergency.

“Local governments are best equipped to make decisions about the health of their communities,” said Amanda Cahill, the Montana government relations director for the American Heart Association and American Stroke Association. “Public health safeguards are more important than ever, and we hope that the ability of local decision-makers to take protective action remains intact.”

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

But not anymore.

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

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

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

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

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

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

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

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

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

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

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

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

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Ski Resorts Work to Stay Open as COVID Cases Snowball

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Pandemic-Related Paid Sick Days and Leave to Expire Dec. 31 — With No Extension in Sight

Like tens of millions of other parents nationwide, Jonathan and Sara Sadowski struggle to assist their four children, ages 5 to 11, with their online schooling at home. In addition, their eldest child, who has cerebral palsy and is in a wheelchair, needs special care.

So to help the kids and keep them safe — especially their oldest child — Jonathan opted to take 12 weeks of paid leave from his teaching job under a program authorized by an emergency federal law enacted in March.

“Qualifying for paid leave was a huge relief and has worked out really well,” said Jonathan, who lives in Concord, New Hampshire.

But the family has learned about a new wrinkle: The 11-year old needs surgery in January. The operation is expected to require a month or two of recovery. Unfortunately, Jonathan’s leave will be used up by then; what’s more, the emergency federal paid leave program it is based on lapses Dec. 31.

Unions and workers’ rights and consumer advocacy groups are this week waging a last-ditch effort to get Congress to extend the program into 2021. They argue that the program is a critical component helping to prevent the spread of the virus and providing financial assistance to struggling families.

They also assert that a number of unwise exemptions — plus a lack of enforcement and public awareness — have limited the program’s effectiveness.

“The emergency paid-leave provisions have been one important step in helping American families deal with this crisis,” said Sen. Kirsten Gillibrand (D-N.Y.). “Congress must extend the provision until this crisis is over. Paid leave is critical as the economy recovers.”

The program is among two dozen pandemic-related relief measures set to expire at the end of the year. Those include unemployment benefits, protections against evictions, student loan relief and payments for COVID testing.

The Democratic-controlled House twice approved bills extending most of those, including paid leave. But Republican leaders in the Senate have until this month refused to consider new relief and stimulus legislation. This week, negotiations have intensified on a compromise bill that extends some of the expiring measures. But an extension of paid sick days and paid leave is not included in that bill.

Capitol Hill staffers and workers’ rights advocates say a paid-leave extension could still be added to the relief bill or a government spending bill that Congress must pass this month.

“It’s outrageous that paid leave is not in this legislation,” said Vicki Shabo, a senior fellow for paid-leave policy and strategy at New America, a Washington think tank. “The evidence is very clear paid sick days and leave help prevent spread of the virus, and it’s a benefit families overwhelmingly want and need.” 

Neither the Trump administration nor President-elect Joe Biden responded to requests for comment, and neither has announced a position on the issue.

Paid Sick Leave ‘Is in the Public Interest’

The current law requires businesses with fewer than 500 workers to allow their employees to take up to 10 days of sick leave at full pay and up to 50 more at two-thirds pay to care for a child when schools or day care centers are closed because of COVID-19.

The federal government covers the cost via tax credits to employers. The benefit covers mandatory 14-day quarantine periods for those exposed to the virus, whether they get sick or not.

Larger firms were exempted on the theory that most already provide paid sick days and some forms of extended paid leave — and don’t need federal subsidies.

But an analysis after the law was enacted found that the exemption leaves about 70 million workers in large businesses — roughly half the nation’s workforce — without the full protections offered under the COVID law.

The law and subsequent Department of Labor rules also permit firms with 50 or fewer employees to opt out of providing paid sick days or leave if they think their business will be adversely affected.

About 34 million people work for those small businesses — and the majority offer fewer than 10 paid sick days, if any. Few have extended paid leave.

In addition, the law has no guarantee of paid sick days or leave for the nation’s 13 million health care and emergency response workers.

The justification for that when the measure was enacted: Hospitals, clinics, nursing homes and emergency response companies needed to ensure that these essential workers would show up in a time of crisis.

“This was extremely shortsighted and bad policy,” said Pronita Gupta, director of job quality at the Center for Law and Social Policy in Washington, D.C. “We have seen the harmful outcome — the high number of coronavirus cases in health care facilities, especially among low-wage nursing home workers.”

Nor does the law offer extended paid leave for people who have COVID-19 or need to care for a family member with the disease beyond 10 days. Republicans opposed a broad-based benefit beyond at-home child care, advocates for the benefit noted.

“The problem is we now know that thousands of people who have COVID are sick for more than two weeks, some for months,” said Shabo. “These people need to be able to stay home and recover; that’s in the public interest as well.”

In a letter this month, a coalition of nine national public health groups urged Congress to extend the paid-leave benefits. “Paid sick leave can reduce the spread of COVID-19 in workplaces and communities by removing the barrier to employees staying home if they might have the virus,” the groups wrote. “Even one infection can set off an outbreak.”

Business groups are sympathetic, but some still oppose extending paid leave. Chief among them is the National Federation of Independent Business, a lobbying powerhouse that represents small businesses. Beth Milito, the group’s senior executive counsel, said that while small-business owners have been “highly sensitive” to their workers’ needs during the pandemic, mandating paid sick days and extended leave puts an undue burden on them.

“Figuring out who qualifies, monitoring who takes leave and then applying for the tax credit is all too much red tape,” Milito said. “It’s the hassle factor at a time when many businesses are barely making ends meet.”

Estimates of the Program’s Costs Vary Widely

Surveys show a majority of the estimated 70 million private- and public-sector workers covered under the law — after all the exemptions and carve-outs — don’t know about their right to paid sick days or leave.

“The lack of awareness has limited the potential of this benefit,” said Dawn Huckelbridge, director of the Paid Leave for All campaign, which is supported by a coalition of unions and employees and other groups. The Department of Labor, which administers the benefit, “simply fell down on the job,” she said.

Estimates last spring of the use and cost of the benefit varied widely — from around $20 billion to $105 billion.

But more recent estimates suggest it may be less. According to a Government Accountability Office report citing IRS data, as of the end of October about 150,000 employers had filed for paid family and sick leave tax credits, totaling $1.3 billion. The report noted, however, that many employers will likely wait until filing their taxes in the spring to claim the credit and recoup their costs.

The congressional Joint Committee on Taxation last month released fresh projections on the cost of an extension of paid leave — $1.4 billion if extended for two months and $1.8 billion for three months.

Although it’s too early for any full assessment of the paid-leave program’s impact, advocates point to a key study, published online in October in the journal Health Affairs. Researchers at Cornell University and the KOF Swiss Economic Institute found that in states where workers gained the right to paid sick leave under the emergency law, 400 fewer confirmed COVID cases were reported per day.

The researchers conclude: “Our findings suggest that the U.S. emergency sick leave provision was a highly effective policy tool to flatten the curve in the short run.”

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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Voces confiables ayudan a inmigrantes a superar el temor a la vacuna contra COVID

MINNEAPOLIS.- Gloria Torres-Herbeck se aplica la vacuna contra la gripe cada temporada. Pero la maestra de 53 años de Rochester, Minnesota, aún no está convencida de querer estar primera en la fila para una contra COVID-19.

“No soy muy mayor, pero no soy tan fuerte como otras personas”, dijo. “Por eso, necesito ser realista sobre mi situación. ¿Quiero participar en algo que podría ponerme en riesgo? ”

La Administración de Drogas y Alimentos (FDA) ya otorgó la autorización de uso de emergencia para una vacuna y está considerando la aprobación de una segunda.

Mientras tanto, funcionarios de salud pública de todo el país se preparan para lo que podría ser tan desafiante como la distribución de la vacuna: persuadir a comunidades que han sido duramente afectadas por el virus, familias de bajos ingresos, personas de raza negra y latinos (de cualquier raza) de que se vacunen.

Sin embargo, funcionarios creen que algunas zonas tienen ventaja. Rochester, en Minnesota, sede de la Clínica Mayo, es uno de ellas. La Rochester Healthy Community Partnership ha estado trabajando para reducir las disparidades de salud en las comunidades de inmigrantes del área, residentes somalíes, hispanos, camboyanos, sursudaneses y etíopes, durante 15 años.

La asociación está compuesta por investigadores y proveedores de salud de Mayo, funcionarios de salud pública del condado y voluntarios comunitarios como Torres-Herbeck, quien emigró desde México hace 27 años.

“Cuando la pandemia impactó en marzo, nos dimos cuenta que con estas alianzas de larga data estábamos en una posición única por la confianza construida a lo largo de los años entre los expertos de Mayo y sus socios comunitarios”, dijo el doctor Mark Wieland, quien apoya al grupo y estudia el impacto de estas asociaciones.

Aunque hasta ahora solo se ha recopilado evidencia preliminar, hay indicios de que desde que comenzaron estos esfuerzos, Rochester ha aumentado las pruebas para COVID-19, ha mejorado el rastreo de contactos y ha impulsado comportamientos preventivos como el uso de máscaras y el distanciamiento físico en estas comunidades vulnerables, agregó Wieland.

El grupo espera que esos primeros éxitos sean un buen augurio para la aceptación de la vacuna.

Aprendiendo del sarampión

La asociación de Rochester apuesta por un enfoque de sentido común que se centra en valores compartidos, transparencia y comunicación clara.

Es una estrategia que ha tenido éxito en el pasado.

Cuando una epidemia de sarampión golpeó a la población somalí en Minneapolis-St. Paul, en 2017, la Clínica Mayo se acercó a los líderes comunitarios de los 25,000 inmigrantes somalíes que viven en el área de Rochester.

Muchos tenían miedo de vacunarse por la falsa presunción de que la vacuna podría causar autismo, y las tasas de vacunación eran bajas en la comunidad. Médicos realizaron reuniones públicas en mezquitas y centros comunitarios, respondiendo preguntas sobre la seguridad de las vacunas y asegurando a los residentes que no había evidencia científica de un vínculo con el autismo.

Actores somalíes crearon videos de YouTube para ayudar a abordar preocupaciones comunes. Al final, no se registraron casos de sarampión en el condado de Olmsted, hogar de Rochester.

Hace aproximadamente un año, y a pedido de un rabino, el doctor Robert Jacobson, director médico del Programa de Ciencias de la Salud de la Población en la Clínica Mayo, visitó una comunidad judía ortodoxa en Nueva York en la que el rechazo a la vacuna estaba generando otro brote de sarampión. Ayudó a líderes de la atención médica a disipar preocupaciones.

“Los judíos ortodoxos de esa comunidad rechazaban esa vacuna por la misma razón por la que la recomendamos”, dijo Jacobson. “Estaban tratando de proteger a sus hijos”.

Los esfuerzos de líderes judíos, expertos en salud pública como Jacobson y legisladores que endurecieron las leyes sobre exenciones de vacunas, ayudaron a sofocar el brote.

Desde marzo, la asociación de Rochester ha transmitido mensajes similares sobre COVID-19. El miedo o los malentendidos fueron un problema al comienzo de la pandemia. Los miembros de las comunidades de inmigrantes colgaban cuando los llamaban del departamento de salud.

Entonces, la asociación desarrolló mensajes en varios idiomas para explicar la importancia de esas llamadas telefónicas. Resolvieron problemas de comunicación. Por ejemplo, en somalí se usa la misma palabra para “resfriado” y “gripe”.

Ahora, menos gente cuelga.

Los miembros de esta alianza “son expertos en las sutilezas de sus comunidades”, observó Wieland.

Cuando el grupo se enteró de que muchos inmigrantes se sentían intimidados por las pruebas de COVID-19 y no estaban seguros de la logística, recomendó simplificar el proceso: ahora, videos con líderes comunitarios en las redes sociales dirigen a las personas a los sitios de prueba. Una vez allí, cualquiera que no hable inglés puede realizar la prueba sin necesidad de identificación ni tarjeta de seguro médico.

Faltaba el “por qué”

Solo el 40% de los adultos mayores de raza negra y el 51% de los hispanos mayores dijeron que probablemente se vacunarían contra COVID-19, en comparación con el 63% de los blancos no hispanos mayores, reveló una encuesta de la Universidad de Michigan.

Sus preocupaciones reflejan las de Torres-Herbeck: qué tan bien funciona la vacuna o qué tan segura es.

Una encuesta aún más reciente de personas de todas las edades para COVID Collaborative, un grupo de defensa de salud, mostró que la confianza en la seguridad de las vacunas es tan baja como el 14% para los afroamericanos y el 34% para los latinos.

Los adultos mayores dijeron que les gustaría recibir recomendaciones de personas en las que confían, según la encuesta de Michigan. Y los afroamericanos tienen el doble de probabilidades de confiar en voceros de su propia raza, reveló la otra encuesta.

La ventaja de grupos como la asociación de Rochester es que sus miembros son mensajeros de confianza.

Torres-Herbeck contó que había estado hablando con un jardinero que no usaba máscara. Ella le explicó que COVID-19 es un virus y cómo se propaga. El jardinero se sorprendió y se puso un cubrebocas.

A menudo, los funcionarios de salud pública ofrecen instrucciones sobre cómo actuar y qué hacer, como usar una máscara y lavarse las manos, pero no explican por qué, dijo Torres-Herbeck.

Sin embargo, no se trata solo de difundir hechos. Centrarse en los valores compartidos es clave para generar confianza. Cuando Adeline Abbenyi, gerente del programa de Mayo Clinic para el Centro de Investigación sobre Equidad Saludable y Participación Comunitaria, dijo que su madre, que nunca había temido a las vacunas, dudaba en recibir una vacuna COVID-19, Jacobson entendió.

“Muchos de nosotros sentimos lo mismo”, dijo Jacobson en una reunión por Zoom. “Participo del optimismo de que tendremos una vacuna que sea segura y efectiva, pero no la usaré hasta que vea esa evidencia”.

Es normal que la gente dude, no son anti-vacunas. Los médicos y enfermeras que están recibiendo las primeras dosis probablemente ayudarán a muchas personas a superar esa vacilación, agregó.

De hecho, Torres-Herbeck dijo que lo que la persuadiría a ella de vacunarse es ver a Jacobson recibir la vacuna.

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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Trusted Messengers May Help Disenfranchised Communities Overcome Vaccine Hesitancy

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MINNEAPOLIS — Gloria Torres-Herbeck gets the flu vaccine every year, but the 53-year-old teacher in Rochester, Minnesota, isn’t yet convinced she wants to be first in line for a potential COVID-19 vaccine.

“I’m not super old, but I’m not as strong as other people,” she said. “So, I need to be realistic on my own situation. Do I want to participate in something that might be a big risk for me?”

This month, the Food and Drug Administration gave emergency use authorization for one vaccine and is weighing approval of another. So, public health officials around the country are gearing up for what might be as challenging as figuring out how to store a vaccine at 70 degrees below zero Celsius. They need to persuade people who are part of communities that have been hit hard by the virus — those in low-income families and some minority populations, especially Black and Latino residents — to take a vaccine developed in less than a year and approved under emergency use authorization.

Yet there are a few places where officials think they have a head start. Rochester, Minnesota, home of the Mayo Clinic, is one of them. The Rochester Healthy Community Partnership has been working to reduce health disparities in the area’s immigrant communities, including Somali, Hispanic, Cambodian, South Sudanese and Ethiopian residents, for 15 years.

The partnership is composed of Mayo health providers and researchers, county public health officials and community volunteers like Torres-Herbeck, who immigrated to the U.S. 27 years ago from Mexico. One of the first of its kind, other similar efforts have sprung up around the country, but no one officially tracks such partnerships.

“What we realized when the pandemic hit in spades in March was that with long-established partnerships we were uniquely positioned to leverage” trust built up over the years between Mayo experts and their community partners, said Dr. Mark Wieland, who helps direct the group and studies the impact of such partnerships. “We realized we were obligated to jump in with two feet.”

Although only preliminary evidence has been gathered so far, there are indications that since the efforts began, Rochester has increased COVID-19 testing, improved contact tracing and boosted preventive behaviors such as mask-wearing, hand-washing and physical distancing in these vulnerable communities, he said. The group is hoping those early successes portend well for vaccine acceptance.

Learning From a Measles Outbreak

The Rochester partnership is banking on a commonsense approach that focuses on shared values, transparency and clear communication.

It’s a strategy that has succeeded in the past.

When a measles epidemic hit the large Somali population in Minneapolis-St. Paul in 2017, the Mayo Clinic reached out to community leaders among the 25,000 Somali immigrants in the Rochester area. Many had been frightened of the measles vaccine by baseless claims that it could cause autism, and vaccination rates were low in the community. Medical experts held town hall meetings in mosques and community centers, answering questions about vaccine safety and reassuring people that there was no scientific evidence of a link to autism. Somali actors created YouTube videos to help address common concerns. In the end, there were no recorded cases of measles in Olmsted County, home to Rochester.

About a year ago, Dr. Robert Jacobson, medical director for the Population Health Science Program at Mayo Clinic, at the request of a rabbi visited an Orthodox Jewish community in New York in which vaccine refusal was fueling another measles outbreak. He helped health care leaders there allay concerns.

“The Orthodox Jews in that community were refusing that vaccine for the same reason we were recommending it,” Jacobson said. “They were trying to protect their children.”

Efforts by Jewish leaders, public health experts such as Jacobson and lawmakers who tightened up laws on vaccine exemptions helped quell the outbreak.

Since March, the Rochester partnership has broadcast similar messages about COVID-19 to diverse audiences. Fear or misunderstanding was an issue at the beginning of the pandemic. Health leaders found that members of the immigrant communities were hanging up when the public health department called. So, the partnership developed messaging in several languages to explain the importance of the phone calls. They worked around problems, including that other languages don’t always have terms that mesh with English words for illnesses. For example, the word for “cold” and “flu” is the same in Somali.

Now fewer people hang up.

At the same time, these public health teams report back to the medical experts on what the community needs. “They’re the experts on the subtleties of their communities,” Wieland said.

So when the group learned that many immigrants were intimidated by COVID-19 testing and unsure of the logistics, the group recommended simplifying the process: Now, videos featuring community leaders on social media direct people to testing sites. Once there, anyone who doesn’t speak English automatically gets tested — no identification or insurance card necessary.

“We think that’s part of the reason that, as a county, we have overtested minority populations in relation to white populations,” Wieland said.

The ‘Why’ Was Missing

Only 40% of older Black adults and 51% of older Hispanics said they are somewhat or very likely to get the COVID-19 vaccination — compared with 63% of older white people, a University of Michigan poll shows. Their concerns mirror Torres-Herbeck’s: how well will the vaccine work or how safe it will be.

An even more recent survey of people of all ages for the COVID Collaborative, an advocacy group of national and state health and economic leaders, the NAACP and other groups shows trust in vaccine safety is as low as 14% in Black Americans and 34% in Latinos.

Older adults said they would like recommendations from doctors, health officials, or family and friends — people they trust, according to the Michigan poll. And Black Americans are twice as likely to trust Black messengers versus white messengers, the other survey showed.

“Even if people don’t trust doctors in general, they trust their own doctor,” said Dr. Preeti Malani, one of the authors of the Michigan survey and chief health officer of the university.

The advantage of groups like the Rochester partnership is that its members are also trusted messengers.

Several weeks ago, Torres-Herbeck said, she talked to a landscaper who didn’t wear a mask while working with his business partner. She told him that COVID-19 is a virus and explained how it spreads. He was surprised, and Torres-Herbeck understood. “When I came here 27 years ago, we were not as educated on that,” she said. “When I grew up, it was believed that if you walk barefoot you will catch a cold.”

Often, she said, public health officials provide directions on how to act and what to do, such as use a mask and clean your hands, but don’t explain why.

“That ‘why’ was missing for him,” she said.

Now when she talks to him, he puts a mask on.

In mid-November, Jacobson visited with members of the Rochester partnership via Zoom, part of the group’s initial effort to disseminate vaccine information.

Approving a vaccine under emergency use authorization is no less stringent than the normal procedure, he explained. The process has been dramatically sped up and condensed, he said, by the amount of money poured in and newer technology — and by increased FDA resources.

It’s not all about disseminating facts, however. Focusing on shared values is key to building trust. So when Adeline Abbenyi, the Mayo Clinic program manager for the Center for Healthy Equity and Community Engagement Research, said her mother, who had never feared vaccines, was hesitant to get a COVID-19 vaccine, Jacobson understood.

“A lot of us are feeling the same way,” Jacobson said in that Zoom meeting. “I go into this optimistic that we will have a vaccine that’s safe and effective, but I won’t use it until I see that evidence” of safety and efficacy the FDA is reviewing.

It’s normal for people to hesitate, he said, but that is far different from — and more widespread than — the anti-vaccine movement. Doctors and nurses getting the first doses will likely help many people overcome that hesitancy, he said.

Indeed, one thing that would persuade Torres-Herbeck to be inoculated? Seeing Jacobson get the vaccine, 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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As Congress Bickers Over Pandemic Relief, Flight Attendant’s Life Is in a Holding Pattern

Troy Muenzer has seen the damage that COVID can do. A flight attendant who was diagnosed with a “suspected” case of the deadly virus, Muenzer, 32, endured months of lingering breathing problems; hefty, unexpected medical bills; lost wages, then furlough; and, earlier this month, the loss of his health insurance.

Last week, his bank account was hacked, causing him to lie awake one night worrying he wouldn’t be able to get back all that 2020 has taken. “From everything that’s happened this year, it just seems like it’s never-ending,” he said.

At the beginning of the pandemic, Congress passed several relief bills to help the country’s companies and its workforce: business grants and loans, paycheck protection for furloughed workers, one-time stimulus checks for taxpayers, expanded unemployment benefits. Much of the aid is set to expire by year’s end, if it hasn’t already.

This week, Muenzer’s furlough checks will stop coming. His monthly unemployment check is not enough to cover food and rent. He gave up his health insurance earlier this month because he could no longer afford the premium.

A little over two months ago, just before cutting his hours from few to none, his employer — a major airline — told him Congress could save his job. But lawmakers have shown they can’t, or won’t, put partisan politics aside to help the millions of Americans like Muenzer suffering the devastating impacts of the pandemic.

The chances for another round of pandemic relief before the end of the year look grim. Senate Majority Leader Mitch McConnell has signaled that Republicans could not accept a $908 billion bipartisan compromise written by moderates. Last spring, House Democrats introduced a proposal more than three times larger that they said was necessary to tackle the pandemic. Congress approved its last substantial relief bill nearly eight months ago.

Muenzer first got blindsided by COVID-19 in March. He was on a business trip, and as he got ready for bed in his hotel room, he began having trouble breathing. A former college football player who normally ran near his home by Lake Michigan, he lay awake, short of breath and terrified he would die in his sleep.

When the pandemic first gripped the nation, he had taken what precautions he could but was not permitted to wear a mask while working crowded flights. The Centers for Disease Control and Prevention did not recommend that Americans wear masks in public until April 3, but Muenzer was already sick.

Muenzer notified his employer that he had COVID symptoms and isolated himself at home. A telehealth doctor told him he needed in-person medical attention, but he was afraid he couldn’t afford it. He was already burning through his sick days.

Meanwhile, on April 14, with COVID cases exploding in cities like New York and San Francisco and among close-quartered groups like nursing homes and prisons, McConnell announced the Senate would extend its already weeks-long recess on the advice of public health officials. The day before, Democratic leaders said the House would do the same.

Congress had just passed a record $2 trillion stimulus package, its third relief measure. With House Democrats calling for more, including worker protections and medical leave, Rep. Kevin McCarthy of California, the House Republican minority leader, said it was too soon to talk about more aid. “I wouldn’t be so quick to say you have to write something else,” he said, according to NPR. “Let’s let this bill work.”

Muenzer did benefit from those early interventions. He received the one-time $1,200 stimulus check. But it barely made a dent in the wages he had lost being out sick, let alone once passenger demand cratered and the airline reduced his hours.

His employer was one of many companies that accepted help from the government on the condition they would temporarily hold off on furloughing employees. Muenzer was furloughed Oct. 1.

Muenzer has been receiving unemployment since then. But the extra $600 Congress gave the unemployed early in the pandemic expired long before that, and his monthly $1,200 unemployment check is not enough to cover his rent in Chicago, let alone food or medical care.

The relief legislation also required Muenzer’s private insurance plan to cover testing to detect or diagnose COVID-19 without Muenzer being required to pay anything. But that didn’t work.

The day the Senate extended its recess, Muenzer was so short of breath that he went to Northwestern Memorial Hospital’s emergency room. There, health care workers in full protective suits examined him and administered a chest X-ray. Diagnosed as “suspected COVID” and sent home to quarantine for 14 days, he did not get a COVID test.

With those critical diagnostic tests in short supply across the country at that time, they were reserved for seniors or patients with serious health conditions.

Muenzer received a bill for $108.59 for that emergency room visit, which he paid. Then another arrived, this one for $806.85 for the chest X-ray and other emergency room charges. Such billing problems were not unusual in the early days of the pandemic. Because COVID tests were not administered widely, patients like Muenzer lacked the official COVID diagnosis that required the medical system to zero out patient charges.

“I went to the COVID testing sign,” Muenzer said. “Then I didn’t even get tested and still got billed all that money.”

Muenzer was fortunate: A local television reporter heard about his problems and called the billing department herself. Though he had been fighting the bills for weeks, that day, the hospital returned Muenzer’s calls, blaming the problem on a coding error and assuring him his bills would be covered. But the hospital never returned his first payment.

When the payroll protection program’s conditions expired on Oct. 1, thousands of pilots, flight attendants like Muenzer and other airline employees — whose hours had already been trimmed — were furloughed. Muenzer said they were told the airline may be able to hold onto them a little longer, if Congress could pass another relief bill.

Indeed, Congress had considered legislation that would specifically bail out the airline industry. Muenzer watched as lawmakers debated bills that could have saved his job. But he did not overtly root for the legislation to pass. “It felt almost selfish,” he said. “Everybody’s hurting.”

Muenzer’s employer will stop sending him furlough pay on Dec. 15. Because it was calculated by averaging his pay for the past year, and his pay is based on flight hours, it wasn’t much. And given he has barely worked since he began feeling sick in March, his average work hours dropped significantly. He has tried to find a new job, but no luck yet.

But he feels lucky because he received furlough pay at all. He feels lucky because the hospital reduced his COVID testing bill to just $109. He feels lucky because he has family who can help him.

His company has assured its furloughed employees that they hope to bring them back in waves next year, if a vaccine is successful, if customer demand goes up again and if Congress can pass a relief bill.

That’s a lot of ifs at the moment — especially that last one, with Congress at a partisan logjam over a new COVID stimulus bill as it also tries to close out business for the year. Republicans are pushing for broader protections for businesses that could be sued if workers or customers become infected with the coronavirus. Democrats are pushing for funding for state and local governments battling the pandemic. Some lawmakers are also pushing for another round of one-time, $1,200 stimulus checks.

Even the bipartisan compromise would boost unemployment by only $300 a week through April. But it also includes support for the transportation sector, including airlines.

When he isn’t drowning out his anxieties watching Netflix, he keeps a close eye on Congress, “praying for something to happen.” It has been “very stressful, to say the least,” he said, “to feel like your life depends on the decisions of people in political power.”

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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Behind Each of More Than 300,000 Lives Lost: A Name, a Caregiver, a Family, a Story

More than 300,000 people have died from COVID-19 in the United States.

It is the latest sign of a generational tragedy — one still unfolding in every corner of the country — that leaves in its wake an expanse of grief that cannot be captured in a string of statistics.

“The numbers do not reflect that these were people,” said Brian Walter, of New York City, whose 80-year-old father, John, died from COVID-19. “Everyone lost was a father or a mother, they had kids, they had family, they left people behind.”

There is no analogue in recent U.S history to the scale of death brought on by the coronavirus, which now runs unchecked in countless towns, cities and states.

“We’re seeing some of the most deadly days in American history,” said Dr. Craig Spencer, director of Global Health in Emergency Medicine at NewYork-Presbyterian/Columbia University Medical Center.

During the past two weeks, COVID-19 was the leading cause of death in the U.S., outpacing even heart disease and cancer.

“That should be absolutely stunning,” Spencer said. And yet the most deadly days of the pandemic may be to come, epidemiologists predict.

Even with a rapid rollout of vaccines, the U.S. may reach a total of more than half a million deaths by spring, said Ali Mokdad of the Institute for Health Metrics and Evaluation at the University of Washington.

Some of those deaths could still be averted. If everyone simply began wearing face masks, more than 50,000 lives could be saved, IHME’s model shows. And physical distancing could make a difference too.

No other country has come close to the calamitous death toll in the U.S. And the disease has amplified entrenched inequalities. Blacks and Hispanics/Latinos are nearly three times more likely to die from COVID-19 than whites.

“I’m really amazed at how we have this sense of apathy,” said Dr. Gbenga Ogedegbe, a professor of medicine and population health at New York University Grossman School of Medicine. He said there’s evidence that socioeconomic factors, not underlying health problems, explain the disproportionate share of deaths.

The disease, he said, reveals “the chronic neglect of Black and brown communities” in this country.

Though the numbers are numbing, for bereaved families and for front-line workers who care for people in their dying moments, every life is precious.

Here are reflections from people who’ve witnessed this loss — how they are processing the grief and what they wish the rest of America understood.

‘There Are Things We Can Do to Still Make a Difference’

Darrell Owens, a doctor of nursing practice in Seattle, was startled to learn recently that he had signed more death certificates for COVID-19 than anyone else in Washington.

Owens runs the palliative care program at the University of Washington Medical Center-Northwest, where he has treated COVID patients since the early spring.

“I’m feeling much more anger and frustration than I did before because much of what we’re dealing with now was preventable,” Owens said.

“We’re all in this great big storm, but some people are in a yacht and some people are on a cruise ship and some people are on a raft,” he added. “We’re not all in this together.”

Owens still finds moments of grace and meaning as he cares for the dying.

“The other day, there was a lady I was taking care of who’d come from a local nursing home and it was very clear that she was nearing the end,” Owens said. “I just picked up her hand. I sat there. I held her hand for about 25 minutes until she took her last breath.”

He stepped out of the room and called the patient’s daughter.

“It made such a difference for her that her mom was not alone,” he said. “What an incredible gift that she gave me and that I was able to give her daughter. So there are things that we can do to still make a difference.”

‘It’s Not a Joke. It’s Not a Hoax.’

Since his father died of COVID-19 in the spring, Brian Walter of Queens, New York, has helped run a support group on Facebook for people who’ve lost family and friends to COVID-19.

It’s helped him grieve his father John, whom he describes as a very loving man dedicated to his autistic grandson and to running a youth program for teenagers.

“It’s been lifesaving in a lot of ways,” Walter said. “Together, we face a lot of issues since we are grieving in isolation. But at the same time, we’re also dealing with people that openly tell us that this is not a real condition, that this is not a real issue.”

Some in their group admit they denied the severity of the virus and shunned precautions until it was too late.

“It’s not a joke. It’s not a hoax, and you will not understand how horrible this is until it enters your family and takes away someone,” he said.

All of this complicates the grief, but it has also led Walter and others in his group to speak out and share their stories, so that numbers don’t obscure the actual people who were leading full lives before dying from COVID-19.

“I know what it’s like to have to say goodbye to somebody over a Zoom call and to not have a funeral,” Walter said.

‘300,000 Stories That Got Shut Down Too Quickly’

Martha Phillips, an ER nurse who took assignments in New York and Texas in the spring and summer, said there is one patient who has become almost a stand-in for the grief of the many whose deaths she witnessed.

It was the very last COVID patient she cared for in Houston.

“I reached down to just adjust her oxygen tubing just a little bit,” Phillips recalled. “And she looks up at me and she sees me through my goggles and my mask and my shield and meets my eyes and she goes, ‘Do you think I’m going to get better?’”

“What do you say to someone who’s not ready to die? Who has so much to live for, but got this and now they’re trapped?”

Two months later, Phillips discovered the woman’s obituary online.

“That one was the hardest,” she said. “But there’s 300,000 people who had time left that was stolen from them; 300,000 stories that got shut down too quickly.”

‘This Is Worse Than Being in War’

ER physician Dr. Cleavon Gilman, a veteran of the Iraq War, said it’s still hard to communicate the brutality of a disease that kills people in the privacy of a hospital wing.

When Gilman was in New York City during the spring surge, he never imagined the U.S. would be losing thousands of people each day to COVID-19 so many months later.

“That 300,000 Americans would be dead and life would go on and people would not have empathy for their fellow Americans,” he said. “I can tell you this is worse than being in war.”

The enemy is invisible, he said, the war zone is everywhere, and many refuse to take the most simple actions to combat the virus, even as morgues fill up in their own community.

Throughout the pandemic, Gilman, who is now working in Yuma, Arizona, has shared photos and stories of people who’ve died from COVID-19 each day on social media.  “It’s really important to honor them,” he said.

This story is from a reporting partnership with 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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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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Agrícolas, bomberos y azafatas buscan estar entre los primeros en recibir la vacuna

Se espera que los trabajadores de salud de primera línea, así como los residentes y el personal de los hogares de adultos mayores, reciban las dosis iniciales de la vacuna contra COVID. La cuestión más espinosa es averiguar quiénes serán los siguientes.

La respuesta probablemente dependerá de en dónde vivas.

Aunque una influyente junta asesora federal hará sus recomendaciones a finales de este mes, los departamentos de salud estatales y los gobernadores decidirán sobre quién tendrá acceso a un número limitado de vacunas este invierno.

Como resultado, las últimas semanas han sido tensas, ya que fabricantes, empleados en tiendas, cajeros de bancos, dentistas y compañías que proveen servicios de transporte se agolpan literalmente para estar lo más arriba posible en la lista.

El Comité Asesor sobre Prácticas de Inmunización (ACIP) de los Centros para el Control y Prevención de Enfermedades (CDC) votó 13 a 1, este mes, para dar prioridad de vacunación a los trabajadores de salud y a los residentes de centros de atención de largo plazo una vez que la Administración de Alimentos y Medicamentos (FDA) aprobara una o más vacunas COVID-19 para uso de emergencia.

Se espera que el comité asesor proporcione más detalles de su lista de receptores prioritarios antes de finales de año.

Es probable que sus próximas recomendaciones se centren en dar prioridad a las personas que hacen que la sociedad funcione, como los trabajadores de la alimentación y la agricultura, la seguridad pública y la educación. Las personas mayores y las que padecen enfermedades crónicas también se consideran prioritarias.

Pero debido a que los primeros suministros de vacunas son limitados, habrá que tomar decisiones difíciles. Por ejemplo: ¿Es más importante dar prioridad a los maestros que entran en contacto con muchas personas cada día, o a los trabajadores agrícolas que no pueden trabajar a distancia para proporcionar alimentos al país?

“Tenemos que ser conscientes de las cuestiones de equidad, de la comorbilidad y de la probabilidad de muerte o supervivencia, incluso entre estos trabajadores esenciales”, dijo Mitch Steiger, activista legislativo de la Federación del Trabajo de California. Surgirán “muchas conversaciones realmente duras y muchos principios que compiten entre sí”.

Al principio, los estados no conseguirán suficientes dosis de vacunas para cubrir incluso sus grupos de mayor riesgo.

En California, un estado de 40 millones de residentes, los envíos iniciales de alrededor de 1 millón de dosis se quedarán muy cortos para cubrir a quienes están en primera línea. Más de 2 millones de personas entran en la categoría de fase 1 de distribución de la vacuna, que cubre sólo a aquellos que corren el riesgo de enfermarse en un centro de atención médica o de cuidado de largo plazo.

Incluso dentro de esa categoría de trabajadores de salud, ha comenzado toda una carrera para situarse primeros en la lista, con farmacéuticos y dentistas abogando por ser prioridad.

La doctora Laurie Forlano, comisionada adjunta para la salud de la población en el Departamento de Salud de Virginia, dijo que el estado ha escuchado los intereses de muchos a través de cartas, llamadas telefónicas y reuniones virtuales antes de decidir cuáles “trabajadores críticos” seguirán al grupo inicial para ser vacunados. “Es complejo”, aseguró. “Pero no es nuevo para la salud pública tener que tomar este tipo decisiones”.

Los estados ya han señalado diferentes prioridades.

Ron DeSantis, gobernador de Florida, dijo que después de que se inoculen a los adultos mayores en hogares y los trabajadores sanitarios de primera línea, el estado intentará vacunar a las personas de 65 años o más y a los residentes con enfermedades importantes.

El gobernador de Kentucky, Andy Beshear, dijo que los maestros de escuelas primarias deberían ser los siguientes en la lista luego de los trabajadores de salud y adultos mayores en centros, junto a los miembros de la seguridad pública y los adultos con enfermedades significativas.

Pennsylvania incluirá a los “trabajadores esenciales” y a las personas con condiciones de alto riesgo en la parte superior de su lista de prioridades, junto con los trabajadores de salud, los residentes y el personal de las residencias de adultos mayores y los equipos de intervención inmediata, según Rachel Kostelac, vocera del departamento de salud estatal.

A nivel nacional, organizaciones de derechos de los pacientes señalan que las personas con algunas condiciones preexistentes corren un mayor riesgo de muerte si se infectan con el coronavirus. La Asociación Americana de Diabetes publicó un artículo de opinión en defensa de sus pacientes; la Asociación Nacional de Administradores Renales escribió a los reguladores federales diciendo que se debería dar prioridad a los enfermos del riñón.

El doctor Marcus Plescia, director médico de la Asociación de Funcionarios de Salud Estatales y Territoriales, dijo que espera que los estados sigan, en gran medida, la lista de prioridades del comité. Pero no está claro cuántos detalles proporcionará el comité de los CDC en su próxima ronda de recomendaciones, como por ejemplo qué “individuos de alto riesgo” y trabajadores críticos incluir.

Dejar algo de flexibilidad a los estados es bueno, indicó Plescia, porque pueden diferir en las formas de vacunar de manera eficiente. Por ejemplo, algunos estados pueden albergar grandes fábricas donde las personas están en mayor riesgo y podrían vacunarse en el lugar de trabajo.

Ahí es también donde el lobby o cabildeo entra en juego.

“La prioridad 1a para nosotros es conseguir que nuestros empleados entren en ese grupo de ‘prioridad 1b’”, comentó Bryan Zumwalt, vicepresidente ejecutivo de asuntos públicos de la Asociación de Marcas de Consumo, que representa a las empresas que fabrican miles de productos para el hogar, desde papel higiénico hasta gaseosas. De sus 2,3 millones de miembros, 1,7 millones se consideran trabajadores esenciales, añadió.

“Los trabajadores de nuestras empresas fabrican productos para que la vida siga”, explicó Zumwalt. La asociación ha enviado cartas a los departamentos de salud estatales, pero Zumwalt aclara que el proceso sería más fácil si hubiera un orden nacional uniforme para la vacuna, en lugar de dejar que los estados tengan la última palabra.

Estas compañías están lidiando con tasas de ausentismo laboral de un 10%, apuntó, lo que podría causar retrasos en la producción de alimentos y otros productos clave.

“Cuando un trabajador da positivo, entre cinco y diez trabajadores adicionales deben ser retirados de las líneas de producción”, señaló Zumwalt.

En Idaho, una junta asesora de COVID-19 decidió este mes que, después de los trabajadores de la salud y los residentes y el personal de las residencias de mayores, debían recibir las vacunas el personal de intervención inmediata, como policía y bomberos, así como los maestros y el personal no docente de las escuelas, seguidos por el personal de las instituciones correccionales, los trabajadores de la industria alimentaria, los trabajadores de los supermercados y la Guardia Nacional estatal.

La doctora Elizabeth Wakeman, catedrática de filosofía en el College of Idaho y miembro de la junta directiva, les había dicho a sus colegas que tenía más sentido vacunar para reducir la transmisión del virus en lugar de clasificar a los grupos según su valor para la sociedad.

Eso pondría a los trabajadores de la industria alimentaria por delante de los empleados de supermercados, porque hay más espacio para mantener la distancia y mejor ventilación en un mercado, opinó.

También hay presión para proteger de inmediato a los trabajadores de la alimentación y la agricultura. Diana Tellefson Torres, directora ejecutiva de la Fundación de Trabajadores Agrícolas Unidos, dijo que estos trabajadores son esenciales y están en riesgo inminente. Pueden trabajar al aire libre donde el riesgo de transmisión es menor, pero a menudo viven y viajan al trabajo con muchas personas que no viven con ellos, explicó.

La mayoría de los trabajadores agrícolas son inmigrantes indocumentados que carecen de seguro médico y “puede que ni siquiera sepan que padecen condiciones de salud subyacentes”, señaló Tellefson Torres, que forma parte del Comité Asesor de Vacunas de la Comunidad de California. “Hay mucha vulnerabilidad”.

Ya casi es temporada de cosechar los cítricos de invierno en California, y hay que recoger la lechuga en Arizona.

“Es importante que a la comunidad de personas que proporcionan alimentos a este país, los alimentos que llegan a nuestras mesas, también se les tenga en cuenta como una prioridad”, concluyó Tellefson Torres.

En la semana de apertura de la sesión legislativa de California, uno de los primeros proyectos de ley que se presentó argumentó que la mano de obra de suministro de alimentos debe ser la primera en la lista para las vacunas y las pruebas rápidas.

La Asociación Internacional de Bomberos, un sindicato que representa a 322,000 bomberos y personal médico de emergencia, presiona para incluir a sus miembros entre los primeros en tener acceso a la vacuna, argumentando que los bomberos proporcionan servicios médicos de emergencia que los llevan a los hogares de las personas y a otros espacios cerrados.

Los empleados de las aerolíneas también quieren ser vacunados rápidamente.

Y los farmacéuticos también han alzado su voz. Aunque el ACIP incluyó a los farmacéuticos en su categoría de trabajadores de la salud de Fase 1a, cada estado interpreta las recomendaciones de manera diferente en función de su suministro de vacunas, señaló Mitchel Rothholz, de la Asociación Americana de Farmacéuticos, que le reclama a los estados situar a sus miembros en la parte superior de la lista.

“Es una carrera por quién recibe la vacuna primero”, dijo. “Todo el mundo desea que haya suficiente suministro para todos desde el principio, pero esa no es la situación”.

Esta historia fue producida por KHN, que publica California Healthline, un servicio editorialmente independiente de la California Health Care Foundation.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Supply Is Limited and Distribution Uncertain as COVID Vaccine Rolls Out

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High stakes and big challenges await as the U.S. prepares to roll out vaccines against COVID-19, with front-line health care workers and vulnerable nursing home residents recommended as the top priority.

Doses could be on their way very soon. An independent advisory committee to the Food and Drug Administration on Thursday gave a green light to the first vaccine candidate, made by Pfizer in conjunction with the German company BioNTech — a recommendation expected to be approved by the agency within days. The committee is scheduled to consider a second candidate, made by Moderna, Dec. 17.

On tap is an initial stockpile of vaccines made during the approval process, with federal officials hoping to distribute at least 20 million doses by year’s end.

While that will go a long way toward reaching the top-priority groups — the nation’s 21 million health care workers and 3 million long-term care residents — there won’t be enough to inoculate everyone on Day One, or even the first week.

In Ohio, for example, the governor expects an initial delivery of 98,000 doses, with the state allocating 88,000 of those to long-term care facilities, said Pete Van Runkle, executive director of the Ohio Health Care Association, which represents long-term care facilities.

“It’s more than a drop in the bucket, but it’s not all that’s needed,” said Van Runkle, who estimated there are between 150,000 and 175,000 residents and staff members in long-term care centers in the state.

Consequently, the doses will be distributed in waves, with the centers and hospitals not chosen for the first wave getting them in the coming weeks, he said.

Facilities will have to divvy up the supplies to best address the needs of patients and employees.

For hospitals, first up are likely to be “workers with the greatest exposure” to the virus, said Anna Legreid Dopp, a senior director at the American Society of Health-System Pharmacists, a trade group representing more than 55,000 pharmacists who work for hospitals and health systems.

Then who? Perhaps those with personal medical conditions putting them at higher risk. And there may be other considerations specific to individual hospitals. What if, for example, only two people are trained to run a specialized treatment system in the ICU needed to care for patients seriously ill with COVID-19?

“Are they at the top of the list?” asked Dopp.

Nursing homes have a slightly different calculation because they have fewer employees than hospitals, said Van Runkle.

“It’s more a question of choosing which facilities” will get the initial doses, he said. “Once those are chosen, they’ll vaccinate everyone there [who consents], not pick and choose among people.”

Even so, there may be some selectivity because most nursing home employees are women and many are of child-bearing age. Because the vaccines have not yet been tested on pregnant women, those who are pregnant or breastfeeding may not be eligible in the initial rollout.

Which long-term care facilities get the vaccine first may come down to where they are located in relation to two large pharmacy chains: CVS and Walgreens.

In October, the federal government signed an agreement with CVS and Walgreens to store and administer the vaccines. Most long-term care facilities opted to join the partnership.

Under the agreement, the pharmacist teams will make at least three trips to each nursing home over a couple of months to administer the vaccines, which must be given in two doses, set several weeks apart.

One big hurdle in distributing the two vaccines seeking FDA approval is keeping them cold. The Pfizer vaccine is stored at around 94 degrees below zero, while the Moderna option is kept at minus 4 degrees. CVS expects to keep the vaccine at 1,100 locations around the country that have the required refrigeration technology, said Mike DeAngelis, senior director of corporate communications at CVS Health. From those hubs, teams of pharmacists and pharmacy technicians will take thawed doses of the vaccines to the long-term care facilities and administer them to staff and residents. About 30,000 homes have signed on with CVS for the clinics.

Walgreens expects to administer the vaccinations in more than 23,000 long-term care locations, according to a written statement.

While there’s no charge to the nursing homes or residents, Medicare will pay an administrative fee to CVS and Walgreens of $16.94 for the first shot and $28.39 for the second.

Yet there’s a flip side to the supply equation: What if no one wants to go first?

“That’s what keeps me up at night,” said Dr. Michael Wasserman, the immediate past president of the California Association of Long Term Care Medicine, a group of physicians, nurses, social workers and others who provide care to seniors.

That’s key because a good portion of America must be vaccinated to get to the much-sought-after “herd immunity,” in which most people are protected and the virus finds it difficult to spread.

“What if government and pharmacies do a great job in getting vaccine to the front door, then no one takes it?” Wasserman worries.

Nursing home residents are particularly vulnerable to COVID-19 and account for 40% of all reported deaths.

With COVID-positive test results on the rise in almost every state, vaccinating nursing home workers is crucial to protecting not only themselves, but also their patients.

That reality meets a reluctance among many front-line nursing home workers to take the vaccine, said Lori Porter, co-founder and CEO of the National Association of Health Care Assistants, which represents certified nursing assistants who work in long-term care.

Their distrust stems from many things, she said, including politicization around the vaccines, fueled by misinformation on social media.

Educational campaigns and personal endorsements from trusted organizations could help counter the falsehoods, she said. A nationwide event planned for next week by her organization will allow certified nursing assistants to ask questions directly of physician experts and hear from a panel of their peers.

“I’m asked 100 times a day if I’m going to be taking it,” said Porter, who definitely will, hoping to do so in a live webcast, to further convince her members it’s safe.

Despite the need to vaccinate staff to protect residents, Wasserman, a former regulator and nursing home executive, does not think mandates are appropriate for workers, many of whom are low-paid and people of color. “As a society, are we prepared to force this group of folks to get a brand-new vaccine?” he asked.

A better approach, he said, is the type of educational programs that Porter mentioned, so that workers can weigh the evidence and decide whether they want to get vaccinated.

Although employers may have the authority to mandate vaccination, many experts don’t think that policy will be widespread in the nursing home industry, given a shortage of workers and a fear of losing staffers who choose not to comply.

“I can tell you our members are not going to do that,” said Van Runkle, with the Ohio trade group. “If they were to try a mandate, some number of workers would say, ‘Sorry, this is the last straw. I’m leaving.’”

Instead of a mandate, Porter said, a few nursing homes are offering prizes or financial incentives — with at least one talking about offering a drawing for a new car among those who participate. Others, however, may take the opposite approach: ending supplemental hazard pay for workers who refuse.

As for residents, there is no debate. They will not get the vaccine unless they agree, often in writing, said Van Runkle.

For those with dementia or other health problems that prevent making such a decision, family members or others with legal authority must sign, which could slow down the vaccination process considerably.

“During a pandemic, it may be difficult to get hold of them or get their handwritten signature on a document,” said Van Runkle. “We’ve got to sort all this out in the next couple of weeks.”

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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Farmworkers, Firefighters and Flight Attendants Jockey for Vaccine Priority

With front-line health workers and nursing home residents and staff expected to get the initial doses of COVID vaccines, the thornier question is figuring out who goes next.

The answer will likely depend on where you live.

While an influential federal advisory board is expected to make its recommendations later this month, state health departments and governors will make the call on who gets access to a limited number of vaccines this winter.

As a result, it’s been a free-for-all in recent weeks as manufacturers, grocers, bank tellers, dentists and drive-share companies all jostle to get a spot near the front of the line.

The Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices (ACIP) voted 13 to 1 this month to give first vaccination priority to health care workers and residents of long-term care facilities once the Food and Drug Administration approves one or more COVID-19 vaccines for emergency use. The advisory committee is expected to provide further details of its list of prioritized recipients before year’s end.

Its next recommendations are likely to focus on prioritizing people who keep society functioning, like workers in food and agriculture, public safety and education. Older people and those with chronic diseases are also considered high on the list.

But because early supplies of vaccine are limited, tough choices lie ahead, such as: Is it more important to prioritize teachers who come into contact with many people each day, or farmworkers, who can’t work remotely and provide the country’s food?

“We have to be mindful of equity issues, comorbidities and the likelihood of death versus survival, even within these essential workers,” said Mitch Steiger, a legislative advocate for the California Labor Federation. There will be “a lot of really tough conversations and a lot of different competing principles.”

Initially, states won’t get enough vaccine doses to cover even their top-ranked groups.

In California, a state of 40 million residents, the initial shipments of around 1 million doses won’t come close to covering everyone at the front of the line. More than 2 million people fall into the Phase 1a category of vaccine distribution, which covers only those at risk of getting sick at a health care or long-term care setting.

Even within that health worker category, there’s jockeying to get to the front of the line, with pharmacists and dentists arguing for priority.

Dr. Laurie Forlano, deputy commissioner for population health at the Virginia Department of Health, said the state has been hearing from numerous parties via letters, phone calls and virtual meetings as it decides which “critical workers” will follow the initial bunch in getting vaccinated. “It is complex,” she said of the undertaking. “But it is not new for public health to make these decisions.”

States have already signaled different priorities.

Florida Gov. Ron DeSantis said that after nursing home residents and front line health workers are inoculated, the state will try to vaccinate people 65 and over and residents with significant illnesses.

Kentucky Gov. Andy Beshear said grade school teachers should be next in line after health care workers and nursing home residents, along with first responders and adults with significant illnesses.

Pennsylvania will include “critical workers” and people with high-risk conditions at the top of its priority list, along with health workers, nursing home residents and staff and first responders, according to state health department spokesperson Rachel Kostelac.

Nationally, disease advocacy groups point out that people with some preexisting conditions are at a greater risk of death if they become infected with the coronavirus. The American Diabetes Association published an opinion piece advocating for its patients; the National Renal Administrators Association wrote to federal regulators saying kidney patients should be prioritized.

Dr. Marcus Plescia, chief medical officer of the Association of State and Territorial Health Officials, said he expects states to largely follow the committee’s priority list. But it’s unclear how much detail the CDC committee will provide in its next round of recommendations — such as which “high-risk individuals” and critical workers to include.

Leaving some flexibility for states is good, Plescia said, because they may differ on ways to vaccinate people efficiently. For example, some states may be home to large factories where people are at higher risk and could get vaccinated on-site.

That’s also where lobbying comes into play.

“Priority 1a for us is getting our employees into that ‘priority 1b’ priority group,” said Bryan Zumwalt, executive vice president of public affairs for the Consumer Brands Association, which represents companies that make thousands of household products, from toilet paper to soda. Of the membership’s 2.3 million employees, 1.7 million are considered essential, he said.

“Workers at our companies are making life-sustaining products,” Zumwalt said. The association is reaching out with letters to state health departments, but Zumwalt said the process would be easier if there were a uniform national priority order for the vaccine, instead of letting states have final say.

These companies are dealing with absenteeism rates averaging 10%, he said, which could cause delays in producing food and other key products.

“When one worker tests positive, an additional five to 10 workers have to be taken off the production lines,” he said.

In Idaho, a COVID-19 advisory board decided this month that after health workers and nursing home residents and staff, first responders such as police and firefighters, and grade school teachers and staff should get the shots, followed by correctional facility staff, then food-processing workers, grocery workers and the Idaho National Guard.

Dr. Elizabeth Wakeman, an associate professor of philosophy at the College of Idaho, and a member of the board, had told her colleagues that it made more sense to vaccinate with the aim of slowing virus transmission rather than ranking groups on their value to society.

That would put food-processing workers ahead of grocery clerks, because there’s more room to maintain distance and better ventilation in a grocery store, Wakeman said.

There’s also pressure to quickly protect food service and farmworkers. Diana Tellefson Torres, executive director of the United Farm Workers Foundation, said farmworkers are both essential and deeply at risk. They may work outdoors where transmission risk is lower, but they often live and ride to work with many people outside their immediate families, she said.

Most farmworkers are undocumented immigrants who lack health insurance and “might not even know they have underlying health conditions,” said Tellefson Torres, who sits on California’s Community Vaccine Advisory Committee. “There’s a lot of vulnerability.”

It’s almost time for the winter citrus crops to be harvested in California, and the lettuce needs to be picked in Arizona.

“It’s important to ensure that the community of individuals who provide food for this country, the food at each one of our tables, is also taken into consideration as a top priority,” said Tellefson Torres.

In the opening week of California’s legislative session, one of the first pieces of legislation to be introduced argued that the food-supply workforce should be first in line for vaccines and rapid tests.

The International Association of Fire Fighters, a union representing 322,000 firefighters and emergency medical personnel, is pushing to include its members as among the first to get access to the vaccine, arguing that firefighters provide emergency medical services that bring them into people’s homes and other closed spaces.

Airline employees also want to be quickly vaccinated.

Pharmacists, too, have also been making their case. While the ACIP included pharmacists in its Phase 1a health worker category, each state interprets the recommendations differently based on its vaccine supply, noted Mitchel Rothholz, chief of governance and state affiliates for the American Pharmacists Association, which is urging states to keep its members atop the list. “It’s a race for who gets the vaccine first,” he said. “Everybody wishes there was enough supply for everyone right out of the gate, but that’s not the situation.”



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A Battle-Weary Seattle Hospital Fights the Latest COVID Surge

As hospitals across the country weather a surge of COVID-19 patients, in Seattle — an early epicenter of the outbreak — nurses, respiratory therapists and physicians are staring down a startling resurgence of the coronavirus that’s expected to test even one of the best-prepared hospitals on the pandemic’s front lines.

After nine months, the staff at Harborview Medical Center, the large public hospital run by the University of Washington, has the benefit of experience.

In March, the Harborview staff was already encountering the realities of COVID-19 that are now familiar to so many communities: patients dying alone, fears of getting infected at work and upheaval inside the hospital.

This forced the hospital to adapt quickly to the pressures of the coronavirus and how to manage a surge, but all these months later it has left staff members exhausted.

“This is a crisis that’s been going on for almost a year — that’s not the way humans are built to work,” said Dr. John Lynch, an associate medical director at Harborview and associate professor of medicine at the University of Washington.

“Our health workers are definitely feeling that strain in a way that we’ve never experienced before,” he said.

Until the late fall, the Seattle area had mostly kept the virus in check. But now cases are rising faster than ever, and Washington Gov. Jay Inslee has warned a “catastrophic loss of medical care” could be on the horizon.

“This is the very beginning, to be honest, so thinking about what that looks like in December and January has got me very concerned,” Lynch said.

Lessons Learned From Spring Surge

When the outbreak first swept through western Washington, hospitals were in the dark on many fronts. It was unclear how contagious the virus was, how widely it had spread and how many intensive care beds would be needed.

Intensive care unit nurse Whisty Taylor remembers the moment she learned one of her colleagues — a young, active nurse — was hospitalized on their floor and intubated.

“That’s really when it hit — that could be any of us,” Taylor said.

Concerns over infection control and conserving personal protective equipment meant nurses were delegated all sorts of unusual tasks.

“The nurses were the phlebotomists and physical therapists,” said nurse Stacy Van Essen. “We mopped the floors and we took the laundry out and made the beds, plus taking care of people who are extremely, extremely sick.”

A lot has changed since those early days.

Staff members besides just nurses are now trained to go into COVID rooms and be near patients, and the hospital has ironed out the thorny logistics of caring for these highly contagious patients, said Vanessa Makarewicz, Harborview’s manager of infection control and prevention.

How to clean the rooms? Who’s going to draw the blood? What’s the safest way to move people around?

“We’ve grown our entire operation around it,” Makarewicz said.

The physical layout of the hospital has changed to accommodate COVID patients, too.

“It’s still busy and chaotic, but it’s a lot more controlled,” said Roseate Scott, a respiratory therapist in the ICU.

Harborview has also learned how to stretch its supplies of PPE safely. And as cases started to rise significantly last month, the hospital quickly reimposed visitor restrictions.

“In the past, we’ve had visitors who then call us two days later and say, ‘Oh, my gosh, I just came up positive,’” said nurse Mindy Boyle.

Boyle said months of caring for COVID patients — and all the steps the hospital has taken, including having health care workers observed as they don and doff their PPE — has tamped down the fears of catching the virus at work.

“It still scares me somewhat, but I do feel safe, and I would rather be here than out in the community, where we don’t know what’s going on,” said Boyle.

‘We’re All Tired of This’

Preparation can go only so far, though. The hospital still runs the risk of running low on PPE and staff, just like so much of the country.

During the spring, the hospital cleared out beds and recruited nurses from all over the nation, but that is unlikely to happen this time, with so many hospitals under pressure at once.

“All things point to what could be an onslaught of patients on top of a very tired workforce and less staff to go around,” said Nate Rozeboom, a nurse manager on one of the COVID units. “We’re all tired of this, tired of taking care of COVID patients, tired of the uncertainty.”

Already, COVID’s footprint at Harborview is expanding and bringing the hospital close to where it was at its previous peak.

“The fear I have personally is overwhelming the resources, using up all the staff — and the numbers are still going to go up,” said Scott.

And she said the realities of caring for these desperately ill patients have not changed.

“When they’re on their belly, laying down with all the tubes and drains and all these extra lines hanging off of them, it takes about four to five people to manually flip them over,” Scott said. “It feels intense every time. It doesn’t matter how many times you’ve done it.”

Hospitalized patients are faring better than in the spring, but there are still no major breakthroughs, said Dr. Randall Curtis, an attending physician in the COVID ICU and a professor of medicine at the University of Washington.

“The biggest difference is that we have a better sense of what to expect,” Curtis said.

The few treatments that have shown promise, including the steroid dexamethasone and the antiviral remdesivir, have “important but marginal effects,” he said.

“They’re not magic bullets. … People are not jumping out of bed and saying, ‘I feel great. I’d like to go home now,’” Curtis said.

Taylor said nursing has never quite felt the same since she started in the COVID ICU.

“These people are in the rooms for months. Their families can only see them through Zoom. The only interaction they have is with us through our mask, eyewear, plastic,” Taylor said. “We’re just giving their body a runaround trying to keep them alive.”

This story is from a reporting partnership that includes 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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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.


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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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As More Red States Legalize Marijuana, Some Officials Try to Nip It in the Bud

With his state reeling amid one of the worst COVID-19 outbreaks in the nation, the last thing South Dakota Speaker of the House Steven Haugaard wants to be dealing with during the upcoming legislative session is marijuana. But the state’s voters haven’t left the Republican much choice.

This fall, South Dakota became the first state in the U.S. to legalize both medical marijuana and recreational marijuana in the same election. Haugaard, who long opposed any form of marijuana legalization, now must participate in the creation of a medical marijuana program.

South Dakota voters enshrined legal marijuana in the state’s constitution. So if Haugaard had any thoughts about reversing the initiative once lawmakers reconvene on Jan. 12, they’ve been dashed.

“With a constitutional amendment, there’s really not much we can do about it. It’s written in stone until it’s repealed,” Haugaard said.

South Dakota is one of a handful of states in which voters both approved marijuana ballot questions and elected Republicans to lead state governments. Montana and Arizona, two other states in which Republicans control (or will soon control) the governor’s office and legislature, also backed recreational marijuana at the ballot box. Mississippi passed a measure legalizing medical marijuana.

New Jersey, which has a Democratic governor and Democratic-majority legislature, also passed a recreational marijuana ballot question.

Many conservative lawmakers oppose the legalization of marijuana, an illegal drug under federal law. But they are discovering obstacles to simply passing bills to reverse the initiatives when state legislatures return to work in January. Some marijuana opponents, realizing the limitations to altering a constitutional amendment, are turning to the courts or local officials to undo the measures or at least blunt the effects of legal pot.

Before the November election, 11 states and Washington, D.C., had legalized recreational marijuana, most of them left-leaning states, with exceptions like Alaska. An additional 21 states allow medical marijuana. In the wake of the election, 15 states will have legalized recreational marijuana and 35 will allow medical marijuana.

In conservative states like Montana, where passage of a bill can change or negate a ballot initiative, one thing giving lawmakers pause is that many voters who elected them also approved the legalization of marijuana use for adults 21 and up.

In Montana, 57% of voters approved the recreational marijuana initiative — the same share received by President Donald Trump. In South Dakota, 54% voted for recreational marijuana and a whopping 70% approved medical marijuana. In Arizona, the recreational pot proposition also passed easily.

Those kinds of margins are what caused state Rep. Derek Skees to reconsider a bill he was drafting to repeal the Montana ballot measure in anticipation of its passage.

Skees told the Missoulian the day after the election that after it became clear voters supported it — while also supporting Republican candidates for office up and down the ballot — he decided to shelve it.

“There’s no way I’m going to try to overturn the will of Montana,” Skees told the newspaper.

Haugaard said opposition to the South Dakota measure was derailed by the pandemic and voters never got the message from opponents about the potential negative impacts of legalization.

Proponents of legalization spent nearly $800,000 on their campaign in South Dakota — most of it coming from the New Approach Political Action Committee, a pro-legalization group that works across the country — and five times what opponents of ballot measures raised.

Colorado, the first state to allow recreational use of marijuana in 2014, is often held up as the poster child for what can happen. Proponents say the state has benefited from increased tax income and economic activity. But opponents, including Haugaard, point to studies about increased traffic deaths in Colorado since legalization to explain why they think it’s a bad idea.

“That side of the story wasn’t told and had it been told I think this vote would have gone differently,” Haugaard said.

Marijuana opponents aren’t waiting to see what state lawmakers do, if anything — they’re going to court. The Pennington County, South Dakota, sheriff and the superintendent of the South Dakota Highway Patrol have filed a lawsuit challenging the constitutionality of the marijuana amendment. The Rapid City Journal reported the suit had the backing of Gov. Kristi Noem, and that the state was paying for part of the suit. Noem was a vocal opponent of legalization during the campaign.

Should the legal challenge fail, the amendment is scheduled to take effect July 1 and, according to the governor’s office, it will be up to the state health department to implement it. The legislature will have more control over how the medical marijuana program will work. Haugaard said that will be a big focus of the 37-day session.

Opponents in Montana are also asking the courts to disallow recreational marijuana. Steve Zabawa, a Billings car dealer who has campaigned against legalized marijuana for years, said in his lawsuit that what the voters passed would illegally take power from state lawmakers by designating where tax revenue will go.

Zabawa blamed its passage at the ballot box on pro-marijuana advocacy groups that so outraised and outspent opponents of the measure that he compared it to David and Goliath.

“They candy-coated this deal. They lied to the entire state of Montana by saying that this would benefit veterans and fish and wildlife,” Zabawa said. “They crossed a line and we’re calling them on it.”

Zabawa said that if the courts don’t block recreational marijuana, he’s hopeful that Montana’s Republican-controlled Statehouse will stymie its implementation.

“I just don’t think there’s a lot of love for marijuana in Montana,” Zabawa said.

In Arizona, a recreational marijuana ballot measure was rejected by voters just four years ago. This year it passed by a wide margin. The state’s voters also chose Joe Biden over President Donald Trump, the first time a Democrat won the presidential election in the state since 1996.

It’s unlikely Arizona’s Republican-led legislature can do anything to stop implementation because of a 1998 law that prohibits lawmakers from changing a voter-approved initiative without a three-quarters majority.

State lawmakers’ hands may be tied, but the initiative did give municipalities some power to restrict its use. The day after the initiative passed, Oro Valley Town Council approved an emergency declaration that would limit which type of businesses could sell marijuana and prohibited its use in public places.

The declaration was based on language written by the League of Arizona Cities and Towns and given to members prior to Election Day.

One of the major backers of the state ballot measures is the Marijuana Policy Project, a Washington, D.C.-based organization that supports sweeping marijuana policy changes across the country. Deputy Director Matthew Schweich said this election showed how the public’s opinion on marijuana is rapidly evolving.

Schweich said he believes the results of the 2020 election bode well for future legalization efforts in states and even at the federal level. Because of that growing support, he dismissed any chance Montana or South Dakota could derail recreational legalization but added that his organization will do whatever it can to fight those efforts.

“This is a bipartisan issue [and] I think we’re at a tipping point. We’ve passed it in big states and small states, liberal states and conservative states,” he said. “We’re feeling pretty good. We believe that 2021 is our year.”

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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It’s Time to Scare People About COVID

I still remember exactly where I was sitting decades ago, during the short film shown in class: For a few painful minutes, we watched a woman talking mechanically, raspily through a hole in her throat, pausing occasionally to gasp for air.


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The public service message: This is what can happen if you smoke.

I had nightmares about that ad, which today would most likely be tagged with a trigger warning or deemed unsuitable for children. But it was supremely effective: I never started smoking and doubt that few if any of my horrified classmates did either.

When the government required television and radio stations to give $75 million in free airtime for antismoking ads between 1967 and 1970 — many of them terrifyingly graphic — smoking rates plummeted. Since then, numerous smoking “scare” campaigns have proved successful. Some even featured celebrities, like Yul Brynner’s posthumous offering with a warning after he died from lung cancer: “Now that I’m gone, don’t smoke, whatever you do, just don’t smoke.”

As the United States faces out-of-control spikes from COVID-19, with people refusing to take recommended, often even mandated, precautions, our public health announcements from governments, medical groups and health care companies feel lame compared with the urgency of the moment. A mix of clever catchphrases, scientific information and calls to civic duty, they are virtuous and profoundly dull.

The Centers for Disease Control and Prevention urges people to wear masks in videos that feature scientists and doctors talking about wanting to send kids safely to school or protecting freedom.

Quest Diagnostics made a video featuring people washing their hands, talking on the phone, playing checkers. The message: “Come together by spending time apart.”

As cases were mounting in September, the Michigan government produced videos with the exhortation, “Spread Hope, Not Covid,” urging Michiganders to put on a mask “for your community and country.”

Forget that. Mister Rogers-type nice isn’t working in many parts of the country. It’s time to make people scared and uncomfortable. It’s time for some sharp, focused, terrifying realism.

“Fear appeals can be very effective,” said Jay Van Bavel, associate professor of psychology at New York University, who co-authored a paper in Nature about how social science could support COVID response efforts. (They may not be needed as much in places like New York, he noted, where people experienced the constant sirens and the makeshift hospitals.)

I’m not talking fear-mongering, but showing in a straightforward and graphic way what can happen with the virus.

From what I could find, the state of California came close to showing the urgency: a soft-focus video of a person on a ventilator, featuring the sound of a breathing machine, but not a face. It exhorted people to wear a mask for their friends, moms and grandpas.

But maybe we need a PSA featuring someone actually on a ventilator in the hospital. You might see that person “bucking the vent” — bodies naturally rebel against the machine forcing pressurized oxygen into the lungs, which is why patients are typically sedated.

(Because I had witnessed this suffering as a practicing doctor, I was always upfront about the trauma with loved ones of terminally ill patients when they were trying to decide whether to consent to a relative being put on a ventilator. It sounds as easy as hooking someone to an IV. It’s not.)

Another message could feature a patient lying in an ICU bed, immobile, tubes in the groin, with a mask delivering 100% oxygen over the mouth and nose — eyes wide with fear, watching the saturation numbers rise and dip on the monitor over the bed.

Maybe some PSAs should feature a so-called COVID long hauler, the 5% to 10% of people for whom recovery takes months. Perhaps a professional athlete like the National Football League’s Ryquell Armstead, 24, who has been in and out of the hospital with serious lung issues and missed the season.

These PSAs might sound harsh, but they might overcome our natural denial. “One consistent research finding is that even when people see and understand risks, they underestimate the risks to themselves,” Van Bavel said. Graphs, statistics and reasonable explanations don’t do it. They haven’t done it.

Only after Chris Christie, an adviser to President Donald Trump, experienced COVID, did he start preaching about mask-wearing: “When you have seven days in isolation in an ICU, though, you have time to do a lot of thinking,” Christie said, suggesting that people, “follow CDC guidelines in public no matter where you are and wear a mask to protect yourself and others.”

We hear from many who resist taking precautions. They say, “I know someone who had it and it’s not so bad.” Or, “It’s just like the flu.”

Sure, most longtime smokers don’t end up with lung cancer — or tethered to an oxygen tank — either. (That, in fact, was the justification of smokers like my father, whose two-pack-a-day habit contributed to his death at 47 of a heart attack.)

These new ads will seem hard to watch. “We live in a Pixar era,” Van Bavel reflected, with traditional fairy tales now stripped of their gore and violence.

But studies have shown that emotional ads featuring personal stories about the effects of smoking were the most effective at persuading folks to quit. And quitting smoking is much harder than maintaining physical distance and mask-wearing.

Once a vaccine has proved successful and enough people are vaccinated, the pandemic may well be in the rearview mirror. In the meantime, the creators of public health messaging should stop favoring the cute, warm and dull. And — at least sometimes — scare you.

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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With Pandemic Surging, Ohio Gov. DeWine Dials Back His Aggressive Response

Eric Shanteau didn’t know he was about to create a viral pandemic meme when he made a cutout of Ohio Gov. Mike DeWine’s head with two fingers pointing at his eyes, photographed the smiling visage in various strategic, comedic locations around the Toledo suburb of Maumee, and then posted the images online.

He also didn’t know that the Republican governor was that day in mid-November visiting Toledo after announcing new coronavirus restrictions to counter an alarming surge in the state’s infection rates.

Shanteau, a graphic artist, was hoping to give a few friends a little lift in the face of the worsening health crisis by taking pictures of his “DeWine Is Watching” prop peering around corners, over fences and from bushes.

“The last few weeks, it kind of punched me in the stomach again, just being overwhelmed,” said Shanteau, about the “skyrocketing” local case numbers. “It’s hard to laugh or smile lately. It’s kind of a scary thing, and anybody that knows me personally knows that I just want to make people laugh all the time. And that was my intention.”

But his bid to lighten things up ended up offering a window into the darkening mood of the state and the pressures mounting on DeWine. On one side are most Ohioans, weary of the pandemic but wanting the governor to maintain his highly praised, aggressive response. On the other — largely on the right wing of the Republican Party — there is a growing clamor for DeWine to dial back restrictions as well as accusations that he’s abusing his authority.

Shanteau saw it in the reaction to his image, which a surprising number of people used to craft Christmas tree ornaments. It’s also shown up printed on at least one bakery’s cookies, casting DeWine as a sort of creepy Santa with the caption “He knows when you’re sleeping.” Then there are harsher uses on Twitter in which the smiling DeWine is deployed to make accusations of tyranny and a “totalitarian agenda.”

DeWine is feeling that pressure, particularly from growing numbers of Republicans who see mask mandates and other restrictions as overly intrusive limitations on their freedom, said Lauren Copeland, a political science professor at Baldwin Wallace University in Berea, Ohio.

“He’s in a tough spot,” said Copeland. “He really has to walk a tightrope between balancing public safety while maintaining a healthy economy, and also making it seem like people’s liberties aren’t under threat.”

DeWine is up for reelection in 2022, and he would have seemed to be in a secure position after his initial COVID response won plaudits across the spectrum, even as the leader of his party, President Donald Trump, sought to play down the threat.

DeWine declared a state of emergency on March 9 on the advice of his then-health director, Dr. Amy Acton, when just three people were known to be infected in Ohio. He closed schools three days later and mandated one of the earliest state lockdowns. He also won praise for his near-daily, level-headed briefings with Acton.

His approval ratings for handling the virus climbed to 85% in the Great Lakes Poll conducted by Baldwin Wallace and other universities in late April.

But a backlash was already brewing as Trump called lockdowns and other health-based restrictions worse than the disease itself.

Acton bore the brunt of early dissatisfaction. After being taunted with anti-Semitic slurs and having gun-toting protesters show up at her home in May, state officials gave her a security detail. That month, the Ohio House of Representatives voted to limit her power to issue health orders. She ultimately resigned.

DeWine’s overall approval remained high through the summer, but took a 13-point hit in a late September survey, falling to 72%. Republicans’ dissatisfaction with him jumped from 13% in April to 28%.

After Acton left, statehouse Republicans shifted their sights to the governor, recently passing a bill that would subject his health measures to legislative approval. And four Republican state lawmakers filed articles of impeachment against him last week.

DeWine responded to the changing landscape with an approach that critics see as less aggressive. With cases spiking past 480,000 and the fatality count surpassing 7,000 as of Tuesday, he ventured in recent weeks only as far as instituting a curfew while allowing businesses to remain open with stepped-up mask enforcement. This week, he announced that the curfew, which was slated to expire, would continue.

DeWine has framed his latest moves as an attempt to better balance the state’s response based on lessons learned from the shutdown.

“We don’t want to have a total lockdown in Ohio,” DeWine told reporters on the day of his Toledo trip. “Why not? Well, there’s a lot of bad things that happen.”

He cited potential mental health and addiction problems among residents, difficulties for kids out of school, child abuse and economic impacts. Just before Thanksgiving, in a news conference with four doctors from around the state warning the health care system was in dire straits, DeWine stuck by his approach, saying it was up to Ohioans to turn the numbers around.

“The most important thing — every one of these doctors will tell you — is what individuals do in their own lives,” DeWine said. “This comes down to personal responsibility.”

Democratic strategists watching DeWine don’t see any principle in his latest moves.

“DeWine won praise from a number of folks on the other side of the aisle when the pandemic started, myself included,” said Justin Barasky, who managed Democratic Ohio Sen. Sherrod Brown’s 2018 reelection victory. “But fairly quickly he cowered in the face of ‘Trump World.’ It’s not a secret that there are Republicans looking at ‘primarying’ him in the state. It’s unfortunate because it’s going to kill people.”

Trump himself has tweeted that DeWine deserves to be challenged, and there are some high-profile Republican critics such as former Rep. Jim Renacci and current Rep. Jim Jordan who could take a shot.

Republicans who know DeWine are offended both by suggestions of political calculation and the more Trumpian salvos winging in from the right.

“A Democrat who would suggest that DeWine is caving to political pressure here just doesn’t know the man,” said Ryan Stubenrauch, a consultant who worked for DeWine when he was attorney general and in his campaign for governor. “This is a guy who spent a long time in politics — 30-plus years — and he has never wilted in the face of public pressure.”

That includes pressure from Republicans. “Just because a couple of morons in the Ohio General Assembly say stupid things, that is not anything that would certainly factor into the governor’s process,” Stubenrauch said.

Still, if the governor wants to remain governor, he has to be aware of the threat.

“That’s a political risk that’s very much in play for DeWine,” Copeland said. “If he wants to stay in office, he can’t put measures in place that are too restrictive.”

Shanteau, the graphic artist, said he was a little nervous when he made his DeWine cutout because he knows the pandemic stirs up political passions. He took the chance anyway, and he’s glad he did.

Some people asked to buy the cutouts and that helped him raise enough money to buy 11 family Thanksgiving dinners and grocery store gift cards for another 15 families in need. And although people sometimes had entirely opposite reasons for laughing at the meme, most did laugh. Shanteau found his own glimmer of hope in that bit of unity.

“I know people who were asking me for the signs that did not agree with the governor one bit,” Shanteau said. “And then there were others — nurses — that asked for them that just maybe wanted to brighten someone’s day for what they’re going through right now. … It was unbelievable.”

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

They include Dr. Rochelle Walensky, an infectious disease expert at Harvard Medical School who practices at Massachusetts General Hospital in Boston, as the next director of the Centers for Disease Control and Prevention. Biden’s choice for COVID “czar” is Jeffrey Zients, a private equity executive and former Obama administration official who will steer the pandemic response from the White House. Dr. Vivek Murthy is the nominee for U.S. surgeon general, a position he held in the final Obama years.

Biden has said he will let the federal government’s longtime scientists guide his pandemic response, in particular those at the CDC, which is overseen by HHS. President Donald Trump sidelined the agency, damaging its reputation as the world’s most trusted public health institution.

That Becerra’s deepest experience is political makes some observers wary.

“I think there’s always a danger of letting that sort of cloud the scientific and medical judgment of how best to do things. I hope they can manage that well,” said Jeffrey Morris, a biostatistics professor at the University of Pennsylvania who has worked on COVID issues. He said he had mixed feelings about the Becerra selection. “What is the leadership style, and is there going to be micromanaging from the top down into these organizations? To me, that’s the key aspect.”

Garry South, a Los Angeles-based Democratic strategist, called Becerra’s appointment “curious.”

“A lot of people are raising eyebrows — even those who are pleased and proud that Biden picked another Californian to join his administration,” South said. “If Republicans are looking to target a few Biden appointees for rejection, you can expect them to make the case that there is no logical nexus between a state attorney general and serving as secretary of Health and Human Services.”

Still, Becerra, who as a member of Congress worked in the House Democratic leadership and was a member of the powerful Ways and Means Committee, has more health policy background and knowledge of U.S. health care finance and delivery systems than many previous heads of the sprawling HHS, which employs more than 80,000 people and has a $1.3 trillion budget.

For three years, Becerra has managed California’s Justice Department, with a $1.1 billion budget and 4,800 employees. As attorney general, he’s been deeply involved in crafting health policy. His office has gone after anti-competitive behavior from hospitals. And he’s sponsored legislation to take on drugmakers and pay-for-delay schemes.

“He’s gone after powerful health care interests,” said Anthony Wright, executive director of the nonprofit Health Access California.

Antitrust enforcement is more commonly handled by the U.S. Department of Justice and the Federal Trade Commission. But Becerra made it a priority as California’s top cop. In May 2018, he brought an antitrust case against nonprofit health care giant Sutter Health, accusing the system of monopolistic practices that drove up the cost of medical care in Northern California.

“This is a big ‘F’ deal,” Becerra said at a news conference unveiling the lawsuit. The case — which encompassed years of work by the department and his predecessors and millions of pages of documents — alleged that Sutter had aggressively bought up hospitals and physician practices across the region and illegally exploited that market power for profit. Health care costs in Northern California, where Sutter dominates with its 24 hospitals, are 20% to 30% higher than in Southern California, even after adjusting for Northern California’s higher cost of living, according to a 2018 study from the Nicholas C. Petris Center at the University of California-Berkeley that was cited in the complaint.

In December 2019, Sutter agreed to pay $575 million to settle the case and promised to end a host of practices that Becerra alleged stifled competition.

Becerra channeled lessons learned from the Sutter case into an antitrust bill in the California legislature. The legislation ultimately failed, but it would have given the attorney general power to review private equity- or hedge fund-led mergers or acquisitions of a health care system or hospital.

“The Sutter case is a blueprint for a national policy that could start to restore competition for the health care system and save American health care consumers billions of dollars right away,” said Glenn Melnick, a health care economist at the University of Southern California. He views Becerra as “a real expert in some of the most important issues facing our health care system, not just in California but nationally.”

If confirmed by the Senate, Becerra supporters say, he will bring to the job a political acumen from his two decades-plus on Capitol Hill that’s likely to be an asset for the Biden administration as it negotiates pandemic relief bills and other health legislation with a politically divided Congress.

Former California Democratic member of Congress Henry Waxman worked with nearly a dozen HHS secretaries during his time on the House Energy and Commerce Committee. He said he’s not worried that Becerra lacks experience leading a vast health care bureaucracy. The HHS secretary job, he said, is one “where you need political skills to see how far you can get with other people in a political context.” That’s why most HHS secretaries, Republicans and Democrats, have had political backgrounds.

Becerra “understands the policies and has a deep commitment to them,” he said. “I think he’ll do well.”

Public health officials say the job before Becerra is gigantic.

Dr. Gary Pace, the health officer in rural Lake County, California, said Becerra would be tasked with rebuilding a broken public health system.

“We want a federal partner who can give us good guidance — we haven’t had that,” Pace said. “For him, I’d say what we need first is starting to get the CDC back into a flagship public health role, with trusted and timely evidence-based guidance.”

Born in Sacramento to Mexican immigrant parents, Becerra would be the first Latino HHS secretary. He was elected to Congress in his 30s and has been involved in national health legislation during the past two decades, even though he is more widely known for his involvement in immigration and tax issues. He joined the powerful House Ways and Means Committee, which oversees tax and health legislation, in the 1990s. The committee played a central role in the drafting of what would become the Affordable Care Act in 2010.

While HHS oversees major federal health agencies, including the CDC, the Centers for Medicare & Medicaid Services, the Food and Drug Administration and the National Institutes of Health, it also has a wide-ranging human services portfolio, including oversight of child care and welfare programs, Head Start, programs for seniors and refugee resettlement.

“It’s not like any one person is going to have everything,” said Dan Mendelson, a former Clinton administration health official, who called Becerra an “inspired choice.” “I think that the most important point is that this is a leader of a team and not the be-all and end-all.”

KHN staff writers Rachel Bluth and Samantha Young contributed to this story.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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Xavier Becerra en sus propias palabras: “La atención de salud es un derecho”

El presidente electo Joe Biden nombró al fiscal general de California, Xavier Becerra, para dirigir el Departamento de Salud y Servicios Humanos (HHS) de los Estados Unidos. Becerra, quien sería el primer secretario latino del HHS, ha tomado algunas posiciones innovadoras en atención de salud, especialmente desde que se convirtió en fiscal general, en 2017.

Becerra ha demandado a la administración Trump docenas de veces por temas de atención médica, control de la natalidad, inmigración, cambio climático y más, con California liderando la defensa de la Ley de Cuidado de Salud a Bajo Precio (ACA) ante la Corte Suprema de Estados Unidos. Becerra también ganó un importante acuerdo legal contra Sutter Health, después de acusar al gigante de la atención de salud sin fines de lucro de usar su dominio del mercado en el norte de California para aumentar los precios de manera ilegal.

El año pasado, Becerra le dijo a KHN que sus puntos de vista han sido moldeados por su experiencia como hijo de inmigrantes mexicanos. Al describir el aborto espontáneo de su madre, dijo que todos deberían poder ir al médico: “Para mí, la atención médica es un derecho”, dijo. “He sido un defensor del pagador único toda mi vida”.

Aquí hay más de lo que le dijo a KHN sobre sus puntos de vista sobre la atención médica en los últimos años:

A principios del año pasado, Becerra le contó a Samantha Young, corresponsal política de California Healthline, sobre su experiencia como hijo de inmigrantes y cómo eso moldeó su carrera legal y política.

Hace dos años, Becerra participó del podcast “What a Health?”, que conduce Julie Rovner, corresponsal principal de KHN en Washington, en donde habló sobre su énfasis en la atención de salud como fiscal general.

El mes pasado, Becerra habló con Samantha Young sobre su defensa de la Ley de Cuidado de Salud a Bajo Precio (ACA) ante la Corte Suprema de los Estados Unidos.

Esta historia fue producida por KHN, que publica California Healthline, un servicio editorialmente independiente de la California Health Care Foundation.

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

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Xavier Becerra in His Own Words: ‘Health Care Is a Right’

President-elect Joe Biden has tapped California Attorney General Xavier Becerra to lead the U.S. Department of Health and Human Services. Becerra, who would be the nation’s first Latino HHS secretary, has taken some ground-breaking positions on health care, especially since he became attorney general in 2017.

He has sued the Trump administration dozens of times on health care, birth control, immigration, climate change and more, with California leading the defense of the Affordable Care Act before the U.S. Supreme Court. Becerra has also won a major legal settlement from Sutter Health after accusing the nonprofit health care giant of using its market dominance in Northern California to illegally drive up prices.

Becerra told KHN last year that his views have been shaped by his experience as the son of Mexican immigrants. Describing his mother’s miscarriage, he said that everyone should be able to go to the doctor: “For me, health care is a right,” he said. “I’ve been a single-payer advocate all my life.”

Here’s more of what he told KHN about his views on health care in the past few years:

Early last year, Becerra told Samantha Young, California Healthline’s state politics correspondent, about his experience as the child of immigrants, and how that shaped his legal and political career.

Becerra joined KHN chief Washington correspondent Julie Rovner on her “What the Health?” podcast two years ago about his emphasis on health care as attorney general.

Last month, Becerra spoke with Samantha Young about his defense of the Affordable Care Act before the U.S. Supreme Court.

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

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

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California Lawmakers to Newsom: Give All Immigrants Health Coverage

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SACRAMENTO — California Democratic lawmakers so far have failed to convince Gov. Gavin Newsom that the state can afford to spend an estimated $2.6 billion a year to expand its Medicaid program to all unauthorized immigrants.

Now, they’re trying a new strategy.

Rather than working independently, a fiercely liberal state senator from Los Angeles and a moderate Assembly member from the Central Valley are joining forces to pressure Newsom to make California the first state in the nation to cover every income-eligible resident regardless of immigration status. Unauthorized immigrants up to age 26 can already qualify for Medi-Cal, the state’s Medicaid program for low-income residents.

Emboldened by the win of Democratic President-elect Joe Biden and spurred by the urgency of the coronavirus pandemic, state Sen. María Elena Durazo (D-Los Angeles) and Assembly member Joaquin Arambula (D-Fresno) plan to introduce a two-bill package on Monday that would cover unauthorized senior immigrants first, and eventually the remainder of California’s undocumented immigrant population.

“It’s a national issue. Look at how all the national Democratic candidates raised their hands in front of the world to support covering undocumented immigrants in health insurance,” Durazo told California Healthline. “We want a clear commitment to finally do this, not just lip service.”

Newsom has long touted his goal of achieving universal health coverage in California and made campaign promises to work toward a single-payer health care system. But after nearly two years in office, Newsom’s ambitious health care agenda has been sidetracked by deadly wildfires and a widening homelessness crisis — as well as the COVID-19 pandemic — and he has not managed to dramatically expand coverage.

California currently covers about 200,000 unauthorized immigrant children and young adults, according to the state Department of Health Care Services. The state budgeted about $375 million to cover young adults ages 19 through 25 this fiscal year, but does not track spending for undocumented immigrant children, according to the state Department of Finance.

Opening the low-income health program to all eligible undocumented immigrants would expand coverage to at least 915,000 low-income residents and cost an additional $2.6 billion annually, according to a projection this year by the nonpartisan state Legislative Analyst’s Office. There are an estimated 1.5 million undocumented immigrant Californians who are uninsured, estimates show, but not all of them would qualify.

Public support for expanding coverage to unauthorized immigrants has risen over the past few years, according to the Public Policy Institute of California. But expending scarce taxpayer resources on such an effort is politically risky, said Doug Herman, a Los Angeles-based national Democratic strategist.

“Gavin’s got bigger priorities right now and he has been wounded, so he has to be very cautious about what he does,” Herman said. “Look at the French Laundry and [Employment Development Department] scandals. The homelessness crisis is raging and the prison outbreak happened on his watch. This doesn’t rise to that level.”

Newsom communications director Jesse Melgar said no one from his office was available for comment.

Since Newsom took office, Durazo and Arambula have authored separate bills to expand Medi-Cal to more undocumented immigrants. Durazo has gotten close after negotiating with Newsom — only for the first-term Democratic governor to back out, citing costs.

Such proposals have received widespread legislative support among Democratic lawmakers, who hold supermajority power in both houses of the state legislature.

A worsening economic outlook and long-term budget pressures could once again derail their efforts. Because the federal government prohibits states from using federal Medicaid dollars to cover undocumented immigrants — except for emergency services — California would have to pick up most of the price tag, which could top $3 billion annually to cover everyone, including children and adults, according to the Legislative Analyst’s Office.

Newsom will be forced to weigh an onslaught of budget demands while managing, and paying for, the ongoing COVID-19 emergency.

“That gives Newsom the ability to delay or oppose anything that doesn’t fit his agenda,” Herman said.

But some lawmakers, immigration rights activists and health care advocates argue the COVID pandemic has made their campaign more urgent as Latino and Black residents get sick and die at disproportionate rates.

Politicians cannot ignore that the pandemic has exposed a broken health care system that has left millions of taxpaying Californians without health coverage because their immigration status renders them ineligible, said Sarah Dar, director of health and public benefits for the California Immigrant Policy Center, which is already lobbying the governor to support the Medi-Cal expansion.

“Now we have a full picture of what this crisis is, and the blatant disparities faced by our essential workers, so there’s no excuse,” she said. “Immigrant communities and farmworkers in the food and agricultural sector, like meatpacking plants, have literally been hotbeds for the spread of disease.”

Dar acknowledged financial pressures ahead for the state, and said advocates will be pushing for ways to generate money to pay for the expansion, possibly including tax increases.

There could be some hope for a one-time cash infusion. Fiscal estimates show California could reap a $26 billion surplus next year, largely from personal income tax receipts from high-income earners who have not suffered devastating economic losses during the pandemic, according to state fiscal analysts. Durazo and Arambula are eyeing that revenue for the Medi-Cal expansion.

“He has routinely stated his vision, but we’d like Gov. Newsom to deliver on health care for all during his governorship,” Arambula said. “I’m not going to sit and wait.”

Durazo said she would introduce a bill Monday to expand Medi-Cal to unauthorized immigrant Californians age 65 and older. She put a similar bill on hold in 2019, in exchange for a commitment from Newsom to include the proposal in this year’s state budget.

Newsom included the proposal in the first version of his state budget in January, but then withdrew it, citing soaring unemployment, business closures and an economy decimated by the pandemic.

Durazo and other backers decided to craft a new approach: Alongside Durazo’s bill to cover older adults, Arambula plans to introduce companion legislation to cover all undocumented immigrant adults.

The lawmakers are using the two bills as a negotiating tactic. Arambula and advocates said they hope to win coverage for undocumented immigrants 65 and older next year, while developing a plan with Newsom to expand coverage to the entire population at some point during his governorship.

Durazo said both bills are equally important and are intentionally being used to pressure the governor into action next year.

“This is our way to finally have a real conversation about what it’ll take to get everyone covered, given we’ll have federal partners with the Biden-Harris administration,” said Orville Thomas, director of government affairs for the California Immigrant Policy Center.

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

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

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Last Call for COVID: To Avoid Bar Shutdowns, States Serve Up Curfews

As states and cities around the country enact curfews on bars and restaurants to limit the spread of COVID-19, many different calls are being made on “last call.”

In Massachusetts, eateries must stop serving at 9:30 p.m. New York, Ohio and an increasing number of states are setting 10 p.m. closing times for indoor dining, while in Oklahoma, bars and restaurants can keep the rounds going until the wee hour of 11 p.m. In Virginia, alcohol has to be off the tables at 10 p.m., but restaurants can stay open until midnight.

With coronavirus outbreaks being traced back to bars and restaurants, curfews are being embraced not just by governors but also by many restaurant and bar owners who see them as a more appetizing alternative to the total cessation of indoor dining.

“I do think things need to be a little bit tightened down,” said David Lopez, general manager of Manny’s Restaurant in Kansas City, Missouri, and incoming president of the city’s restaurant association. Mayor Quinton Lucas ordered a 10 p.m. curfew that took effect Friday.

“When you close at 10 p.m., you’re taking away a good portion of that time when people are standing with no mask on,” Lopez said. “Each hour that goes by and you’re standing in the same space, you make yourself more susceptible to contracting the virus.”

Along with anecdotal reports that as the evenings wear on, an older set of rule-abiding diners are replaced by younger, more defiant — and often more intoxicated — patrons, there has been some empirical evidence to justify the curfews. In Minnesota, public health authorities found that among people who tested positive for COVID-19 and had visited a restaurant, those who visited after 9 p.m. were twice as likely to be part of an outbreak cluster.

To some epidemiologists, establishing cutoff times ignores the fact that the coronavirus does not obey curfews. But they endorse any tool that helps slow the spread.

“It’s a half measure and maybe less than a half measure, but that’s better than no measure at all,” said Raymond Niaura, interim chair of the epidemiology department at the New York University School of Global Health.

From June 1 to Nov. 16, 190 outbreaks in Minnesota — involving 3,201 infected people — were traced back to restaurants and bars by public health authorities. That represented 46% of the outbreaks in public settings. Weddings came in second, with 107 outbreaks (14%), followed by sports (11%), gyms (11%), social gatherings (9%), churches (4%) and funerals (3%). In all, there were 4,145 unique cases from all these kinds of gatherings out of the 250,000 infections Minnesota has catalogued since the start of the pandemic.

The benefit of curfews may come not primarily from targeting the late-night revelers but by curtailing the number of patrons at restaurants and bars. “Their effect is to reduce the amount of time that will allow people to congregate,” said Stephen Kissler, a research fellow at the Harvard T.H. Chan School of Public Health.

In an interview with KHN, Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, expressed broad concern about inside dining given the aggressive COVID-19 spread. Fauci did not make any distinctions in the time of day.

“If we’re in the hot zone the way we are now, where there’s so many infections around, I would feel quite uncomfortable even being in a restaurant, particularly if it was at full capacity,” he said.

For those people who do go to bars and restaurants, curfews provide some added protection, Fauci said. “If you look at what happens as you get into the evening, people have a few drinks, they get a little bit more loose, they start taking masks off if they have masks on, they let down their guard,” he said.

The curfews and closures are frustrating to many restaurateurs and tavern owners who struggled through a round of shutdowns in the spring and have been enforcing mask and distancing rules and aggressively disinfecting their tables and bathrooms.

“We had no outbreaks in the time we’ve been open,” said Sean Kenyon, who owns three restaurants and bars in Denver. “We knew there would be a second wave, but we thought society would be more well equipped and well informed to deal with it.”

Kenyon said late-night bargoers are a problem only for establishments that don’t strictly enforce their rules, which he added takes effort given the blowback from patrons who don’t want to wear masks when they enter. When he has worked the door checking IDs, he said, “the vitriol we’ve had spewed at us for the past six months has been unbelievable.”

Restaurateurs argue that infections passed along through their establishments are eclipsed in number by transmissions taking place in gathering places. “In Minnesota, it is a small percentage coming from restaurants and bars if you look at the contact tracing,” said David Benowitz, chief operating officer at Craft & Crew, which has five locations in and around the Twin Cities.

Curfews are not the province of just the United States. In Canada, Saskatchewan restaurants and nightclubs were ordered to stop serving liquor at 10 p.m. as of Nov. 16. Italy ordered restaurants in regions with the heaviest coronavirus outbreaks to close at 6 p.m.

Troy Reding, who owns three restaurants in Minnesota, said merely the announcement of a curfew, made by the governor earlier in the month, put a damper on the number of customers coming to his restaurant at any hour. “When the curfew was announced, sales plummeted,” he said. “It became very real to them that going out and dining wasn’t the safest thing to do.”

In a reflection of how leaders are struggling to keep up with the coronavirus running amok, even before Minnesota’s restaurant and bar curfew could kick in, it was superseded by a complete ban on indoor dining and drinking at those establishments.

With curfews and closures, restaurants have reopened their playbooks from the spring for outdoor dining and takeout. Nonetheless, they will take an economic hit. Benowitz said he must furlough 140 people from his 200-person workforce.

“We’re constantly pivoting,” Benowitz said. “If you’re not able to change in this environment on a dime, then you’re not going to be able to succeed.”

KHN Editor-in-Chief Elisabeth Rosenthal contributed to this report.

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

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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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After a Deadly COVID Outbreak, Maryland County Takes Steps to Protect Health Workers


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

A Maryland health department is taking new steps to protect its workers six months after a COVID-19 outbreak killed a veteran employee who was twice denied permission to work from home.

Chantee Mack, 44, died in May. More than 20 colleagues also caught the coronavirus, and some are suffering lasting problems.

Now, after a KHN and Associated Press story in July spurred an investigation, Prince George’s County officials say they have added an appeals process to their work-at-home policy and hired a consultant to identify “operational and management needs for improvement” in the department. Union officials say the county has also made personal protective equipment, such as masks and gloves, more available in recent months and put a greater emphasis on social distancing.

“We’re getting somewhere,” said Rhonda Wallace, leader of a local branch of the American Federation of State, County and Municipal Employees. “But we’re not there yet.”

In an email to KHN, health department spokesperson George Lettis said officials can’t release results of the county investigation because of personnel and medical information. But a county official’s letter to Wallace shares the inquiry’s main conclusions: that the health department tried to get PPE in early March and advised employees about social distancing and proper hygiene via a newsletter.

“It must not be overlooked that this was a rapidly evolving situation,” said the letter from Dr. George Askew, deputy chief administrative officer for health, human services and education. “Best efforts were made to keep the community and Health Department employees safe and informed during this unprecedented time.” The letter does not acknowledge any lapses made by the county.

Some employees argue the investigation didn’t delve into the circumstances around Mack’s death and say the county should publicly acknowledge its role in what happened. At a news conference in July, County Executive Angela Alsobrooks said Mack’s death “deserves an investigation” and the county would “spare no time or expense.”

Mack, who worked in the department’s sexually transmitted diseases program, was denied permission to work from home in March even though she had health problems that put her at high risk for COVID-19 complications.

At least three other employees whose requests to work from home were denied around that time also got sick. Revonda Watts, a nurse and program manager, said she was allowed to work from home for one day before being called back to the office. Some of these employees worked face-to-face with the public at least part of the time.

A union document obtained by KHN detailed a conference call by department managers in which Diane Young, an associate director, laid out criteria for working from home, such as being 65 or older or having small children. She said decisions would be made case by case.

Meanwhile, protective masks, gowns and other safety equipment were in short supply nationally and at the health department, which distributed them only to certain workers. In early April, when Young asked Watts about PPE needs, Watts wrote in an email obtained by KHN: “N-95 masks are needed for all staff. We were given 1 mask to reuse. We have no face shields for the clinicians nor do we have gowns.”

Young responded that even though goggles were available, “face shields and gowns are in limited supply and will be used for those who are testing patients for COVID-19.”

Several employees described meetings and “morning huddles” in the office in March and April held without social distancing and during which few, if any, participants wore masks.

One employee after another got sick.

Watts, who is 58 and has asthma, developed bronchitis on top of COVID-19, then chest pain from spasms in her blood vessels. She spread the virus to her adult daughter.

Administrative aide Natania Bowen also spread the virus to her family, including her husband and 7-year-old daughter, who have since recovered. Bowen, a 47-year-old with asthma, experienced a bacterial lung infection along with COVID-19.

Receptionist Yolanda Potter, 53, had severe headaches for a month from her coronavirus infection. She developed a blood clot in her right leg and had to inject blood thinners into her stomach for 45 days to prevent it from breaking off and traveling to her lungs or brain. She and Carolyn Ferguson, an X-ray tech now on desk duty, suffer ongoing memory problems, while Bowen continues to have lung issues.

While Bowen now works from home, Watts, Potter and Ferguson are back at the office. As of mid-November, Lettis said, 141 health department employees were working fully on-site, 68 partly on-site and 196 at home.

Employees said they are pleased that social distancing is now the norm in the health department, that more places to sanitize hands exist and that PPE is easier to get. They’re also hopeful about the new policy on remote work.

The countywide rules include two levels of review for work-at-home requests: one by a supervisor and another by a higher-up boss who must give a reason if a worker’s request is denied. The employee can then ask the Office for Human Resource Management to review the denial.

Despite such measures, some employees still worry about contracting COVID-19 at work, especially as the state’s COVID dashboard puts the county’s cumulative caseload over 42,000.

Several employees are seeking long-term disability leave or talking to lawyers about getting workers’ compensation. Watts said she is awaiting a workers’ comp hearing and has asked again for permission to work from home as she deals with crushing fatigue and numbness in her legs and hands. Since returning to the office, she said, she has had to bring her own mask from home.

“I get frustrated with not being able to just bounce back,” she said. The health department officials “really let us down and didn’t do their due diligence to make sure the staff was protected.”

This story is a collaboration between The Associated Press 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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NYC Hospital Workers, Knowing How Bad It Can Get, Brace for COVID 2nd Wave

No single municipality in the country suffered more in the first wave of the pandemic than New York City, which saw more than 24,000 deaths, mainly in the spring. Medical staff in New York know precisely how difficult and dangerous overwhelmed hospitals can be and are braced warily as infections begin to rise again. 

Around the New York metropolitan area, public health leaders and health care workers say they’re watching the trend lines, as intensive care units fill up in other parts of the United States and around the world. They say it gives them flashbacks to last spring, when ambulance sirens were omnipresent and the region was the country’s coronavirus epicenter.

There is wide agreement that hospitals and care providers are in much better shape now than then, because there is much more knowledge about the disease and how to handle it; much larger stockpiles of personal protective equipment; and much, much more widespread testing.

But at the same time, many front-line workers are nervous about hospital preparedness, and many observers are less bullish about the effectiveness of the coronavirus testing and tracing infrastructure.

“I think there’s a lot of anxiety about doing this a second time,” said Dr. Laura Iavicoli, head of emergency preparedness for NYC Health + Hospitals, the country’s largest municipal hospital system. Iavicoli is also an active emergency room physician at Elmhurst Hospital, in Queens, which came to be called “the epicenter of the epicenter” back in April. Still, she has enormous confidence in the staff of the municipal hospital system.

“They will rally, because I know them,” she said. “I’ve worked with them for 20 years, and they’re the most amazing people I can possibly speak of, but there’s anxiety and there’s COVID fatigue.”

Iavicoli said some of the city’s hospitals are at capacity, but she hastened to add that she’s not talking about “COVID capacity” — meaning not all the beds and recently reconfigured spillover spaces for COVID patients are full. Rather, she said, two of the network’s 11 hospitals have had to transfer ICU patients to others to make room for incoming patients.

“We are doing a little bit of redistributing around the system to give them COVID capacity, but it’s very manageable within the system,” Iavicoli said. “The increase is definitely typical in flu season, but knowing that we have just entered upon the second wave [of COVID-19] and predicting what is to come, we’re a little even more cognizant than normal to make sure we leave capacity in all of our facilities.”

Many nurses, however, say hospital administrators have not learned enough from the experience in March and April.

“We’re scared because we’re afraid we’re going to have to go through this again,” said Michelle Gonzalez, a critical care nurse at Montefiore Medical Center, in the Bronx, and a union representative for NYSNA, the New York State Nurses Association.

She said that in her unit nurses typically handle one or two intensive care unit patients at a time — but now have to handle three, with the number of COVID patients creeping up once again. Tending to four patients or more was common at the peak of the pandemic surge. Gonzalez said that’s overwhelming. If one patient crashes, several nurses need to converge at once, leaving other patients unmonitored.   

“When we start to get triples with the frequency we’re seeing right now, we know it’s because we’re short-staffed, and they’re not getting ICU nurses into the building,” she said at a demonstration that featured a phalanx of nurses marching from Montefiore to a nearby cemetery, bearing floral wreaths for fallen comrades, while a band and bagpiper played “When the Saints Go Marching In” and “Amazing Grace.”

A spokesperson for the union said Montefiore, by its own reckoning, has 476 vacant nursing positions — a number that has climbed by nearly 100 since 2019.

“Management is not living up to their promise to fill vacancies and hire nurses,” said Kristi Barnes, from NYSNA. “As of last week, they have 188 full-time nursing jobs they have not even posted, so there is no way they can be filled.” 

The Montefiore administration disagrees.

“We have a contractual agreement with the union, and we meet the contractual obligations of that agreement,” said Peter Semczuk, senior vice president of operations. “We tailor our staffing in such a flexible way to meet the needs of the patient.”

Like many hospital systems, Montefiore relied heavily on temporary staffing agencies for “traveling nurses” from around the country earlier this year. Hospitals are preparing to do so again — but there is demand all over the country

“They got us travelers in April, but that was four or six weeks in, and until that we were on our own,” said Kathy Santoiemma, who’s been a nurse at Montefiore New Rochelle for 43 years. “I don’t even know where they’re going to get travelers now — everyone around the whole country needs travelers.”

NYSNA led a two-day strike at Montifiore New Rochelle on Tuesday, after contract negotiations in the works for two years stalled on Monday.

Iavicoli said each of her network’s facilities has submitted requests, so that NYC Health + Hospitals could place a preliminary order now.

Health planners are hoping New Yorkers won’t flood into emergency rooms this time. They point to the modest climb in COVID hospitalizations over the past two months compared with other areas, including New Jersey and Connecticut. One thing they hope will keep the curve relatively flat is testing, which is more pervasive in New York than almost anywhere else in the country. About 200,000 people across New York state are getting tested each day, roughly one-third of them in New York City.

“It’s the first step to actually interrupting further spread,” said Dr. Dave Chokshi, the city health commissioner.

He said mass testing works on two levels — by highlighting which areas are hot zones, so health workers can target residents with “hyper-local” messages about COVID-19 spread, to get them to change their behavior, and also by allowing contact tracers to communicate individually with newly infected people.

“Once someone tests positive, we very quickly help them isolate,” Chokshi said. “We do an interview with them to know who their close contacts are, and then we call those contacts and make sure they’re quarantining as well.”

However, the city’s contact-tracing program has had a mixed record. The people it reaches say they’re staying put — but fewer than half of them share names of people they might have exposed. Denis Nash, an epidemiologist who previously worked for the city’s Department of Health and Mental Hygiene and the Centers for Disease Control and Prevention, said the city hasn’t successfully drilled down into how the coronavirus actually spreads, because contact tracers aren’t asking people enough questions about their behaviors and possible exposures.

“During the summer and early fall, when things were slowly ramping up, there were missed opportunities to use contact tracing to talk to 80 or 90% of all newly diagnosed people, to understand what their risk factors were and what kinds of things … were they exposed to that could have potentially resulted in them getting the virus,” he said. “You can never know with 100% certainty [where they contracted the virus], but if you ask these questions, you could begin to understand what some likely patterns were — for example, of public transportation use, or working in office buildings that didn’t have rigorous safety protocols, or indoor dining.”

This knowledge, though imperfect, could lead to better informed public policy decisions, Nash said, about whether to close indoor restaurants, beauty salons or fitness centers. Without that data, leaders are just making guesses.

Others fault the city’s testing and tracing program for not reaching out enough to poor communities of color — which suffered disproportionately during the first COVID wave. Chokshi, the health commissioner, said getting testing sites to these neighborhoods has been a priority — but a recent analysis suggested it’s not working as well as the city intended.

“There’s clearly a disparity in providing widespread testing across New York City,” said Wil Lieberman-Cribbin, a graduate student and environmental health researcher at Columbia University.

He looked at how many people are getting tested, by neighborhood, and correlated those figures with race, income level and COVID positivity. In wealthier areas, people are getting many more tests and have much less illness. In poorer ones, people are getting many fewer tests and are much sicker. More testing in those areas would pick up cases sooner, before people develop symptoms.

“Testing is really, really needed, not only to protect the most vulnerable, but to collectively try and get a handle on COVID and reopen New York City,” Lieberman-Cribbin said.

Personal protective equipment, or PPE, is also much more ample than it was last spring but, similarly, remains a source of contention.

New York state health authorities are requiring hospitals to stockpile a 90-day supply of PPE; for nursing homes, it’s 60 days’ worth. Many facilities have complied with September and October deadlines, but others have not.

Montefiore, NYC Health + Hospitals, and other large hospital networks say they have at least that much, if not more.       

Nurses, though, say they should be able to get fresh N95 masks each time they see a new patient, to limit the risk of contamination. Many administrators counter that isn’t feasible, given the precariousness of the supply chain. They note that CDC guidelines permit “extended use” of some PPE.

“[Nurses and other caregivers] change their gloves between every patient, but they might wear the same N95 mask for one shift and put a surgical mask over it just to preserve it and only switch it out if there’s some integrity issue or it gets contaminated,” said Iavicoli, of the city hospital system. “But definitely at the next shift, they’re getting a new one.”

Iavicoli acknowledged the challenges as the pandemic rolls on and said there are four kinds of days: “blue skies, or normal,” “busier than normal,” “a little stretched” and “extremely stretched.” 

“I think we’re at the top end of ‘busy normal’ bordering on ‘a little more than overstretched,’” said Iavicoli.

This story is from a reporting partnership that includes WNYC, 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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As LA County Sets New Infection Record, State Leaders’ Behavior Sends Mixed Messages

California, like the rest of the nation, is seeing a dramatic rise in COVID infections and deaths — and Los Angeles County has some of the most dire statistics.

Health officials reported more than 7,500 new cases in the county on Tuesday, shattering the old record, set last week. Hospitalizations tripled in the past month, and on average 30 people are dying of COVID-19 in the county every day.

The most populous county in the country, Los Angeles leads all U.S. counties in raw numbers of both infections and deaths, according to statistics compiled by Johns Hopkins University.

On Monday, the county started a three-week stay-at-home order, and Gov. Gavin Newsom said a similar order for the whole state could prove necessary.

“If these trends continue, we’re going to have to take much more dramatic — arguably drastic — action,” Newsom said.

But even as the restrictions began in Los Angeles, leaders across California took heat for their do-as-I-say-not-as-I-do pandemic behavior.

Los Angeles County Supervisor Sheila Kuehl dined outdoors at a favorite restaurant shortly after she voted to ban outdoor dining, a local TV station reported.

San Jose Mayor Sam Liccardo apologized for spending Thanksgiving with eight people from five households in his extended family.

And the San Francisco Chronicle reported that San Francisco Mayor London Breed joined a party of seven to dine at the famed French Laundry restaurant the day after Newsom did, angering many.

The questionable behavior threatens to overshadow alarming news about pandemic trends. Tuesday, California reported 20,759 new cases, a few hundred less than the record number of the day before. The state is in its worst situation since the pandemic started. Yet despite the record case numbers, California is so populous that it’s far from the top of the list of states with the most new cases per capita. (That spot was held by Montana on Wednesday.)

Newsom said Monday that Southern California is forecast to run out of intensive care unit capacity by mid-December if trends continue. By Christmas Eve, ICU beds are forecast to be at 107% of capacity across the region. There’s no clear plan in place for what to do when hospital demand outstrips capacity.

All races and ethnicities are seeing increases in cases, but disparities are widening. In Los Angeles County, Hispanics’ infection rate is more than twice that of whites.

“Death rates among people in high rates of poverty are three times the death rate of people in more affluent areas,” county public health director Barbara Ferrer said Wednesday.

Health officials estimate that one in every 200 people in the county has the virus and is infectious.

The hope is that the new restrictions of the stay-at-home order in Los Angeles County will slow that spread.

The order is designed to keep people in their homes as much as possible. It prohibits gatherings with anyone outside of a household and reduces capacity at stores. K-12 schools will continue to operate but at 20% capacity. Outdoor areas like beaches, parks and trails will remain open, but people are not allowed to gather.

Officials say they are trying to find a sweet spot where they can keep people from gathering and spreading the virus, but still allow some stores to remain open. Thus far the rules are less stringent than those imposed in the spring, because businesses owners have pushed back hard against more restrictions. They are losing money and, unlike in the spring, have no federal aid to offset their losses.

This story is from a reporting partnership that includes KPCCNPR and KHN, an editorially an editorially independent program of KFF.

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

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During ACA Open Enrollment, Picking a Plan Invites New COVID Complications

People buying their own health insurance have even more to think about this year, particularly those post-COVID-19 patients with lingering health concerns, the “long haulers,” who join the club of Americans with preexisting conditions.

What type of plan is best for someone with an unpredictable, ongoing medical concern? That question is popping up on online chat sites dedicated to long haulers and among people reaching out for assistance in selecting insurance coverage.

“We are hearing from a lot of people who have had COVID and want to be able to deal with the long-term effects they are still suffering,” said Mark Van Arnam, director of the North Carolina Navigator Consortium, a group of organizations that offer free help to state residents enrolling in insurance.

The good news for those shopping for their own coverage is that the Affordable Care Act bars insurers from discriminating against people with medical conditions or charging them more than healthier policyholders. Former COVID patients could face a range of physical or mental effects, including lung damage, heart or neurological concerns, anxiety and depression. Although some of these issues will dissipate with time, others may turn out to be long-standing problems.

So sign up, said Van Arnam and others to whom KHN reached out for tips on what people with post-COVID-19 should consider when selecting coverage. There’s no one-size-fits-all answer, but they all emphasized the need to consider a wide range of factors.

But don’t delay. Open enrollment in ACA plans is ongoing until Dec. 15 in most states — longer in some of the 14 states and the District of Columbia that run their own marketplaces.

Here are tips if you are shopping for health insurance, especially if you are a COVID long hauler or have other health issues:

Make sure to select an ACA-qualified plan.

It may be tempting to consider other, often far less expensive types of coverage offered by insurers, brokers, organizations and private websites. But those non-ACA plans offer less comprehensive coverage — and are not eligible for federal subsidies to help people who qualify cover the cost of the premiums. These are key factors for patients experiencing medical problems after battling the coronavirus.

Short-term, limited-duration plans, for example, are cheaper, but the insurers offering them don’t have to accept people with preexisting conditions — or, if they do enroll those people, the plans don’t cover the members’ medical conditions. Many short-term plans don’t cover benefits such as prescription drugs or mental health care.

Another type of plan that doesn’t meet ACA requirements are “sharing ministries,” in which members agree to pay one another’s medical bills. But such payments aren’t guaranteed — and many don’t cover anything considered preexisting.

Shop around to consider all the ACA plans available in your region.

This will help you meet your post-COVID medical needs while also getting the best buy.

Comparison-shopping also lets consumers adjust their income information, which may have changed from last year, especially after being sick, and could affect subsidy levels for those eligible for assistance in purchasing a plan.

Under the ACA, subsidies to offset premium costs are available on a sliding scale for people who earn between 100% and 400% of the federal poverty level. That range next year is $12,760 to $51,040 for an individual and $26,200 to $104,800 for a family of four.

Networks matter. Look for your doctor or hospital in the plan.

One of the first things to do once you’ve narrowed down your choices of plans is to dig deeper to see if the doctors, specialists and hospitals you use are included in those plans’ networks. Also, check plan formularies to see if the prescription medications you take are covered.

Many insurance plans don’t have out-of-network benefits, except for emergency care. That means if a doctor or hospital doesn’t participate in the network, consumers must switch medical providers or risk huge bills by receiving out-of-network care. This should be a concern for long haulers.

This subset of COVID patients who report lingering health concerns may need to see a range of specialists, including pulmonologists, cardiologists, neurologists, rheumatologists and mental health professionals.

“So, you are already talking about five or six,” said Erika Sward, assistant vice president for national advocacy at the American Lung Association.

To check the network status of medical providers, go to the healthcare.gov website, which will direct you to your state site if you are in one of the 14 states or the District of Columbia, which run their own. Enter a ZIP code and some other information to start looking for available plans.

Narrow the search using the “add your medical providers” button on healthcare.gov, or access each plan’s “provider directory” under plan documents to see which specific doctors and hospitals are included. To be safe, Sward said, call each office to make sure they are participating with that insurer next year.

Don’t just look at premium costs: Deductibles also matter.

Consumers must pay deductible amounts before the bulk of financial assistance kicks in. That can be a big hit, especially for those who need complex care all at once or very expensive prescription drugs. Long haulers, as well as others with chronic health conditions, often fall into this category.

Median deductibles — the mark at which half cost more and half cost less — vary across the different “tiers” of ACA plans, hitting $6,992 for bronze plans; $4,879 for silver plans and $1,533 for gold plans, according to an analysis by the Centers for Medicare & Medicaid Services.

Generally, plans with higher deductibles have lower monthly premiums. But getting past the deductible is a challenge for many.

What’s best for those with ongoing health conditions depends on individual circumstances.

“Balancing the deductibles and premiums is a really important consideration for consumers,” said Laurie Whitsel, vice president of policy research and translation at the American Heart Association.

Those with ongoing health conditions need to carefully weigh the expected annual out-of-pocket costs for various health plans, given that they may well be moderate to high users of health services. Healthcare.gov has a financial estimator tool that can help with the decision. Consumers can select whether they think they will have low, medium or high medical use next year to see the estimated total annual costs of each plan.

Frequent users of health services may discover that plans that initially seem least expensive, based solely on the premium or the deductible, may be costlier once all out-of-pocket factors are considered.

Finally, insurers in some markets are touting zero-deductible plans.

Instead of an annual deductible, such policies have higher copayment or coinsurance amounts each time a patient sees a doctor, gets a test or has surgery. Those can range from $50 to more than $1,000, depending on the visit, test or service provided. Still, for some costly services, those payments may amount to less than paying a deductible.

Broker John Dodd in Columbus, Ohio, said such plans appeal to some people who don’t want to have to shell out thousands of dollars in deductible payments before their insurance picks up the bulk of medical costs.

Still, he cautioned that many of the zero-deductible plans do have what can be a sizable deductible — hundreds or even thousands of dollars — for brand-name prescription drugs.

Long haulers should weigh those factors carefully, as such zero-deductible plans may be more suited to those who don’t expect to use a lot of medical care.

Read the fine print, because there are other costs.

While plans may tout similar premiums, their dissimilar structures could affect how much a consumer will shell out in flat-dollar copayments or percentage coinsurance to see a doctor, pick up a prescription, get a blood test or spend the night in the hospital. This is, again, something long haulers should focus on.

These details are spelled out in the plan’s “summary of benefits,” a required document under the ACA, which can be found on healthcare.gov or insurers’ websites.

Still, ACA plans limit how much a consumer must pay out-of-pocket for the year. Next year, the maximum is $8,550 for an individual or $17,100 for a family plan.

Ask for help.

While services such as Van Arman’s navigator program have seen stiff budget cuts during the past few years, consumers there and in many states still have access to online or phone help. Healthcare.gov has a “find local help” button that can refer people by ZIP code to navigators, assisters and brokers.

Finally, those affected by COVID who miss the open enrollment deadline can request an extension under rules that allow special enrollment for emergencies or disasters.

“It’s not a guarantee and you have to telephone the call center and ask for it,” said Karen Pollitz, a senior fellow at KFF.

Still, she said, it’s best to sign up before Dec. 15.

“Just get it done,” Pollitz 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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Con récord de internaciones por COVID, la crisis ahora es la falta de personal médico

Los hospitales en gran parte del país están tratando de hacer frente a un número sin precedentes de pacientes con COVID-19.

El lunes 30 de noviembre hubo 96,039 internaciones a lo largo del país, un récord alarmante que supera con creces los dos picos anteriores en abril y julio de poco menos de 60,000 pacientes hospitalizados.

Pero las camas y el espacio no son la principal preocupación. Es la fuerza laboral. A los hospitales les preocupa que los niveles de personal no puedan satisfacer la demanda, ya que los médicos, enfermeras y especialistas, como los terapeutas respiratorios, se agotan o, peor aún, se infectan y enferman.

La solución típica para la escasez de personal (contratar médicos de afuera) ya no es la solución, a pesar de que ayudó a aliviar la tensión al principio de la pandemia, cuando el primer aumento de casos se concentró en un puñado de “puntos calientes” como Nueva York, Detroit, Seattle y Nueva Orleans.

Reclutar esos refuerzos temporales también fue más fácil en la primavera porque los hospitales fuera de esas primeras ciudades afectadas estaban atendiendo a menos pacientes de lo normal, lo que llevó a despidos masivos.

Eso hizo que muchas enfermeras cesantes no dudaran en viajar a otra ciudad y ayudar en otro frente de batalla.

En muchos casos, los hospitales compitieron por las enfermeras itinerantes y las tasas de pago de las enfermeras temporales se dispararon. En abril, el Centro Médico de la Universidad de Vanderbilt en Nashville, Tennessee, tuvo que aumentar el salario de algunas enfermeras del personal, que ganaban menos que las temporales recién llegadas.

En la primavera, estas enfermeras que viajaron a las “zonas calientes” no solo recibieron mejores salarios. Muchas contaron lo gratificante que fue salvar vidas en una pandemia histórica, estar cerca de pacientes que morían lejos de su familia.

“Era realmente una zona caliente, no nos sacábamos el equipo de protección y todos los que ingresaban eran COVID positivos”, contó Laura Williams, de Knoxville, Tennessee, quien ayudó a inaugurar el Ryan Larkin Field Hospital en la ciudad de Nueva York.

“Trabajaba seis o siete días a la semana, pero me sentí muy realizada”.

Después de dos meses agotadores, Williams regresó en junio a su trabajo de enfermería en el Centro Médico de la Universidad de Tennessee. Durante un tiempo, el frente de COVID se mantuvo relativamente tranquilo en Knoxville.

Pero luego golpeó la segunda ola. Y ha habido hospitalizaciones récord en Tennessee casi todos los días: aumentaron un 60% en el último mes.

Los funcionarios de salud informan que es mucho más difícil encontrar médicos suplentes.

Tennessee ha construido sus propios hospitales de campaña para manejar el desborde de pacientes: uno se encuentra dentro de las antiguas oficinas del periódico Commercial Appeal en Memphis y otro ocupa dos pisos sin usar en el Nashville General Hospital.

Pero si fueran necesarios en este momento, el estado tendría problemas para encontrar médicos y enfermeras para administrarlos porque los hospitales ya están luchando para cubrir las camas que tienen.

“La capacidad hospitalaria depende casi exclusivamente de la dotación de personal”, explicó la doctora Lisa Piercey, quien dirige el Departamento de Salud de Tennessee. “Las camas no son el problema”.

Cuando se trata de dotación de personal, el coronavirus crea un desafío extremo.

A medida que el número de casos alcanza nuevos picos, un número récord de empleados del hospital tienen COVID-19 o se ven obligados a dejar de trabajar porque tienen que ponerse en cuarentena después de una posible exposición.

“Pero aquí está la trampa”, dijo el doctor Alex Jahangir, que preside el grupo de trabajo sobre el coronavirus de Nashville. “No se infectan en los hospitales. De hecho, los hospitales en su mayor parte son bastante seguros. Se están infectando en la comunidad”.

Algunos estados, como Dakota del Norte, ya han decidido permitir que las enfermeras con COVID positivo sigan trabajando mientras se sientan bien, una medida que ha generado una reacción violenta.

La escasez de enfermeras es tan aguda que algunos puestos de enfermeras itinerantes pagan un salario de $8,000 a la semana. A algunas enfermeras y médicos jubilados se les pidió que consideraran regresar a la fuerza laboral al comienzo de la pandemia, y al menos 338 de 65 años o más murieron de COVID-19.

En Tennessee, el gobernador Bill Lee emitió una orden de emergencia que flexibiliza algunas restricciones regulatorias sobre quién puede hacer qué dentro de un hospital, dándoles más flexibilidad al personal.

La doctora Jessica Rosen es médica de emergencias en St. Thomas Health en Nashville, donde tener que derivar pacientes a otros hospitales era algo raro. Dijo que ahora es algo común.

“Tratamos de enviar ambulancias a otros hospitales porque no tenemos camas disponibles”, expresó.

Incluso los hospitales más grandes de la región se están llenando. La primera semana de diciembre, el Centro Médico de la Universidad de Vanderbilt abrió espacio en su hospital infantil para pacientes que no tenían COVID. Su hospital de adultos tiene más de 700 camas. Y como muchos otros hospitales, ha enfrentado el desafío de dotar de personal a dos unidades de cuidados intensivos, una exclusivamente para pacientes con COVID y otra para todos los demás.

Y los pacientes vienen de lugares tan lejanos como Arkansas y el suroeste de Virginia.

“La gran mayoría de nuestros pacientes que ahora están en la unidad de cuidados intensivos no ingresan a través de nuestro departamento de emergencias”, dijo el doctor Matthew Semler, neumonólogo en VUMC que trabaja con pacientes con COVID.

“Los transfieren a este centro, que está a horas de distancia, porque no hay capacidad en ningún otro”.

Semler dijo que su hospital normalmente traía enfermeras de fuera de la ciudad para ayudar. Pero ya no hay.

Los grupos de proveedores nacionales todavía están enviando personal, aunque cada vez más significa dejar a otro lugar con menos trabajadores. El doctor James Johnson, de la empresa de servicios médicos Envision, con sede en Nashville, ha desplegado refuerzos en Lubbock y El Paso, Texas.

Con esta crisis, la limitación no serán los ventiladores o el equipo de protección, dijo. En la mayoría de los casos, será la fuerza laboral médica. El poder de la gente.

Johnson, veterano de la Fuerza Aérea que trató a soldados heridos en Afganistán, dijo que está más concentrado que nunca en tratar de levantar la moral de los médicos y evitar el agotamiento. En general, es optimista, especialmente después de servir cuatro semanas en la ciudad de Nueva York al comienzo de la pandemia.

“Lo que experimentamos en Nueva York, y desde entonces, muestra que la humanidad está a la altura de las circunstancias”, dijo.

Pero Johnson agregó que los sacrificios no deberían provenir solo de los trabajadores de salud. Todos son responsables de tratar de evitar que los demás, y ellos mismos, se enfermen en primer lugar, dijo.

Esta historia es parte de una colaboración que incluye Nashville Public Radio, NPR y 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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As Hospitals Fill With COVID Patients, Medical Reinforcements Are Hard to Find

Hospitals in much of the country are trying to cope with unprecedented numbers of COVID-19 patients. As of Monday, 96,039 were hospitalized, an alarming record that far exceeds the two previous peaks in April and July of just under 60,000 inpatients.

But beds and space aren’t the main concern. It’s the workforce. Hospitals are worried staffing levels won’t be able to keep up with demand as doctors, nurses and specialists such as respiratory therapists become exhausted or, worse, infected and sick themselves.

The typical workaround for staffing shortages — hiring clinicians from out of town — isn’t the solution anymore, even though it helped ease the strain early in the pandemic, when the first surge of cases was concentrated in a handful of “hot spot” cities such as New York, Detroit, Seattle and New Orleans.

Recruiting those temporary reinforcements was also easier in the spring because hospitals outside of the initial hot spots were seeing fewer patients than normal, which led to mass layoffs. That meant many nurses were able — and excited — to catch a flight to another city and help with treatment on the front lines.

In many cases, hospitals competed for traveling nurses, and the payment rates for temporary nurses spiked. In April, Vanderbilt University Medical Center in Nashville, Tennessee, had to increase the pay of some staff nurses, who were making less than newly arrived temporary nurses.

In the spring, nurses who answered the call from beleaguered “hot spot” hospitals weren’t merely able to command higher pay. Some also spoke about how meaningful and gratifying the work felt, trying to save lives in a historic pandemic, or the importance of being present for family members who could not visit loved ones who were sick or dying.

“It was really a hot zone, and we were always in full PPE and everyone who was admitted was COVID-positive,” said Laura Williams of Knoxville, Tennessee, who helped launch the Ryan Larkin Field Hospital in New York City.

“I was working six or seven days a week, but I felt very invigorated.”

After two taxing months, Williams returned in June to her nursing job at the University of Tennessee Medical Center. For a while, the COVID front remained relatively quiet in Knoxville. Then the fall surge hit. There have been record hospitalizations in Tennessee nearly every day, increasing by 60% in the past month.

Health officials report that backup clinicians are becoming much harder to find.

Tennessee has built its own field hospitals to handle patient overflows — one is inside the old Commercial Appeal newspaper offices in Memphis, and another occupies two unused floors in Nashville General Hospital. But if they were needed right now, the state would have trouble finding the doctors and nurses to run them because hospitals are already struggling to staff the beds they have.

“Hospital capacity is almost exclusively about staffing,” said Dr. Lisa Piercey, who heads the Tennessee Department of Health. “Physical space, physical beds, not the issue.”

When it comes to staffing, the coronavirus creates a compounding challenge.

As patient caseloads reach new highs, record numbers of hospital employees are themselves out sick with COVID-19 or temporarily forced to stop working because they have to quarantine after a possible exposure.

“But here’s the kicker,” said Dr. Alex Jahangir, who chairs Nashville’s coronavirus task force. “They’re not getting infected in the hospitals. In fact, hospitals for the most part are fairly safe. They’re getting infected in the community.”

Some states, like North Dakota, have already decided to allow COVID-positive nurses to keep working as long as they feel OK, a move that has generated backlash. The nursing shortage is so acute there that some traveling nurse positions posted pay of $8,000 a week. Some retired nurses and doctors were asked to consider returning to the workforce early in the pandemic, and at least 338 who were 65 or older have died of COVID-19.

In Tennessee, Gov. Bill Lee issued an emergency order loosening some regulatory restrictions on who can do what within a hospital, giving them more staffing flexibility.

For months, staffing in much of the country had been a concern behind the scenes. But it’s becoming palpable to any patient.

Dr. Jessica Rosen is an emergency physician at St. Thomas Health in Nashville, where having to divert patients to other hospitals has been rare over the past decade. She said it’s a common occurrence now.

“We have been frequently on diversion, meaning we don’t take transfers from other hospitals,” she said. “We try to send ambulances to other hospitals because we have no beds available.”

Even the region’s largest hospitals are filling up. This week, Vanderbilt University Medical Center made space in its children’s hospital for non-COVID patients. Its adult hospital has more than 700 beds. And like many other hospitals, it has had the challenge of staffing two intensive care units — one exclusively for COVID patients and another for everyone else.

And patients are coming from as far away as Arkansas and southwestern Virginia.

“The vast majority of our patients now in the intensive care unit are not coming in through our emergency department,” said Dr. Matthew Semler, a pulmonary specialist at VUMC who works with COVID patients.

“They’re being sent hours away to be at our hospital because all of the hospitals between here and where they present to the emergency department are on diversion.”

Semler said his hospital would typically bring in nurses from out of town to help. But there is nowhere to pull them from right now.

National provider groups are still moving personnel around, though increasingly it means leaving somewhere else short-staffed. Dr. James Johnson with the Nashville-based physician services company Envision has deployed reinforcements to Lubbock and El Paso, Texas, this month.

He said the country hasn’t hit it yet, but there’s a limit to hospital capacity.

“I honestly don’t know where that limit is,” he said.

At this point, the limitation won’t be ventilators or protective gear, he said. In most cases, it will be the medical workforce. People power.

Johnson, an Air Force veteran who treated wounded soldiers in Afghanistan, said he’s more focused than ever on trying to boost doctors’ morale and stave off burnout. He’s generally optimistic, especially after serving four weeks in New York City early in the pandemic.

“What we experienced in New York and happened in every episode since is that humanity rises to the occasion,” he said.

But Johnson said the sacrifices shouldn’t come just from the country’s health care workers. Everyone bears a responsibility, he said, to try to keep themselves and others from getting sick in the first place.

This story is from a reporting partnership that includes Nashville Public Radio, 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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OSHA Let Employers Decide Whether to Report Health Care Worker Deaths. Many Didn’t.

As Walter Veal cared for residents at the Ludeman Developmental Center in suburban Chicago, he saw the potential future of his grandson, who has autism.


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

So he took it on himself not just to bathe and feed the residents, which was part of the job, but also to cut their hair, run to the store to buy their favorite body wash and barbecue for them on holidays.

“They were his second family,” said his wife, Carlene Veal.

Even after COVID-19 struck in mid-March and cases began spreading through the government-run facility, which serves nearly 350 adults with developmental disabilities, Walter was determined to go to work, Carlene said.

Staff members were struggling to acquire masks and other personal protective equipment at the time, many asking family members for donations and wearing rain ponchos sent by professional baseball teams.

All Walter had was a pair of gloves, Carlene said.

By mid-May, rumors of some sick residents and staffers had turned into 274 confirmed positive COVID tests, according to the Illinois Department of Human Services COVID tracking site. On May 16, Walter, 53, died of the virus. Three of his colleagues had already passed, according to interviews with Ludeman workers, the deceased employees’ families and union officials.

State and federal laws say facilities like Ludeman are required to alert Occupational Safety and Health Administration officials about work-related employee deaths within eight hours. But facility officials did not deem the first staff death on April 13 work-related, so they did not report it. They made the same decision about the second and third deaths. And Walter’s.

It’s a pattern that’s emerged across the nation, according to a KHN review of hundreds of worker deaths detailed by family members, colleagues and local, state and federal records.

Workplace safety regulators have taken a lenient stance toward employers during the pandemic, giving them broad discretion to decide internally whether to report worker deaths. As a result, scores of deaths were not reported to occupational safety officials from the earliest days of the pandemic through late October.

KHN examined more than 240 deaths of health care workers profiled for the Lost on the Frontline project and found that employers did not report more than one-third of them to a state or federal OSHA office, many based on internal decisions that the deaths were not work-related — conclusions that were not independently reviewed.

Work-safety advocates say OSHA investigations into staff deaths can help officials pinpoint problems before they endanger other employees as well as patients or residents. Yet, throughout the pandemic, health care staff deaths have steadily climbed. Thorough reviews could have also prompted the Department of Labor, which oversees OSHA, to urge the White House to address chronic protective gear shortages or sharpen guidance to help keep workers safe.

Since no public agency releases the names of health care workers who die of COVID-19, a team of reporters building the Lost on the Frontline database has scoured local news stories, GoFundMe campaigns, and obituary and social media sites to identify nearly 1,400 possible cases. More than 260 fatalities have been vetted with families, employers and public records.

For this investigation, journalists examined worker deaths at more than 100 health care facilities where OSHA records showed no fatality investigation was underway.

At Ludeman, the circumstances surrounding the April 13 worker death might have shed light on the hazards facing Veal. But no state work safety officials showed up to inspect — because the Department of Human Services, which operates Ludeman and employs the staff, said it did not report any of the four deaths there to Illinois OSHA.

The department said “it could not determine the employees contracted COVID-19 at the workplace” — despite its being the site of one of the largest U.S. outbreaks. Since Veal’s death in May, dozens more workers have tested positive for COVID-19, according to DHS’ COVID tracking site.

OSHA inspectors monitor local news media and sometimes will open investigations even without an employer’s fatality report. Through Nov. 5, federal OSHA offices issued 63 citations to facilities for failing to report a death. And when inspectors do show up, they often force improvements — requiring more protective equipment for workers and better training on how to use it, files reviewed by KHN show.

Still, many deaths receive little or no scrutiny from work-safety authorities. In California, public health officials have documented about 200 health care worker deaths. Yet the state’s OSHA office received only 75 fatality reports at health care facilities through Oct. 26, Cal/OSHA records show.

Nursing homes, which are under strict Medicare requirements, reported more than 1,000 staff deaths through mid-October, but only about 350 deaths of long-term care facility workers appear to have been reported to OSHA, agency records show.

Workers whose deaths went unreported include some who took painstaking precautions to avoid getting sick and passing the virus to family members: One California lab technician stayed in a hotel during the workweek. An Arizona nursing home worker wore a mask for family movie nights. A Nevada nurse told his brother he didn’t have adequate PPE. Nevada OSHA confirmed to KHN that his death was not reported to the agency and that officials would investigate.

KHN asked health care employers why they chose not to report fatalities. Some cited the lack of proof that a worker was exposed on-site, even in workplaces that reported a COVID outbreak. Others cited privacy concerns and gave no explanation. Still others ignored requests for comment or simply said they had followed government policies.

“It is so disrespectful of the agencies and the employers to shunt these cases aside and not do everything possible to investigate the exposures,” said Peg Seminario, a retired union health and safety director who co-authored a study on OSHA oversight with scholars from Harvard’s T.H. Chan School of Public Health.

A Department of Labor spokesperson said in a statement that an employer must report a fatality within eight hours of knowing the employee died and after determining the cause of death was a work-related case of COVID-19.

The department said employers also are bound to report a COVID death if it comes within 30 days of a workplace incident — meaning exposure to COVID-19.

Yet pinpointing exposure to an invisible virus can be difficult, with high rates of pre-symptomatic and asymptomatic transmission and spread of the virus just as prevalent inside a hospital COVID unit as out.

Those challenges, plus May guidance from OSHA, gave employers latitude to decide behind closed doors whether to report a case. So it’s no surprise that cases are going unreported, said Eric Frumin, who has testified to Congress on worker safety and is health and safety director for Change to Win, a partnership of seven unions.

“Why would an employer report unless they feel for some reason they’re socially responsible?” Frumin said. “Nobody’s holding them to account.”

Downside of Discretion

OSHA’s guidance to employers offered pointers on how to decide whether a COVID death is work-related. It would be if a cluster of infections arose at one site where employees work closely together “and there is no alternative explanation.” If a worker had close contact with someone outside of work infected with the virus, it might not have been work-related, the guidance says.

Ultimately, the memo says, if an employer can’t determine that a worker “more likely than not” got sick on the job, “the employer does not need to record that.”

In mid-March, the union that represented Paul Odighizuwa, a food service worker at Oregon Health & Science University, raised concerns with university management about the virus possibly spreading through the Food and Nutrition Services Department.

Workers there — those taking meal orders, preparing food, picking up trays for patient rooms and washing dishes — were unable to keep their distance from one another, said Michael Stewart, vice president of the American Federation of State, County and Municipal Employees Local 328, which represents about 7,000 workers at OHSU. Stewart said the union warned administrators they were endangering people’s lives.

Soon the virus tore through the department, Stewart said. At least 11 workers in food service got the virus, the union said. Odighizuwa, 61, a pillar of the local Nigerian community, died on May 12.

OHSU did not report the death to the state’s OSHA and defended the decision, saying it “was determined not to be work-related,” according to a statement from Tamara Hargens-Bradley, OHSU’s interim senior director of strategic communications.

She said the determination was made “[b]ased on the information gathered by OHSU’s Occupational Health team,” but she declined to provide details, citing privacy issues.

Stewart blasted OHSU’s response. When there’s an outbreak in a department, he said, it should be presumed that’s where a worker caught the virus.

“We have to do better going forward,” Stewart said. “We have to learn from this.” Without an investigation from an outside regulator like OSHA, he doubts that will happen.

Stacy Daugherty heard that Oasis Pavilion Nursing and Rehabilitation Center in Casa Grande, Arizona, was taking strict precautions as COVID-19 surged in the facility and in Pinal County, almost halfway between Phoenix and Tucson.

Her father, a certified nursing assistant there, was also extra cautious: He believed that if he got the virus, “he wouldn’t make it,” Daugherty said.

Mark Daugherty, a father of five, confided in his youngest son when he fell ill in May that he believed he contracted the coronavirus at work, his daughter said in a message to KHN.

Early in June, the facility filed its first public report on COVID cases to Medicare authorities: Twenty-three residents and eight staff members had fallen ill. It was one of the largest outbreaks in the state. (Medicare requires nursing homes to report staff deaths each week in a process unrelated to OSHA.)

By then, Daugherty, 60, was fighting for his life, his absence felt by the residents who enjoyed his banjo, accordion and piano performances. But the country’s occupational safety watchdog wasn’t called in to figure out whether Daugherty, who died June 19, was exposed to the virus at work. His employer did not report his death to OSHA.

“We don’t know where Mark might have contracted COVID 19 from, since the virus was widespread throughout the community at that time. Therefore there was no need to report to OSHA or any other regulatory agencies,” Oasis Pavilion’s administrator, Kenneth Opara, wrote in an email to KHN.

Since then, 15 additional staffers have tested positive and the facility suspects a dozen more have had the virus, according to Medicare records.

Gaps in the Law

If Oasis Pavilion needed another reason not to report Daugherty’s death, it might have had one. OSHA requires notice of a death only within 30 days of a work-related incident. Daugherty, like many others, clung to life for weeks before he died.

That is one loophole — among others — in work-safety laws that experts say could use a second look in the time of COVID-19.

In addition, federal OSHA rules don’t apply to about 8 million public employees. Only government workers in states with their own state OSHA agency are covered. In other words, in about half the country if a government employee dies on the job — such as a nurse at a public hospital in Florida, or a paramedic at a fire department in Texas — there’s no requirement to report it and no one to look into it.

So there was little chance anyone from OSHA would investigate the deaths of two health workers early this year at Central State Hospital in Georgia — a state-run psychiatric facility in a state without its own worker-safety agency.

On March 24, a manager at the facility had warned staff they “must not wear articles of clothing, including Personal Protective Equipment” that violate the dress code, according to an email KHN obtained through a public records request.

Three days later, what had started as a low-grade illness for Mark DeLong, a licensed practical nurse at the facility, got serious. His cough was so severe late on March 27 that he called 911 — and handed the phone to his wife, Jan, because he could barely speak, she said.

She went to visit him in the hospital the next day, fully expecting a pleasant visit with her karaoke partner. “By the time I got there it was too late,” she said. DeLong, 53 “had passed.”

She learned after his death that he’d had COVID-19.

Back at the hospital, workers had been frustrated with the early directive that employees should not wear their own PPE.

Bruce Davis had asked his supervisors if he could wear his own mask but was told no because it wasn’t part of the approved uniform, according to his wife, Gwendolyn Davis. “He told me ‘They don’t care,’” she said.

Two days after DeLong’s death, the directive was walked back and employees and contractors were informed they could “continue and are authorized to wear Personal Protective Gear,” according to a March 30 email from administrators. But Davis, a Pentecostal pastor and nursing assistant supervisor, was already sick. Davis worked at the hospital for 27 years and saw little distinction between the love he preached at the altar and his service to the patients he bathed, fed and cared for, his wife said.

Sick with the virus, Davis died April 11.

At the time, 24 of Central State’s staffers had tested positive, according to the Georgia Department of Behavioral Health and Developmental Disabilities, which runs the facility. To date, nearly 100 staffers and 33 patients at Central State have gotten the virus, according to figures from the state agency.

“I don’t think they knew what was going on either,” Jan DeLong said. “Somebody needs to check into it.”

In response to questions from KHN, a spokesperson for the department provided a prepared statement: “There was never a ban on commercially available personal protective equipment, even if the situation did not call for its use according to guidelines issued by the Centers for Disease Control and Prevention and the Georgia Department of Public Health at the time.”

KHN reviewed more than a dozen other health worker deaths at state or local government workplaces in states like Texas, Florida and Missouri that went unreported to OSHA for the same reason — the facilities were run by government agencies in a state without its own worker safety agency.

Inside Ludeman

In mid-March, staff members at the Ludeman Developmental Center were desperate for PPE. The facility was running low on everything from gloves and gowns to hand sanitizer, according to interviews with current and former workers, families of deceased workers, and union officials.

Due to a national shortage at the time, surgical masks went only to staffers working with known positive cases, said Anne Irving, regional director for AFSCME Council 31, the union that represents Ludeman employees.

Residents in the Village of Park Forest, Illinois, where the facility is located, tried to help by sewing masks or pivoting their businesses to produce face shields and hand sanitizer, said Mayor Jonathan Vanderbilt. But providing enough supplies for more than 900 Ludeman employees proved difficult.

Michelle Abernathy, 52, a newly appointed unit director, bought her own gloves at Costco. In late March, a resident on Abernathy’s unit showed symptoms, said Torrence Jones, her fiancé who also works at the facility. Then Abernathy developed a fever.

When she died on April 13 — the first known Ludeman staff member lost to the pandemic — the Illinois Department of Human Services, which runs Ludeman, made no report to safety regulators. After seeing media reports, Illinois OSHA sent the agency questions about Abernathy’s daily duties and working conditions. Based on DHS’ responses and subsequent phone calls, state OSHA officials determined Abernathy’s death was “not work-related.”

Barbara Abernathy, Michelle’s mom, doesn’t buy it. “Michelle was basically a hermit,” she said, going only from work to home. She couldn’t have gotten the virus anywhere else, she said. In response to OSHA’s inquiry for evidence that the exposure was not related to her workplace, her employer wrote “N/A,” according to documents reviewed by KHN.

Two weeks after Abernathy’s passing, two more employees died: Cephus Lee, 59, and Jose Veloz III, 52. Both worked in support services, boxing food and delivering it to the 40 buildings on campus. Their deaths were not reported to Illinois OSHA.

Veloz was meticulous at home, having groceries delivered and wiping down each item before bringing it inside, said his son, Joseph Ricketts.

But work was another story. Maintaining social distance in the food prep area was difficult, and there was little information on who had been infected or exposed to the virus, according to his son.

“No matter what my dad did, he was screwed,” Ricketts said. Adding, he thought Ludeman did not do what it should have done to protect his dad on the job.

A March 27 complaint to Illinois OSHA said it took a week for staff to be notified about multiple employees who tested positive, according to documents obtained by the Documenting COVID-19 project at the Brown Institute for Media Innovation and shared with KHN. An early April complaint was more frank: “Lives are endangered,” it said.

That’s how Rose Banks felt when managers insisted she go to work, even though she was sick and awaiting a test result, she said. Her husband, also a Ludeman employee, had already tested positive a week earlier.

Banks said she was angry about coming in sick, worried she might infect co-workers and residents. After spending a full day at the facility, she said, she came home to a phone call saying her test was positive. She’s currently on medical leave.

With some Ludeman staff assigned to different homes each shift, the virus quickly traveled across campus. By mid-May, 76 staff and 198 residents had tested positive, according to DHS’ COVID tracking site.

Carlene Veal said her husband, Walter, was tested at the facility in late April. But by the time he got the results weeks later, she said, he was already dying.

Carlene can still picture the last time she saw Walter, her high school sweetheart and a man she called her “superhero” for 35 years of marriage and raising four kids together. He was lying on a gurney in their driveway with an oxygen mask on his face, she said. He pulled the mask down to say “I love you” one last time before the ambulance pulled away.

The Illinois Department of Human Services said that, since the beginning of the pandemic, it has implemented many new protocols to mitigate the outbreak at Ludeman, working as quickly as possible based on what was known about the virus at the time. It has created an emergency staffing plan, identified negative-airflow spaces to isolate sick individuals and made “extensive efforts” to procure more PPE, and it is testing all staffers and residents regularly.

“We were deeply saddened to lose four colleagues who worked at Ludeman Developmental Center and succumbed to the virus,” the agency said in a statement. “We are committed to complying with and following all health and safety guidelines for COVID-19.”

The number of new cases at Ludeman has remained low for several months now, according to DHS’ COVID tracking site.

But that does little to console the families of those who have died.

When a Ludeman supervisor called Barbara Abernathy in June to express condolences and ask if there was anything they could do, Abernathy didn’t know how to respond.

“There was nothing they could do for me now,” she said. “They hadn’t done what they needed to do before.”

Shoshana Dubnow, Anna Sirianni, Melissa Bailey and Hannah Foote contributed to this report.

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

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Thousands of Doctors’ Offices Buckle Under Financial Stress of COVID

Cormay Caine misses a full day of work and drives more than 130 miles round trip to take five of her children to their pediatrician. The Sartell, Minnesota, clinic where their doctor used to work closed in August.

Caine is one of several parents who followed Dr. Heather Decker to her new location on the outskirts of Minneapolis, an hour and a half away. Many couldn’t get appointments for months with swamped nearby doctors.

“I was kind of devastated that she was leaving because I don’t like switching providers, and my kids were used to her. She’s just an awesome doctor,” said Caine, a postal worker who recently piled the kids into her car for back-to-back appointments. “I just wish she didn’t have to go that far away.”

So does Decker, who had hoped to settle in the Sartell area. She recently bought her four-bedroom “dream home” there.

The HealthPartners Central Minnesota Clinic where Decker worked is part of a wave of COVID-related closures starting to wash across America, reducing access to care in areas already short on primary care doctors.

Although no one tracks medical closures, recent research suggests they number in the thousands. A survey by the Physicians Foundation estimated that 8% of all physician practices nationally — around 16,000 — have closed under the stress of the pandemic. That survey didn’t break them down by type, but another from the Virginia-based Larry A. Green Center and the Primary Care Collaborative found in late September that 7% of primary care practices were unsure they could stay open past December without financial assistance.

And many more teeter on the economic brink, experts say.

“The last few years have been difficult for primary care practices, especially independent ones,” said Dr. Karen Joynt Maddox, co-director of the Center for Health Economics and Policy at Washington University in St. Louis. “Putting on top of that COVID, that’s in many cases the proverbial straw. These practices are not operating with huge margins. They’re just getting by.”

When offices close, experts said, the biggest losers are patients, who may skip preventive care or regular appointments that help keep chronic diseases such as diabetes under control.

“This is especially poignant in the rural areas. There aren’t any good choices. What happens is people end up getting care in the emergency room,” said Dr. Michael LeFevre, head of the family and community medicine department at the University of Missouri and a practicing physician in Columbia. “If anything, what this pandemic has done is put a big spotlight on what was already a big crack in our health care system.”

Federal data shows that 82 million Americans live in primary care “health professional shortage areas,” and the nation needed more than 15,000 more primary care practitioners even before the pandemic began.

Once the coronavirus struck, some practices buckled when patients stayed away in droves for fear of catching it, said Dr. Gary Price, president of the Physicians Foundation, a nonprofit grant-making and research organization. Its survey, based on 3,513 responses from emails to half a million doctors, found that 4 in 10 practices saw patient volumes drop by more than a quarter.

On the West Coast, a survey released in October by the California Medical Association found that one-quarter of practices in that state saw revenues drop by at least half. One respondent wrote: “We are closing next month.”

Decker’s experience at HealthPartners is typical. Before the pandemic, she saw about 18 patients a day. That quickly dropped to six or eight, “if that,” she said. “There were no well checks, which is the bread-and-butter of pediatrics.”

In an emailed statement, officials at HealthPartners, which has more than 50 primary care clinics around the Twin Cities and western Wisconsin, said closing the one in Sartell “was not an easy decision,” but the pandemic caused an immediate, significant drop in revenue. While continuing to provide dental care in Sartell, northwest of Minneapolis, the company encouraged employees to apply for open positions elsewhere in the organization. Decker got one of them. Officials also posted online information for patients on where more than 20 clinicians were moving.

The pandemic’s financial ripples rocked practices of all sizes, said LeFevre, the Missouri doctor. Before the pandemic, he said, the 10 clinics in his group saw a total of 3,500 patients a week. COVID-19 temporarily cut that number in half.

“We had fiscal reserves to weather the storm. Small practices don’t often have that. But it’s not like we went unscathed,” he said. “All staff had a one-week furlough without pay. All providers took a 10% pay cut for three months.”

Federal figures show pediatricians earn an average of $184,400 a year, and doctors of general internal medicine $201,400, making primary care doctors among the lowest-paid physicians.

As revenues dropped in medical practices, overhead costs stayed the same. And practices faced new costs such as personal protective equipment, which grew more expensive as demand exceeded supply, especially for small practices without the bulk buying power of large ones.

Doctors also lost money in other ways, said Rebecca Etz, co-director of the Green Center research group. For example, she said, pediatricians paid for vaccines upfront, “then when no one came in, they expired.”

Some doctors took out loans or applied for Provider Relief Fund money under the federal CARES Act. Dr. Joseph Provenzano, who practices in Modesto, California, said his group of more than 300 physicians received $8.7 million in relief in the early days of the pandemic.

“We were about ready to go under,” he said. “That came in the nick of time.”

While the group’s patient loads have largely bounced back, it still had to permanently close three of 11 clinics.

“We’ve got to keep practice doors open so that we don’t lose access, especially now that people need it most,” said Dr. Ada Stewart, president of the American Academy of Family Physicians.

Caine, the Minnesota mom, said her own health care has suffered because she also saw providers at the now-closed Sartell clinic. While searching for new ones, she’s had to seek treatment in urgent care offices and the emergency room.

“I’m fortunate because I’m able to make it. I’m able to improvise. But what about the families that don’t have transportation?” she said. “Older people and the more sickly people really need these services, and they’ve been stripped away.”

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

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Why Employers Find It So Hard to Test for COVID

Brandon Hudgins works the main floor at Fleet Feet, a running-shoe store chain, for more than 30 hours a week. He chats with customers, measuring their feet and dashing in and out of the storage area to locate right-sized shoes. Sometimes, clients drag their masks down while speaking. Others refuse to wear masks at all.

So he worries about COVID-19. And with good reason. Across the U.S., COVID hospitalizations and deaths are hitting record-shattering new heights. The nation saw 198,633 new cases on Friday alone.

Unlike in the early days of the pandemic, though, many stores nationwide aren’t closing. And regular COVID-19 testing of those working remains patchy at best.

“I’ve asked, what if someone on staff gets symptoms? ‘You have to stay home,’” said Hudgins, 33, who works in High Point, North Carolina. But as an hourly employee, staying home means not getting paid. “It’s stressful, especially without regular testing. Our store isn’t very big, and you’re in there all day long.”

To the store’s credit, Hudgins said the manager has instituted a locked-door policy, where employees determine which customers can enter. They sanitize the seating area between customers and administer regular employee temperature checks. Still, there’s no talk of testing employees for COVID-19. Fleet Feet did not respond to multiple requests to talk about its testing policies.

The federal Centers for Disease Control and Prevention issued guidance to employers to include COVID testing, and it advised that people working in close quarters be tested periodically. However, the federal government does not require employers to offer those tests.

But the board overseeing the California Division of Occupational Safety and Health, known as Cal/OSHA, on Thursday approved emergency safety rules that are soon likely to require the state’s employers to provide COVID testing to all workers exposed to an outbreak on the job at no cost to the employees. Testing must be repeated a week later, followed by periodic testing.

California would be the first state to mandate this, though the regulation doesn’t apply to routine testing of employees. That is up to individual businesses.

Across the nation, workplaces have been the source of major coronavirus outbreaks: meat-processing plants, grocery stores, farms, schools, Amazon warehouses — largely among the so-called essential workers who bear the brunt of COVID infections and deaths.

The U.S. Occupational Safety and Health Administration inspects workplaces based on workers’ complaints — over 40,000 of which related to COVID-19 have been filed with the agency at the state and federal levels.

Workers “have every right to be concerned,” said Dr. Peter Chin-Hong, an epidemiologist at the University of California-San Francisco. “They are operating in a fog. There is little economic incentive for corporations to figure out who has COVID at what sites.”

Waiting for symptoms to emerge before testing is ill-considered, Chin-Hong noted. People can exhibit no symptoms while spreading the virus. A CDC report found that, among people with active infections, 44% reported no symptoms.

Yet testing alone cannot protect employees. While workplaces can vary dramatically, Chin-Hong emphasized the importance of enforcing safety guidelines like social distancing and wearing face masks, as well as being transparent with workers when someone gets sick.

Molly White, who works for the Missouri state government, was required to return to the office once a week starting in July. But White, who is on drugs to suppress her immune system, feared her employer’s “cavalier attitude toward COVID and casual risk taking.” Masks are encouraged for employees but are not mandatory, and there’s no testing policy or even guidance on where to get tested, she said. White filed for and received an Americans With Disabilities Act exception, which lasts through the end of the year, to avoid coming into the office.

After a cluster of 39 COVID cases emerged in September in the building where she normally works, White was relieved to at least get an email notifying her of the outbreak. A few days later, Gov. Mike Parson visited the building, and he tested positive for COVID-19 soon after.

Following pressure from labor groups, Amazon reported in a blog post last month that almost 20,000 employees had tested positive or been presumed positive for COVID-19 since the pandemic began. To help curb future outbreaks, the online retailing giant, which also owns Whole Foods, built its own testing facilities, hired lab technicians and said it planned to conduct 50,000 daily tests across 650 sites by this month.

The National Football League tests players and other essential workers daily. An NFL spokesperson said the league conducts 40,000 to 45,000 tests a week through New Jersey-based BioReference Laboratories, though both organizations declined to share a price tag. Reports over the summer estimated the season’s testing program would cost about $75 million.

Not all companies, particularly those not in the limelight, have the interest — or the money — to regularly test workers.

“It depends on the company how much they care,” said Gary Glader, president of Horton Safety Consultants in Orland Park, Illinois. Horton works with dozens of companies in the manufacturing, construction and transportation industries to write exposure control plans to limit the risk of COVID-19 outbreaks and avoid OSHA citations. “Some companies could care less about their people, never have.”

IGeneX, a diagnostic testing company in Milpitas, California, gets around 15 calls each day from companies across the country inquiring about its employer testing program. The lab works with about 100 employers — from 10-person outfits to two pro sports teams — mainly in the Bay Area. IGeneX tests its own workers every other week.

One client is Tarana Wireless, a nearby telecommunications company that needs about 30 employees in the office at a time to operate equipment. In addition to monthly COVID tests, the building also gets cleaned every two hours, and masks are mandatory.

“It’s definitely a burden,” said Amy Beck, the company’s director of human resources. “We are venture-backed and have taken pay cuts to make our money extend longer. But we do this to make everyone feel safe. We don’t have unlimited resources.”

IGeneX offers three prices, depending on how fast a company wants the results: $135 for a polymerase chain reaction (PCR) test with a 36- to 48-hour turnaround — down to around $100 a test for some higher-volume clients; one-day testing costs $250, and it’s $400 for a six-hour turnaround.

In some cases, IGeneX is able to bill the companies’ health insurance plan.

“Absolutely, it’s expensive,” said IGeneX spokesperson Joe Sullivan. “I don’t blame anyone for wanting to pay as little as possible. It’s not ‘one and done,’ which companies are factoring in.”

Plus, cheaper, rapid options like Abbott’s antigen test, touted by the Trump administration, have come under fire for being inaccurate.

For those going into work, Chin-Hong recommends that companies test their employees once a week with PCR tests, or twice a week with the less sensitive antigen tests.

Ideally, Chin-Hong said, public health departments would work directly with employers to administer COVID testing and quash potential outbreaks. But, as KHN has reported extensively, these local agencies are chronically underfunded and overworked. Free community testing sites can sometimes take days to weeks to return results, bogged down by extreme demand at commercial labs like Quest Diagnostics and LabCorp and supply chain problems.

Hudgins, who receives his health insurance through North Carolina’s state exchange, tries to get a monthly COVID test at CVS on his own time. But occasionally, his insurance — which requires certain criteria to qualify — has declined to pay for it, he said.

“Being in the service industry in a state where numbers are ridiculously high,” he said in an email, “I see volumes of people every day, and I think getting tested is the smart and considerate thing to do.”

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 diabe