From Health Care

Discretamente, Biden está transformando la red de seguridad de Medicaid

La administración Biden está diseñando en silencio una serie de expansiones de Medicaid que pueden reforzar las protecciones para millones de estadounidenses de bajos ingresos y sumar más personas al programa.

Los esfuerzos de Biden, que han sido eclipsados ​​en gran medida por otras iniciativas económicas y de salud, representan un cambio abrupto en contra de todo lo que la administración Trump hizo para reducir el programa.

Las medidas, algunas de las cuales fueron financiadas por el proyecto de ley de ayuda de covid que se aprobó en marzo, podrían impulsar aún más la inscripción en Medicaid, algo que la pandemia elevó a un récord de 80,5 millones en enero, incluidos los beneficiarios del Programa de Seguro Infantil para Niños (CHIP).

Eso es más de los 70 millones antes de que comenzara la crisis de covid. Las nuevas madres, presos y los inmigrantes indocumentados se encuentran entre los que podrían obtener cobertura. Al mismo tiempo, la administración Biden está abriendo la puerta a nuevos servicios financiados por Medicaid, como alimentos y vivienda, que tradicionalmente el plan de seguro del gobierno no ha ofrecido.

“Hay un cambio de paradigma en marcha”, dijo Jennifer Langer Jacobs, directora de Medicaid en Nueva Jersey, uno de un número creciente de estados que intentan expandir los servicios de Medicaid en el hogar para mantener a los beneficiarios fuera de los hogares de adultos mayores y otras instituciones.

“Hemos tenido discusiones a nivel federal en los últimos 90 días que son completamente diferentes de donde hemos estado antes”, dijo Langer Jacobs.

En conjunto, los movimientos de Medicaid representan algunos de los cambios más importantes en la política de salud federal emprendidos por la nueva administración.

“Están tomando medidas muy audaces”, dijo Frank Thompson, politólogo de la Universidad de Rutgers y experto en la historia de Medicaid. Thompson señaló, en particular, la rápida reversión de las políticas de Trump por parte de la administración. “Realmente no hay un precedente”.

Parece poco probable que la administración Biden logre lo que sigue siendo el santo grial para los defensores de Medicaid: que 12 estados que se resisten, incluidos Texas y Florida, amplíen la cobertura de Medicaid a adultos de bajos ingresos en edad laboral a través de la Ley de Cuidado de Salud a Bajo Precio (ACA).

Y aunque algunas expansiones recientes, como la cobertura para las nuevas madres, fueron financiadas con cerca de $20 mil millones en nuevos fondos de Medicaid en el paquete de alivio de covid que Biden firmó en marzo, gran parte de ese nuevo dinero se detendrá en unos pocos años a menos que el Congreso asigne dinero adicional.

La estrategia de la Casa Blanca tiene riesgos. Medicaid, que creció después de la promulgación de la ley de salud de 2010, se ha expandido aún más durante la recesión económica causada por la pandemia. Los programas ahora cuestan a los contribuyentes más de $600 mil millones al año. Y aunque el gobierno federal cubrirá la mayor parte del costo de las expansiones respaldadas por Biden, el gasto creciente de Medicaid es una carga creciente para los presupuestos estatales.

Los costos de la expansión son un objetivo frecuente de los críticos conservadores, incluidos funcionarios de Trump como Seema Verma, ex administradora de los Centros de Servicios de Medicare y Medicaid (CMS), que con frecuencia abogaba por restringir la inscripción y ridiculizaba a Medicaid por considerarlo una cobertura de baja calidad.

Pero expertos aún menos partidistas advierten que Medicaid, que fue creado para brindar atención médica a estadounidenses de bajos ingresos, no puede compensar todas las deficiencias en los programas gubernamentales de vivienda, alimentación y educación.

“Centrarse en los impulsores sociales de la salud … es de vital importancia para mejorar la salud y el bienestar de los beneficiarios de Medicaid. Pero eso no significa que Medicaid pueda o deba ser responsable de pagar todos esos servicios”, dijo Matt Salo, director de la Asociación Nacional de Directores de Medicaid, y señaló que el financiamiento del programa “simplemente no es capaz de sostener esas inversiones”.

Sin embargo, después de cuatro años de esfuerzos de la administración Trump para reducir la cobertura, Biden y su equipo parecen tener la intención no solo de restaurar el apoyo federal para Medicaid, sino también de impulsar el alcance del programa.

“Creo que lo que aprendimos durante el debate sobre la derogación y reemplazo es cuánto le importa a la gente en este país el programa Medicaid y cómo es un salvavidas para millones”, dijo a KHN la nueva administradora de Medicare y Medicaid de Biden, Chiquita Brooks-LaSure. , llamando al programa una “columna vertebral de nuestro país”.

La administración Biden ya retiró el permiso que la administración de Trump había otorgado a Arkansas y New Hampshire para imponer requisitos laborales a algunos afiliados a Medicaid.

En abril, Biden bloqueó una iniciativa multimillonaria de la administración Trump para apuntalar los hospitales de Texas que atienden a pacientes sin seguro, una política que, según muchos críticos, disuadió a Texas de expandir la cobertura de Medicaid a través de ACA (también conocida como Obamacare). Texas tiene la tasa de personas sin seguro más alta del país.

Las medidas han generado críticas de los republicanos, algunos de los cuales acusan a la nueva administración de pisotear los derechos de los estados de ejecutar sus programas de Medicaid como prefieran.

“Biden está reafirmando un papel federal más amplio y no cede ante los estados”, dijo Josh Archambault, miembro principal de la conservadora Foundation for Government Accountability.

Pero las primeras iniciativas de Biden han sido ampliamente aclamadas por defensores de los pacientes, expertos en salud pública y funcionarios estatales en muchos estados azules.

“Es un soplo de aire fresco”, dijo Kim Bimestefer, directora del Departamento de Política y Financiamiento de la Atención Médica de Colorado.

Chuck Ingoglia, director del Consejo Nacional para el Bienestar Mental, dijo: “Estar en un entorno en el que la gente habla de ampliar el acceso a la atención médica ha marcado una enorme diferencia”.

La creciente evidencia muestra que la cobertura ampliada de Medicaid mejora la salud de los beneficiarios, ya que las encuestas y los datos de mortalidad en los últimos años han identificado mejoras de salud más grandes en los estados que ampliaron Medicaid, en comparación con los estados que no lo hicieron.

Además de eliminar las restricciones de Medicaid impuestas por los funcionarios de la administración Trump, la administración Biden ha respaldado una serie de expansiones para ampliar la elegibilidad y agregar servicios que los afiliados pueden recibir.

Biden apoyó una disposición en el proyecto de ley de alivio de covid que brinda a los estados la opción de extender Medicaid a las nuevas madres hasta un año después de dar a luz. Muchos expertos dicen que dicha cobertura podría ayudar a reducir la tasa de mortalidad materna en el país, que es mucho más alta que las tasas de otras naciones ricas.

Varios estados, incluidos Illinois y Nueva Jersey, habían solicitado el permiso de la administración Trump para una cobertura más amplia, pero sus solicitudes nunca avanzaron.

La ayuda por covid, proyecto de ley que se aprobó sin el apoyo de los republicanos, también proporciona dinero adicional de Medicaid a los estados para establecer servicios móviles de crisis para personas que enfrentan emergencias de salud mental o uso de sustancias, ampliando aún más el alcance de Medicaid.

Y los estados obtendrán miles de millones más para expandir los llamados servicios basados ​​en el hogar y la comunidad, como ayuda para cocinar, bañarse y otras actividades básicas que pueden prevenir que los beneficiarios de Medicaid tengan que ser admitidos en costosos hogares de adultos mayores u otras instituciones.

Quizás las expansiones de Medicaid de mayor alcance que está considerando la administración Biden empujarían al plan de salud del gobierno a cubrir servicios que tradicionalmente no se consideran atención médica, como la vivienda.

Esto refleja un consenso emergente entre los expertos en políticas de salud de que las inversiones en algunos servicios no médicos pueden, en última instancia, ahorrar dinero a Medicaid al mantener a los pacientes fuera del hospital.

En los últimos años, funcionarios de Medicaid en estados rojos y azules, incluidos Arizona, California, Illinois, Maryland y Washington, han comenzado a explorar formas de brindar asistencia de alquiler a determinados beneficiarios de Medicaid para prevenir complicaciones médicas relacionadas con la falta de vivienda.

La administración Trump tomó medidas para respaldar esfuerzos similares, autorizando los planes de salud Medicare Advantage para ofrecer a algunos afiliados beneficios no médicos, como alimentos, ayuda para la vivienda y asistencia con los servicios públicos.

Pero los funcionarios estatales de todo el país dijeron que la nueva administración ha mostrado más apoyo tanto para expandir los servicios actuales ​​en el hogar como para agregar otros nuevos.

Eso ha marcado una gran diferencia, dijo Kate McEvoy, quien dirige el programa Medicaid de Connecticut. “Hubo mucha discusión en la administración Trump”, dijo, “pero no el capital para hacerlo”.

Otros estados esperan que la nueva administración respalde los esfuerzos para expandir Medicaid a los reclusos con problemas de salud mental y adicción a las drogas para que puedan conectarse más fácilmente al tratamiento una vez que son puestos en libertad.

Eric Friedlander, secretario de salud de Kentucky, , dijo que espera que los funcionarios federales aprueben la iniciativa de su estado.

California dice que está teniendo una audiencia más receptiva en Washington para propuestas como expandir la cobertura a inmigrantes que están en el país sin papeles, un paso que los expertos en salud pública dicen que puede ayudar a mejorar la salud de la comunidad y ralentizar la propagación de enfermedades transmisibles.

“Cubrir a todos los californianos es fundamental para nuestra misión”, dijo Jacey Cooper, director del programa Medicaid de California, conocido como Medi-Cal. “Realmente sentimos que la nueva administración nos está ayudando a garantizar que todos tengan acceso”.

La administración Trump tomó medidas para restringir incluso el acceso de inmigrantes con visa a la red de seguridad de la atención médica, fortaleciendo la regla de “carga pública” que permitía a las autoridades de inmigración negar las tarjetas de residencia a los solicitantes si usaban programas públicos como Medicaid. En marzo, Biden desestimó esa regla.

La corresponsal de KHN, Julie Rovner, colaboró con este informe.

La esperanza de vida de los hispanos y afroamericanos ha sufrido la peor baja desde la Segunda Guerra Mundial

Aunque James Toussaint nunca ha tenido covid, la pandemia está afectando profundamente su salud.

Primero, en la primavera de 2020, el hombre de 57 años perdió su trabajo entregando repuestos para una concesionaria de automóviles de Nueva Orleans, cuando la economía local se congeló. Luego, se atrasó en el pago del alquiler. El mes pasado, Toussaint tuvo que dejar su apartamento cuando el propietario, que se negó a aceptar la asistencia para el alquiler con fondos federales, encontró un agujero legal en la prohibición federal sobre desalojos.

Toussaint ha tenido problemas para controlar su presión arterial. Con artritis en la espalda y las rodillas no puede levantar más de 20 libras, un gran obstáculo para su trabajo.

Le preocupa lo que sucederá cuando se agoten sus beneficios por desempleo que se otorgaron por la pandemia, lo que podría suceder el 31 de julio.

“He estado sin hogar antes”, dijo Toussaint, quien pudo alquilar un cuarto cerca después de su desalojo. “No quiero volver a quedarme sin hogar”.

Con la caída de las infecciones por coronavirus en el país, muchas personas están ansiosas por dejar atrás la pandemia. Pero ha causado heridas que no se curan fácilmente. Además de matar a 600,000 personas en los Estados Unidos y afectar a unos 3,4 millones o más con síntomas persistentes, la pandemia amenaza la salud de las personas vulnerables devastadas por la pérdida de empleos, hogares y oportunidades futuras.

Es casi seguro que proyectará una larga sombra sobre la salud estadounidense, lo que hará que millones de personas vivan más enfermas y mueran más jóvenes debido a las crecientes tasas de pobreza, hambre e inseguridad en la vivienda.

En particular, exacerbará las discrepancias que ya se han visto en el país entre la riqueza y la salud de los estadounidenses negros e hispanoestadounidenses (que pueden ser de cualquier raza), y las de los estadounidenses blancos.

De hecho, una nueva investigación publicada en la revista BMJ muestra cuán grande se ha vuelto esa brecha. La esperanza de vida en todo el país se desplomó en casi dos años entre 2018 y 2020, el mayor descenso desde 1943, cuando soldados estadounidenses morían en la Segunda Guerra Mundial, según la investigación.

Pero mientras que los estadounidenses blancos perdieron 1,36 años, los estadounidenses negros perdieron 3,25 años y los hispanoestadounidenses, 3,88 años. Dado que la esperanza de vida normalmente varía sólo un mes o dos de un año a otro, las pérdidas de esta magnitud son “bastante catastróficas”, explicó el doctor Steven Woolf, profesor de la Virginia Commonwealth University y autor principal del estudio.

Durante los dos años incluidos en el estudio, la pérdida promedio de esperanza de vida en el país fue casi nueve veces mayor que el promedio en otras 16 naciones desarrolladas, cuyos residentes ahora pueden esperar vivir 4.7 años más que los estadounidenses. En comparación con sus pares en otros países durante este período, los estadounidenses no solo murieron en mayor número sino a edad más temprana.

La tasa de mortalidad del país se disparó casi un 23% en 2020, cuando hubo aproximadamente 522,000 muertes más de las que habría en un año normal. No todas estas muertes fueron directamente atribuibles a covid-19. Los ataques cardíacos mortales y los accidentes cerebrovasculares aumentaron en 2020, en parte impulsados ​​por el retraso en los tratamientos o la falta de acceso a la atención médica, dijo Woolf.

Más del 40% de los estadounidenses pospusieron tratamientos durante los primeros meses de la pandemia, cuando los hospitales estaban colmados, y solo entrar a un centro médico parecía arriesgado. Sin atención médica inmediata, los ataques cardíacos pueden causar insuficiencia cardíaca congestiva; retrasar el tratamiento de los ataques cerebrales aumenta el riesgo de discapacidad a largo plazo.

Gran parte del devastador impacto en la salud pública durante la pandemia puede atribuirse a la disparidad económica. Aunque los precios de las acciones se han recuperado de la caída del año pasado, y han alcanzado máximos históricos, muchas personas siguen sufriendo financieramente, en especial los afroamericanos y los hispanoestadounisenses.

En un informe de febrero, analistas de la economía de McKinsey & Co. predijeron que, en promedio, los trabajadores negros e hispanos no recuperarán su empleo y salarios antes de la pandemia hasta 2024. Y los empleados peor pagos y sin educación secundaria tal vez ni se recuperan para entonces.

Aunque los programas de ayuda federales y estatales han amortiguado el impacto de la pérdida de empleos por la pandemia, el 11,3% de los estadounidenses viven hoy en la pobreza, en comparación con el 10,7% en enero de 2020. Una moratoria federal de desalojos, que ha ayudado a que aproximadamente 2,2 millones de personas permanezcan en sus hogares, expira el 30 de junio.

Sin protección contra los desalojos, “millones de estadounidenses podrían caer en un abismo”, dijo Vangela Wade, presidenta y directora ejecutiva del Centro de Justicia de Mississippi, un grupo de defensa sin fines de lucro.

El desalojo erosiona la salud de una persona de múltiples formas. “La pobreza causa mucho cáncer y enfermedades crónicas, y esta pandemia ha causado mucha más pobreza”, dijo el doctor Otis Brawley, profesor de la Universidad Johns Hopkins que estudia las disparidades en salud. “El efecto de esta pandemia sobre las enfermedades crónicas, como las enfermedades cardiovasculares y la diabetes, se medirá en las próximas décadas”.

Veinte millones de adultos recientemente han tenido problemas para poner comida en la mesa. La imposibilidad de pagar alimentos saludables, que generalmente son más costosos que los alimentos salados y procesados, puede causar daños tanto a corto como a largo plazo. Por ejemplo, las personas con bajos ingresos tienen más probabilidades de ser hospitalizadas por niveles bajos de azúcar en sangre hacia fin de mes, cuando se quedan sin dinero para comprar alimentos.

A largo plazo, la inseguridad alimentaria se asocia con un mayor riesgo de diabetes, colesterol alto, hipertensión, depresión, ansiedad y otras enfermedades crónicas, especialmente en los niños.

“Una vez que haya pasado la fase aguda de esta crisis, enfrentaremos una enorme ola de muerte y discapacidad”, dijo el doctor Robert Califf, ex comisionado de la Administración de Alimentos y Medicamentos (FDA), quien escribió sobre los riesgos para la salud posteriores a una pandemia en un editorial de abril en la revista médica Circulation. “Estas serán las otras consecuencias de Covid”.

Menos riqueza, peor salud

La salud estadounidense era mala incluso antes de la pandemia: el 60% de la población padecía una afección crónica, como obesidad, diabetes, hipertensión o insuficiencia cardíaca. Estas cuatro condiciones se asociaron con casi dos tercios de las hospitalizaciones por covid, según un estudio de febrero en el Journal of the American Heart Association.

Las muertes por algunas enfermedades crónicas comenzaron a aumentar entre los estadounidenses de bajos ingresos en la década de 1990, dijo Woolf. Esa tendencia se vio exacerbada por la Gran Recesión de 2007-09, que socavó la salud no solo de quienes perdieron sus hogares o trabajos, sino también de la población en general.

Sin embargo, la Gran Recesión y sus efectos en la salud no afectaron a todos los estadounidenses por igual. Las personas negras controlan hoy menos riqueza que antes de la recesión, mientras que la brecha en la seguridad financiera entre los estadounidenses blancos y negros se ha ampliado, según un artículo de Nonprofit Quarterly publicado el año pasado. Y la tasa de desempleo entre los trabajadores negros no se recuperó a los niveles anteriores a la recesión hasta 2016.

Los investigadores han desarrollado una mejor comprensión en los últimos años de cómo el estrés crónico, causado por la pobreza, la pérdida del empleo y la falta de vivienda, conduce a la enfermedad. El estrés implacable causa inflamación que puede dañar los vasos sanguíneos, el corazón y otros órganos.

Las investigaciones muestran que las personas con bajos ingresos viven un promedio de siete a ocho años menos que aquéllas que tienen seguridad financiera. El 1% más rico de los estadounidenses vive casi 15 años más que el 1% más pobre.

Las personas pobres tienden a fumar más; tienen un mayor riesgo de enfermedades crónicas como enfermedades cardiovasculares, diabetes, enfermedades renales y trastornos mentales; y es más probable que sean víctimas de la violencia.

El estrés de la pandemia también ha llevado a muchas personas a fumar, beber y aumentar de peso, aumentando el riesgo de enfermedades crónicas. Las sobredosis fatales de drogas aumentaron un 30% entre octubre de 2019 y octubre de 2020.

Jennifer Drury, de 40 años, ha luchado contra el abuso de sustancias, en particular los analgésicos recetados, desde los 20. Culpa al aislamiento y el estrés de la pandemia por una recaída y por haber perdido amigos a causa de sobredosis.

“El tiempo de inactividad no es bueno para la adicción”, dijo Drury, quien se atrasó en el pago del alquiler y fue desalojada de su casa anterior. Dijo que los traficantes nunca están lejos, especialmente en el motel de Nueva Orleans donde ahora vive con su esposo. “A los traficantes de drogas no les importan las pandemias”.

Mujeres perdiendo terreno

El Plan de Rescate Estadounidense, que proporciona $1,9 mil millones en ayuda por la pandemia, fue diseñado para ayudar a los trabajadores desplazados y reducir a la mitad las tasas de pobreza infantil. Los beneficios reales de la ley pueden resultar menos amplios.

Veinticinco estados han optado por eliminar los pagos de desempleo federales adicionales, citando preocupaciones de que estos generosos beneficios pagan a las personas más por quedarse en casa de lo que pueden ganar trabajando.

Muchas mujeres dicen que les gustaría volver a trabajar pero que no tienen a nadie que se ocupe de sus hijos. Casi la mitad de los centros de cuidado infantil han cerrado y otros han reducido el número de niños que atienden.

El Banco de la Reserva Federal de Minneapolis concluyó que “la recuperación económica depende de la disponibilidad de cuidado infantil”. Un informe de marzo del Centro Nacional de Leyes de la Mujer estima que “las mujeres han perdido una generación de ganancias en la participación en la fuerza laboral”, lo que podría dejarlas a ellas y a sus hijos en desventaja financiera durante años.

Ruth Bermúdez es una de las millones de mujeres que se alejaron de la fuerza laboral el año pasado. Bermúdez, quien fue despedida de su empleo como trabajadora social de salud conductual en Nueva Orleans, dijo que sus necesidades de cuidado infantil le han impedido encontrar trabajo. El cuidado de su hija de 6 años se convirtió en su trabajo de tiempo completo después de que la pandemia cerrara las escuelas.

Aunque su hija ha regresado a clases, Bermúdez dijo que los cierres escolares debido a los brotes de covid han sido frecuentes e impredecibles.

“Tuve que ser maestra, hacer el almuerzo, conducir, todo al mismo tiempo”, dijo Bermúdez, de 27 años. “Es agotador”.

Desalojos que cambian la vida

James Toussaint tuvo solo dos semanas para encontrar un nuevo lugar para vivir después de que un juez ordenara su desalojo. No pudo estar con su familia.

“Tengo familia, pero todos tienen sus propios problemas”, dijo Toussaint, quien tuvo que tirar toda su ropa y muebles porque se habían infestado de chinches. “Todos están haciendo todo lo posible para ayudarse a sí mismos”.

Toussaint ahora alquila una habitación en una pensión sin cocina y un baño compartido por $160 a la semana. Tuvo que comprar artículos de limpieza con su propio dinero para desinfectar el baño, que, según dijo, a menudo no se puede usar de lo sucio que está.

Compartir el espacio común a menudo es insalubre y aumenta el riesgo de estar expuesto al coronavirus, dijo Emily Benfer, profesora visitante en la Escuela de Derecho de la Universidad de Wake Forest. Incluso mudarse con la familia presenta riesgos, dijo, porque es imposible aislarlo o ponerlo en cuarentena en hogares abarrotados.

Benfer coescribió un estudio de noviembre que encontró que las tasas de infección por covid crecieron dos veces más en los estados que levantaron las moratorias sobre los desalojos, en comparación con los estados que continuaron prohibiéndolos. Aproximadamente el 14% de los inquilinos se han retrasado en el pago del alquiler, el doble de la tasa antes de la pandemia.

El contrato de arrendamiento anual de Toussaint expiró durante la pandemia, por lo que tuvo que alquilar mes a mes. Si bien algunos estados requieren que los propietarios muestren una “causa justa” para el desalojo, los propietarios de Louisiana pueden desalojar a los inquilinos por cualquier motivo una vez que haya vencido su contrato de alquiler anual.

Los dueños de propiedades han solicitado más de 378,000 desalojos durante la pandemia en solo los cinco estados y las 29 ciudades rastreadas por el Laboratorio de Desalojos de la Universidad de Princeton. Un conjunto de pruebas cada vez mayor muestra que el desalojo es tóxico para la salud y causa daños inmediatos y a largo plazo que aumentan el riesgo de muerte.

Estudios muestran que las personas desalojadas tienen más probabilidades de tener problemas de salud general o de salud mental incluso años después.

“Este evento singular altera el curso de la vida para peor”, dijo Benfer. “Si no intervenimos” para evitar los desalojos masivos cuando finalice la moratoria, “será catastrófico para las generaciones venideras”.

Los daños causados ​​por el desalojo se pueden medir en todas las etapas de la vida:

Cuando las mujeres embarazadas son desalojadas, sus recién nacidos tienen más probabilidades de ser prematuros o muy pequeños, y tienen un mayor riesgo de morir en el primer año de vida. Las mujeres que son desalojadas tienen más probabilidades de sufrir agresiones sexuales, dijo Benfer.

Los niños que son desalojados corren un mayor riesgo de intoxicación por plomo en viviendas deficientes, dijo Benfer. También son más propensos que otros a ser hospitalizados.

Los adultos desalojados reportan una peor salud mental y tienen más probabilidades de ser hospitalizados por una crisis de salud mental, muestran estudios. También tienen mayores tasas de mortalidad por suicidio. Aunque las causas de adicción son complejas, las investigaciones muestran que los condados con tasas de desalojo más altas tienen tasas significativamente más altas de muertes relacionadas con drogas y alcohol.

Las personas que son desalojadas a menudo se mudan a viviendas deficientes en vecindarios con índices de criminalidad más altos. Estos lugares a veces están plagados de moho y cucarachas, no tienen calefacción suficiente o tienen tuberías que no funcionan. Los propietarios no tienen ningún incentivo para hacer reparaciones a los inquilinos que están atrasados ​​en el pago del alquiler, dijo Benfer. De hecho, los que denuncian peligros o piden reparaciones corren el riesgo de ser desalojados.

Aunque los estadounidenses de clase media dan por sentado sus cocinas y dependen de ellas para cocinar comidas saludables, más de 1 millón de hogares carecen de cocinas completas, según la Oficina del Censo.

Nueva Orleans no requiere que las unidades de alquiler incluyan estufas, dijo Hannah Adams, también abogada de Southeast Louisiana Legal Services. La nueva habitación de Toussaint está equipada con microondas y nevera pequeña, pero no tiene fregadero, horno ni fogones. Lava los platos de la cena en el baño. Su casero no permite que los residentes tengan cocinas eléctricas, por lo que la mayoría de sus comidas incluyen cereales fríos, sándwiches de fiambres o comidas que puede calentar en el microondas. Su médico ha instado a Toussaint, que es prediabético, a perder peso, comer con menos sal y dejar de fumar.

Toussaint, que vivió en la calle durante dos años, dijo que está decidido a no regresar allí. Espera solicitar un seguro por discapacidad, que le proporcionaría un ingreso si su artritis le impide encontrar un trabajo estable.

Woolf dijo que espera que los estadounidenses no se olviden del sufrimiento de personas como Toussaint a medida que disminuyen los casos de covid.

“Mi preocupación es que la gente sienta que la crisis ha quedado atrás y todo está bien”, dijo Woolf. Su investigación, que conecta cuatro décadas de oportunidades económicas con la baja en la esperanza de vida, muestra que “estamos ante un gran problema, y ​​eso era cierto antes de que supiéramos que se avecinaba una pandemia”.

La pandemia no tiene por qué condenar a una generación de estadounidenses a la enfermedad y la muerte prematura, dijo el doctor Richard Besser, presidente y director ejecutivo de la Fundación Robert Wood Johnson.

Al abordar problemas como la pobreza, la desigualdad racial y la falta de viviendas asequibles, el país puede mejorar la salud de los estadounidenses y revertir las tendencias que causaron el sufrimiento de las comunidades de color. “La forma en que la pandemia afectará la salud futura de las personas depende de lo que hagamos después de esto”, dijo Besser. “Se necesitará un esfuerzo intencional para compensar las pérdidas que se han producido durante el año pasado”.

KHN’s ‘What the Health?’: How to Expand Health Coverage


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Democrats in Congress and several states are making it a priority to try to boost health insurance coverage, but they have very different ideas. Some are working to expand the Medicaid program, some seek to build on the Affordable Care Act, and others want to expand Medicare. And as support for a federal “public option” government-run plan wanes in Washington, several states are attempting their own proposals.

Meanwhile, efforts to rein in prescription drug prices continue, and lawmakers may have to reach an agreement if they want to be able to finance their coverage expansions with the savings from those proposals.

This week’s panelists are Julie Rovner of KHN, Alice Miranda Ollstein of Politico, Tami Luhby of CNN and Shefali Luthra of The 19th.

Among the takeaways from this week’s episode:

  • Sen. Ron Wyden’s (D-Ore.) outline for reducing Medicare drug prices leaves many questions unanswered. Among them is what sort of mechanism he would use to set drug prices, which drugs would be subject to drug price cuts, how the government would determine prices and whether price controls would affect health plans for younger people not on Medicare.
  • Finding a way to cut Medicare drug prices could provide a major windfall for the federal government, and Democrats hope it would help finance other programs, such as making permanent the enhanced premium subsidies for insurance plans purchased on the Affordable Care Act’s insurance marketplaces. But proponents of efforts to cut drug prices don’t yet have buy-in from all Democratic lawmakers, many of whom maintain close ties to drugmakers.
  • It’s also unclear whether drug prices are a top priority for the administration. President Joe Biden has said he supports efforts to bring down pharmaceutical costs, but he has not emphasized it in his budget or policy initiatives.
  • Lawmakers from the progressive wing of the Democratic Party are signaling they hope to lower the eligibility age for Medicare and expand its benefits as part of a budget deal this summer. Biden ran on a platform of establishing a health plan run by the government — called a “public option” — that consumers could choose on the ACA marketplace, but that is not being discussed much right now.
  • For progressives, that public option has never been as enticing as a single-payer plan run by the government that would cover the entire nation. And since the health care industry might fight a public option as vehemently as it would a single-payer plan, expanding Medicare seems a better choice to those liberals.
  • Democratic lawmakers are also looking for ways to provide health coverage to uninsured, low-income people living in states that refused to accept the ACA’s Medicaid expansion. Some propose bills that would allow cities or counties to opt into the expansion program when state officials don’t or while others back proposals that would let those consumers purchase subsidized plans on the ACA marketplaces, a provision that was not provided in the landmark health law because it was assumed that states would expand their Medicaid programs.
  • Missouri legislators have begun negotiations to renew funding proposals for long-term care in the state’s traditional Medicaid program. As part of that effort, they are considering new limits on what contraceptives Medicaid will cover. Lawmakers are considering banning reimbursement for IUDs and emergency contraception, on the incorrect belief that those methods are abortifacients.
  • Colorado and Nevada, following an initiative by Washington state, are setting up public options for their residents. But the programs will not necessarily reduce premiums, and if the federal government opts to make permanent the increased premium subsidies that took effect this year for marketplace customers around the country, such state efforts may look less appealing.
  • Even as the U.S. begins to return to more normal routines and open up businesses and events as the pandemic eases, concern is growing about the covid virus’s delta variant, which is spreading quickly across the country and the world. Public health experts are working to persuade residents who haven’t been vaccinated to step up for a shot because that can prevent serious illness. Officials have been keen to use incentives to bring people in for vaccination — cash and merchandise prizes, for example — but have been hesitant to penalize anyone for not getting inoculated. That strategy may not be working.

Also this week, Rovner interviews Michelle Andrews, who reported and wrote last month’s KHN-NPR “Bill of the Month” episode about a very expensive sleep study. If you have an outrageous medical bill you’d like to send us, you can do that here.

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

Julie Rovner: The Washington Post’s “Workplace Wellness Programs Are Big Business. They Might Not Work,” by Katherine Baicker and Zirui Song

Tami Luhby: The Associated Press’ “Watchdog: Nursing Home Deaths Up 32% in 2020 Amid Pandemic,” by Ricardo Alonso-Zaldivar

Alice Miranda Ollstein: The New York Times’ “Desperate for Covid Care, Undocumented Immigrants Resort to Unproven Drugs,” by Amy Maxmen

Shefali Luthra: KHN’s “Hemmed In at Home, Nonprofit Hospitals Look for Profits Abroad,” by Jordan Rau


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And subscribe to KHN’s What the Health? on Spotify, Apple Podcasts, Stitcher, Pocket Casts or wherever you listen to podcasts.

Biden Quietly Transforms Medicaid Safety Net

The Biden administration is quietly engineering a series of expansions to Medicaid that may bolster protections for millions of low-income Americans and bring more people into the program.

Biden’s efforts — which have been largely overshadowed by other economic and health initiatives — represent an abrupt reversal of the Trump administration’s moves to scale back the safety-net program.

The moves, some of which were funded by the covid relief bill that passed in March, could further boost Medicaid enrollment — which the pandemic pushed to a record 80.5 million in January, including those served by the related Children’s Health Insurance Program. That’s up from 70 million before the covid crisis began. New mothers, inmates and undocumented immigrants are among those who could gain coverage. At the same time, the Biden administration is opening the door to new Medicaid-funded services such as food and housing that the government insurance plan hasn’t traditionally offered.

“There is a paradigm change underway,” said Jennifer Langer Jacobs, Medicaid director in New Jersey, one of a growing number of states trying to expand home-based Medicaid services to keep enrollees out of nursing homes and other institutions.

“We’ve had discussions at the federal level in the last 90 days that are completely different from where we’ve ever been before,” Langer Jacobs said.

Taken together, the Medicaid moves represent some of the most substantive shifts in federal health policy undertaken by the new administration.

“They are taking very bold action,” said Rutgers University political scientist Frank Thompson, an expert on Medicaid history, noting, in particular, the administration’s swift reversal of Trump policies. “There really isn’t a precedent.”

The Biden administration seems unlikely to achieve what remains the holy grail for Medicaid advocates: getting 12 holdout states, including Texas and Florida, to expand Medicaid coverage to low-income working-age adults through the Affordable Care Act. 

And while some recent expansions — including for new mothers — were funded by close to $20 billion in new Medicaid funding in the covid relief bill Biden signed in March, much of that new money will stop in a few years unless Congress appropriates additional money.

The White House strategy has risks. Medicaid, which swelled after enactment of the 2010 health law, has expanded further during the economic downturn caused by the pandemic. The programs now cost taxpayers more than $600 billion a year. And although the federal government will cover most of the cost of the Biden-backed expansions, surging Medicaid spending is a growing burden on state budgets.

The costs of expansion are a frequent target of conservative critics, including Trump officials like Seema Verma, the former administrator of the Centers for Medicare & Medicaid Services, who frequently argued for enrollment restrictions and derided Medicaid as low-quality coverage.

But even less partisan experts warn that Medicaid, which was created to provide medical care to low-income Americans, can’t make up for all the inadequacies in government housing, food and education programs.

“Focusing on the social drivers of health … is critically important in improving the health and well-being of Medicaid beneficiaries. But that doesn’t mean that Medicaid can or should be responsible for paying for all of those services,” said Matt Salo, head of the National Association of Medicaid Directors, noting that the program’s financing “is simply not capable of sustaining those investments.”

However, after four years of Trump administration efforts to scale back coverage, Biden and his appointees appear intent on not only restoring federal support for Medicaid, but also boosting the program’s reach.

“I think what we learned during the repeal-and-replace debate is just how much people in this country care about the Medicaid program and how it’s a lifeline to millions,” Biden’s new Medicare and Medicaid administrator, Chiquita Brooks-LaSure, told KHN, calling the program a “backbone to our country.”

The Biden administration has already withdrawn permission the Trump administration had granted Arkansas and New Hampshire to place work requirements on some Medicaid enrollees.

In April, Biden blocked a multibillion-dollar Trump administration initiative to prop up Texas hospitals that care for uninsured patients, a policy that many critics said effectively discouraged Texas from expanding Medicaid coverage through the Affordable Care Act, often called Obamacare. Texas has the highest uninsured rate in the nation.

The moves have drawn criticism from Republicans, some of whom accuse the new administration of trampling states’ rights to run their Medicaid programs as they choose.

“Biden is reasserting a larger federal role and not deferring to states,” said Josh Archambault, a senior fellow at the conservative Foundation for Government Accountability.

But Biden’s early initiatives have been widely hailed by patient advocates, public health experts and state officials in many blue states.

“It’s a breath of fresh air,” said Kim Bimestefer, head of Colorado’s Department of Health Care Policy and Financing.

Chuck Ingoglia, head of the National Council for Mental Wellbeing, said: “To be in an environment where people are talking about expanding health care access has made an enormous difference.”

Mounting evidence shows that expanded Medicaid coverage improves enrollees’ health, as surveys and mortality data in recent years have identified greater health improvements in states that expanded Medicaid through the 2010 health law versus states that did not.

In addition to removing Medicaid restrictions imposed by Trump administration officials, the Biden administration has backed a series of expansions to broaden eligibility and add services enrollees can receive.

Biden supported a provision in the covid relief bill that gives states the option to extend Medicaid to new mothers for up to a year after they give birth. Many experts say such coverage could help reduce the U.S. maternal mortality rate, which is far higher than rates in other wealthy nations.

Several states, including Illinois and New Jersey, had sought permission from the Trump administration for such expanded coverage, but their requests languished.

The covid relief bill — which passed without Republican support — also provides additional Medicaid money to states to set up mobile crisis services for people facing mental health or substance use emergencies, further broadening Medicaid’s reach.

And states will get billions more to expand so-called home and community-based services such as help with cooking, bathing and other basic activities that can prevent Medicaid enrollees from having to be admitted to expensive nursing homes or other institutions.

Perhaps the most far-reaching Medicaid expansions being considered by the Biden administration would push the government health plan into covering services not traditionally considered health care, such as housing.

This reflects an emerging consensus among health policy experts that investments in some non-medical services can ultimately save Medicaid money by keeping patients out of the hospital.

In recent years, Medicaid officials in red and blue states — including Arizona, California, Illinois, Maryland and Washington — have begun exploring ways to provide rental assistance to select Medicaid enrollees to prevent medical complications linked to homelessness.

The Trump administration took steps to support similar efforts, clearing Medicare Advantage health plans to offer some enrollees non-medical benefits such as food, housing aid and assistance with utilities.

But state officials across the country said the new administration has signaled more support for both expanding current home-based services and adding new ones.

That has made a big difference, said Kate McEvoy, who directs Connecticut’s Medicaid program. “There was a lot of discussion in the Trump administration,” she said, “but not the capital to do it.”

Other states are looking to the new administration to back efforts to expand Medicaid to inmates with mental health conditions and drug addiction so they can connect more easily to treatment once released.

Kentucky health secretary Eric Friedlander said he is hopeful federal officials will sign off on his state’s initiative.

Still other states, such as California, say they are getting a more receptive audience in Washington for proposals to expand coverage to immigrants who are in the country without authorization, a step public health experts say can help improve community health and slow the spread of communicable diseases.

“Covering all Californians is critical to our mission,” said Jacey Cooper, director of California’s Medicaid program, known as Medi-Cal. “We really feel like the new administration is helping us ensure that everyone has access.”

The Trump administration moved to restrict even authorized immigrants’ access to the health care safety net, including the “public charge” rule that allowed immigration authorities to deny green cards to applicants if they used public programs such as Medicaid. In March, Biden abandoned that rule.

KHN correspondent Julie Rovner contributed to this report.

Black and Hispanic Americans Suffer Most in Biggest US Decline in Life Expectancy Since WWII

Although James Toussaint has never had covid, the pandemic is taking a profound toll on his health.

First, the 57-year-old lost his job delivering parts for a New Orleans auto dealership in spring 2020, when the local economy shut down. Then, he fell behind on his rent. Last month, Toussaint was forced out of his apartment when his landlord — who refused to accept federally funded rental assistance — found a loophole in the federal ban on evictions.

Toussaint recently has had trouble controlling his blood pressure. Arthritis in his back and knees prevents him from lifting more than 20 pounds, a huge obstacle for a manual laborer.

Toussaint worries about what will happen when his pandemic unemployment benefits run out, which could happen as early as July 31.

“I’ve been homeless before,” said Toussaint, who found a room to rent nearby after his eviction. “I don’t want to be homeless again.”

With coronavirus infections falling in the U.S., many people are eager to put the pandemic behind them. But it has inflicted wounds that won’t easily heal. In addition to killing 600,000 in the United States and afflicting an estimated 3.4 million or more with persistent symptoms, the pandemic threatens the health of vulnerable people devastated by the loss of jobs, homes and opportunities for the future. It will, almost certainly, cast a long shadow on American health, leading millions of people to live sicker and die younger due to increasing rates of poverty, hunger and housing insecurity.

In particular, it will exacerbate the discrepancies already seen in the country between the wealth and health of Black and Hispanic Americans and those of white Americans. Indeed, new research published Wednesday in the BMJ shows just how wide that gap has grown. Life expectancy across the country plummeted by nearly two years from 2018 to 2020, the largest decline since 1943, when American troops were dying in World War II, according to the study. But while white Americans lost 1.36 years, Black Americans lost 3.25 years and Hispanic Americans lost 3.88 years. Given that life expectancy typically varies only by a month or two from year to year, losses of this magnitude are “pretty catastrophic,” said Dr. Steven Woolf, a professor at Virginia Commonwealth University and lead author of the study.

Over the two years included in the study, the average loss of life expectancy in the U.S. was nearly nine times greater than the average in 16 other developed nations, whose residents can now expect to live 4.7 years longer than Americans. Compared with their peers in other countries, Americans died not only in greater numbers but at younger ages during this period.

The U.S. mortality rate spiked by nearly 23% in 2020, when there were roughly 522,000 more deaths than expected. Not all of these deaths were directly attributable to covid-19. Fatal heart attacks and strokes both increased in 2020, at least partly fueled by delayed treatment or lack of access to medical care, Woolf said. More than 40% of Americans put off treatment during the early months of the pandemic, when hospitals were stretched thin and going into a medical facility seemed risky. Without prompt medical attention, heart attacks can cause congestive heart failure; delaying treatment of strokes raises the risk of long-term disability.

Much of the devastating public health impact during the pandemic can be chalked up to economic disparity. Although stock prices have recovered from last year’s decline — and have recently hit all-time highs — many people are still suffering financially, especially Black and Hispanic Americans. In a February report, economic analysts at McKinsey & Co. predicted that, on average, Black and Hispanic workers won’t recover their pre-pandemic employment and salaries until 2024. The lowest-paid workers and those with less than a high school education may not recover even by then.

And while federal and state relief programs have cushioned the impact of pandemic job losses, 11.3% of Americans today live in poverty — compared with 10.7% in January 2020. A federal eviction moratorium, which has helped an estimated 2.2 million people remain in their homes, expires June 30. Without protection from evictions, “millions of Americans could fall off the cliff,” said Vangela Wade, president and CEO of the Mississippi Center for Justice, a nonprofit advocacy group.

Being evicted erodes a person’s health in multiple ways. “Poverty causes a lot of cancer and chronic disease, and this pandemic has caused a lot more poverty,” said Dr. Otis Brawley, a professor at Johns Hopkins University who studies health disparities. “The effect of this pandemic on chronic diseases, such as cardiovascular disease and diabetes, will be measured decades from now.”

Nineteen million adults recently have had trouble putting food on the table. The inability to afford healthy food — which is usually more expensive than salty, starchy fare — can cause both short-term and long-term harm. People with low incomes, for example, are more likely to be hospitalized for low blood sugar toward the end of the month, when they run out of money for food.

In the long term, food insecurity is associated with an increased risk of diabetes, high cholesterol, hypertension, depression, anxiety and other chronic diseases, especially in children.

“Once the acute phase of this crisis has passed, we will face an enormous wave of death and disability,” said Dr. Robert Califf, former commissioner of the Food and Drug Administration, who wrote about post-pandemic health risks in an April editorial in Circulation, a medical journal. “These will be the aftershocks of covid.”

Less Wealth, Poorer Health

American health was poor even before the pandemic, with 60% of the population suffering from a chronic condition, such as obesity, diabetes, high blood pressure or heart failure. These four conditions were associated with nearly two-thirds of hospitalizations from covid, according to a February study in the Journal of the American Heart Association.

Deaths from some chronic diseases began rising in lower-income Americans in the 1990s, Woolf said. That trend was exacerbated by the Great Recession of 2007-09, which undermined the health not just of those who lost their homes or jobs but the population as a whole. Still, the Great Recession, and its resultant health effects, did not affect all Americans equally. Black people in the U.S. today control less wealth than they did before that recession, while the gap in financial security between Black and white Americans has widened, according to a Nonprofit Quarterly article published last year. And the unemployment rate among Black workers did not recover to pre-recession levels until 2016.

Researchers have developed a better understanding in recent years of how chronic stress — such as that caused by poverty, job loss and homelessness — leads to disease. Unrelenting stress causes inflammation that can damage blood vessels, the heart and other organs.

Research shows that people with low incomes live an average of seven to eight years less than those who are financially secure. The richest 1% of Americans live nearly 15 years longer than the poorest 1%.

People who are poor tend to smoke more; have higher risks of chronic illnesses such as cardiovascular disease, diabetes, kidney disease and mental illness; and are more likely to become victims of violence.

The stress of the pandemic also has led many people to smoke, drink and gain weight, increasing the risk of chronic disease. Fatal drug overdoses spiked 30% from October 2019 to October 2020.

Jennifer Drury, 40, has struggled with substance abuse, particularly prescription painkillers, since her 20s. She blames the isolation and stress of the pandemic for causing her to relapse — and leading several of her friends to fatally overdose.

“Idle time is not good for addiction,” said Drury, who fell behind on rent and was evicted from her previous home. She said drug dealers are never far away, especially at the New Orleans motel where she and her husband are now staying. “Drug dealers don’t care about pandemics.”

Women Losing Ground

The American Rescue Plan, which provides $1.9 trillion in pandemic relief, was designed to help displaced workers and cut child poverty rates in half. The actual benefits of the law may prove less sweeping.

Twenty-five states have opted to cut off additional federal unemployment payments, citing concerns that such generous benefits pay people more to stay home than to work.

Many women say they would like to return to work but have no one to take care of their children. Nearly half of child care centers have closed and others have reduced the number of children they serve.

The Federal Reserve Bank of Minneapolis concluded that “economic recovery depends on child care availability.” A March report from the National Women’s Law Center estimates “women have lost a generation of labor force participation gains,” which could leave them and their children financially disadvantaged for years.

Ruth Bermudez is one of millions of women who have left the workforce in the past year. Bermudez, who was laid off from her job as a behavioral health caseworker in New Orleans last year, said her child care needs have prevented her from finding work. The care of her 6-year-old daughter became her full-time job after the pandemic closed schools.

Although her daughter has returned to class, Bermudez said school shutdowns due to covid outbreaks have been frequent and unpredictable.

“I had to be the teacher, the lunch lady, the school bus driver, all at one time,” said Bermudez, 27. “It is exhausting.”

Life-Altering Evictions

James Toussaint had just two weeks to find a new place to live after a judge ordered him evicted. His family was unable to take him in.

“I’ve got family, but everybody has their own issues and problems,” said Toussaint, who had to throw away all his clothes and furniture because they had become infested with bedbugs. “Everyone is trying their best to help themselves.”

Toussaint is now renting a room in a boarding house with no kitchen and a shared bathroom for $160 a week. He’s had to buy cleaning supplies with his own money in order to sanitize the bathroom, which he said is often too dirty to use.

Sharing communal space is often unsanitary and increases the risk of being exposed to the coronavirus, said Emily Benfer, a visiting professor at Wake Forest University School of Law. Even moving in with family poses risks, she said, because it’s impossible to isolate or quarantine in crowded homes.

Benfer co-wrote a November study that found covid infection rates grew twice as high in states that lifted moratoriums on evictions, compared with states that continued to ban them. About 14% of tenants have fallen behind on rent — double the rate before the pandemic.

Toussaint’s annual lease expired during the pandemic, leaving him to rent on a month-to-month basis. While some states require landlords to show “just cause” for eviction, Louisiana landlords can evict tenants for any reason once their annual lease has expired.

Property owners have filed for more than 372,000 evictions during the pandemic in just the five states and 29 cities tracked by Princeton University’s Eviction Lab. A growing body of evidence shows that eviction is toxic to health, causing immediate and long-term damage that increases the risk of death.  Studies show that evicted people are more likely to be in poor general health or have mental health concerns even years later.

“This singular event alters the course of one’s life for the worse,” Benfer said. “If we don’t intervene” to prevent mass evictions when the moratorium ends, “it will be catastrophic for generations to come.”

Eviction’s harms can be measured at every stage of life:

When pregnant women are evicted, their newborns are more likely to be born early or very small and have a higher risk of dying in the first year. Women who are evicted are more likely to suffer sexual assault, Benfer said.

Kids who are evicted are at greater risk of lead poisoning from substandard housing, Benfer said. They’re also more likely than others to be hospitalized.

Evicted adults report worse mental health and are more likely to be hospitalized for a mental health crisis, studies show. They also have higher mortality rates from suicide. Although the causes of addiction are complex, research shows that counties with higher eviction rates have significantly higher rates of drug- and alcohol-related deaths.

People who are evicted often move into substandard housing in neighborhoods with higher crime rates. These homes are sometimes plagued by mold and roaches, lack sufficient heating, or have plumbing that doesn’t work. Landlords have no incentive to make repairs for tenants who are behind on their rent, Benfer said. In fact, tenants who request repairs or report safety hazards risk eviction.

Although middle-class Americans take their kitchens for granted — and rely on them to cook healthful meals — more than 1 million homes lack complete kitchens, according to the U.S. Census Bureau.

New Orleans doesn’t require that rental units include stoves, said Hannah Adams, also a lawyer with Southeast Louisiana Legal Services. Toussaint’s new room is equipped with a microwave and small refrigerator, but no sink, oven or stove. He washes dinner dishes in the bathroom. His landlord doesn’t allow residents to have electric hot plates, so most of his meals involve cold cereal, deli sandwiches or meals he can heat in the microwave. His doctor has urged Toussaint, who is borderline diabetic, to lose weight, eat less salt and starch, and stop smoking.

Toussaint, who lived on the street for two years, said he’s determined not to return there. He hopes to apply for disability insurance, which would provide him with an income if his arthritis prevents him from finding steady work.

Woolf said he hopes Americans won’t forget about the suffering of people like Toussaint as cases of covid decline. “My worry is that people will feel the crisis is behind us and it’s all good,” Woolf said. His research connecting four decades of declining economic opportunity with falling life expectancy shows “we are in really big trouble, and that was true before we knew a pandemic was coming.”

The pandemic doesn’t have to doom a generation of Americans to disease and early death, said Dr. Richard Besser, president and CEO of the Robert Wood Johnson Foundation. By addressing issues such as poverty, racial inequality and the lack of affordable housing, the country can improve American health and reverse the trends that caused communities of color to suffer. “How the pandemic will affect people’s future health depends on what we do coming out of this,” Besser said. “It will take an intentional effort to make up for the losses that have occurred over the past year.”

Calming Computer Jitters: Help for Seniors Who Aren’t Tech-Savvy

Six months ago, Cindy Sanders, 68, bought a computer so she could learn how to email and have Zoom chats with her great-grandchildren.

It’s still sitting in a box, unopened.

“I didn’t know how to set it up or how to get help,” said Sanders, who lives in Philadelphia and has been extremely careful during the coronavirus pandemic.

Like Sanders, millions of older adults are newly motivated to get online and participate in digital offerings after being shut inside, hoping to avoid the virus, for more than a year. But many need assistance and aren’t sure where to get it.

A recent survey from AARP, conducted in September and October, highlights the quandary. It found that older adults boosted technology purchases during the pandemic but more than half (54%) said they needed a better grasp of the devices they’d acquired. Nearly 4 in 10 people (37%) admitted they weren’t confident about using these technologies.

Sanders, a retired hospital operating room attendant, is among them. “Computers put the fear in me,” she told me, “but this pandemic, it’s made me realize I have to make a change and get over that.”

With a daughter’s help, Sanders plans to turn on her new computer and figure out how to use it by consulting materials from Generations on Line. Founded in 1999, the Philadelphia organization specializes in teaching older adults about digital devices and navigating the internet. Sanders recently discovered it through a local publication for seniors.

Before the pandemic, Generations on Line provided free in-person training sessions at senior centers, public housing complexes, libraries and retirement centers. When those programs shut down, it created an online curriculum for smartphones and tablets (www.generationsonline.org/apps) and new tutorials on Zoom and telehealth as well as a “family coaching kit” to help older adults with technology. All are free and available to people across the country.

Demand for Generations on Line’s services rose tenfold during the pandemic as many older adults became dangerously isolated and cut off from needed services.

Those who had digital devices and knew how to use them could do all kinds of activities online: connect with family and friends, shop for groceries, order prescriptions, take classes, participate in telehealth sessions and make appointments to get covid vaccines. Those without were often at a loss — with potentially serious consequences.

“I have never described my work as a matter of life or death before,” said Angela Siefer, executive director of the National Digital Inclusion Alliance, an advocacy group for expanding broadband access. “But that’s what happened during the pandemic, especially when it came to vaccines.”

Other organizations specializing in digital literacy for older adults are similarly seeing a surge of interest. Cyber-Seniors, which pairs older adults with high school or college students who serve as technology mentors, has trained more than 10,000 seniors since April 2020 — three times the average of the past several years. (Services are free and grants and partnerships with government agencies and nonprofit organizations supply funding, as is true for several of the organizations discussed here.)

Older adults using digital devices for the first time can call 1-844-217-3057 and be coached over the phone until they’re comfortable pursuing online training. “A lot of organizations are giving out tablets to seniors, which is fantastic, but they don’t even know the basics, and that’s where we come in,” said Brenda Rusnak, Cyber-Seniors’ managing director. One-on-one coaching is also available.

Lyla Panichas, 78, who lives in Pawtucket, Rhode Island, got an iPad from Rhode Island’s digiAGE program three months ago — among many local technology programs for older adults started during the pandemic. She is getting help from the University of Rhode Island’s Cyber-Seniors program, which plans to offer digital training to 200 digiAGE participants in communities hardest hit by covid-19 by the end of this year.

“The first time my tutor called me, I mean, the kids rattle things off so fast. I said, Wait a minute. You have a little old lady here. Let me keep up with you,” Panichas said. “I couldn’t keep up and I ended up crying.”

Panichas persisted, however, and when her tutor called again the next week she began “being able to grasp things.” Now, she plays games online, streams movies and has Zoom get-togethers with her son, in Arizona, and her sister, in Virginia. “It’s kind of lifted my fears of being isolated,” she told me.

OATS (Older Adults Technology Services) is set to expand the reach of its digital literacy programs significantly after a recent affiliation with AARP. It runs a national hotline for people seeking technical support, 1-920-666-1959, and operates Senior Planet technology training centers in six cities (New York; Denver; Rockville, Maryland; Plattsburgh, New York; San Antonio, Texas; and Palo Alto, California). All in-person classes converted to digital programming once the pandemic closed down much of the country.

Germaine St. John, 86, a former mayor of Laramie, Wyoming, found an online community of seniors and made dear friends after signing up with Senior Planet Colorado during the pandemic. “I have a great support system here in Laramie, but I was very cautious about going out because I was in the over-80 group,” she told me. “I don’t know what I would have done without these activities.”

Older adults anywhere in the country can take Senior Planet virtual classes for free. (A weekly schedule is available at https://seniorplanet.org/get-involved/online/.) Through its AARP partnership, OATS is offering another set of popular classes at AARP’s Virtual Community Center. Tens of thousands of older adults now participate.

Aging Connected (https://agingconnected.org/), another new OATS initiative, is focusing on bringing 1 million older adults online by the end of 2022.

An immediate priority is to educate older adults about the government’s new $32 billion Emergency Broadband Benefit for low-income individuals, which was funded by a coronavirus relief package and became available last month. That short-term program provides $50 monthly discounts on high-speed internet services and a one-time discount of up to $100 for the purchase of a computer or tablet. But the benefit isn’t automatic. People must apply to get funding.

“We are calling on anybody over the age of 50 to try the internet and learn what the value can be,” said Thomas Kamber, OATS’ executive director. Nearly 22 million seniors don’t have access to high-speed internet services, largely because these services are unaffordable or unavailable, according to a January report co-sponsored by OATS and the Humana Foundation, its Aging Connected partner.

Other new ventures are also helping older adults with technology. Candoo Tech, which launched in February 2019, works with seniors directly in 32 states as well as organizations such as libraries, senior centers and retirement centers.

For various fees, Candoo Tech provides technology training by phone or virtually, as-needed support from “tech concierges,” advice about what technology to buy and help preparing devices for out-of-the-box use.

“You can give an older adult a device, access to the internet and amazing content, but if they don’t have someone showing them what to do, it’s going to sit there unused,” said Liz Hamburg, Candoo’s president and chief executive.

GetSetUp’s model relies on older adults to teach skills to their peers in small, interactive classes. It started in February 2020 with a focus on tech training, realizing that “fear of technology” was preventing older adults from exploring “a whole world of experiences online,” said Neil Dsouza, founder and chief executive.

For older adults who’ve never used digital devices, retired teachers serve as tech counselors over the phone. “Someone can call in [1-888-559-1614] and we’ll walk them through the whole process of downloading an app, usually Zoom, and taking our classes,” Dsouza said. GetSetUp is offering about 80 hours of virtual technology instruction each week.

For more information about tech training for older adults in your area, contact your local library, senior center, department on aging or Area Agency on Aging. Also, each state has a National Assistive Technology Act training center for older adults and people with disabilities. These centers let people borrow devices and offer advice about financial assistance. Some started collecting and distributing used smartphones, tablets and computers during the pandemic.

For information about a program in your area, go to https://www.at3center.net/.

Miles de niños perdieron a sus padres por covid. ¿Adónde está la ayuda?

Cinco meses después de que su esposo muriera por covid-19, Valerie Villegas puede ver cómo el duelo ha marcado a sus hijos.

Nicholas, el bebé, que tenía 1 año cuando murió su padre y casi desteta, ahora quiere tomar la teta a toda hora, y llama a cada hombre alto de cabello oscuro “Dada”, la única palabra que conoce. Robert, de 3 años, sufre frecuentes rabietas, dejó de usar la pelela, y teme contagiarse gérmenes. Ayden, de 5, anunció recientemente que su trabajo es “ser fuerte”, y proteger a su madre y a sus hermanos.

Sus hijos mayores, Kai Flores, 13, Andrew Vaiz, 16 y Alexis Vaiz, 18, a menudo están callados, tristes o enojados. A los dos mayores les recetaron antidepresivos poco después de perder a su padrastro porque la ansiedad no los dejaba concentrarse o dormir.

“Paso la mitad de las noches llorando”, dijo Villegas, de 41 años, enfermera de cuidados paliativos de Portland, Texas. Se quedó viuda el 25 de enero, solo tres semanas después de que Robert Villegas, de 45, conductor de camión fuerte y saludable, experto en jiujitsu, diera positivo para el virus.

“Mis hijos son mi principal preocupación”, dijo. “Y necesitamos ayuda”.

Pero en una nación donde los investigadores calculan que más de 46,000 niños han perdido a uno o ambos padres a causa de covid desde febrero de 2020, Villegas y otros sobrevivientes dicen que encontrar servicios básicos para que sus hijos sobrelleven el luto (consejería, grupos de apoyo, asistencia financiera) ha sido difícil, si no imposible.

“Dicen que está ahí”, dijo Villegas. “Pero intentar conseguirla ha sido una pesadilla”.

Las entrevistas con casi dos docenas de investigadores, terapeutas y otros expertos en pérdida y duelo, así como con familias cuyos seres queridos murieron por covid, revelan hasta qué punto el acceso a grupos de duelo y terapeutas se volvió escaso durante la pandemia. Los proveedores pasaron a ofrecer visitas virtuales y las listas de espera aumentaron, lo que a menudo dejó a los niños desamparados y a sus padres sobrevivientes, solos.

“Perder a un padre es devastador para un niño”, dijo Alyssa Label, terapeuta de San Diego y gerenta de programas de SmartCare Behavioral Health Consultation Services. “Perder a un padre durante una pandemia es una forma especial de tortura”.

Los niños pueden recibir beneficios destinados a sobrevivientes cuando un padre muere, si el padre trabajó el tiempo suficiente en un empleo “en blanco”, pagando impuestos al Seguro Social. Durante la pandemia, el número de hijos menores de trabajadores fallecidos que recibieron nuevos beneficios ha aumentado, llegando a casi 200,000 en 2020, frente a un promedio de 180,000 en los tres años anteriores.

Los funcionarios de la Administración del Seguro Social (SSA) no rastrean la causa de la muerte, pero las cifras más recientes marcaron la mayor cantidad de beneficios otorgados desde 1994. Las muertes por covid “indudablemente” alimentaron ese aumento, según la Oficina del Actuario Jefe de la SSA.

Y el número de niños elegibles para esos beneficios seguramente es mayor. Solo cerca de la mitad de los 2 millones de niños en los Estados Unidos que perdieron a un padre en 2014 recibieron los beneficios del Seguro Social a los que tenían derecho, según un análisis de 2019 realizado por David Weaver de la Oficina de Presupuesto del Congreso.

Los consejeros dijeron que encuentran que muchas familias no tienen idea de que los niños califican para los beneficios cuando muere un padre que trabaja, o no saben cómo inscribirse.


Valerie Villegas (izq.) sostiene a su hijo Robert Jr. mientras su hijo mayor mayor Andrew le pone las zapatillas a su hermanitos Ayden. Villegas dice que sus seis hijos siguen sufriendo el duelo por haber perdido a su padre y padrastro.(Scott Stephen Ball for KHN)

En un país que ofreció ayuda filantrópica y gubernamental a los 3,000 niños que perdieron a sus padres a causa de los ataques terroristas del 9/11, no ha habido un esfuerzo organizado para identificar, rastrear o apoyar a las decenas de miles de niños de luto por covid.

“No tengo conocimiento de ningún grupo que esté trabajando en esto”, dijo Joyal Mulheron, fundador de Evermore, una fundación sin fines de lucro que se enfoca en políticas públicas relacionadas con el luto. “Debido a que la escala del problema es tan grande, la escala de la solución debe estar a la misma altura”.

Covid se ha cobrado más de 600,000 vidas en el país. En una publicación en la revista JAMA Pediatrics, investigadores calcularon que por cada 13 muertes causadas por el virus, un niño menor de 18 años ha perdido a un padre. Al 15 de junio, eso se traduciría en un estimado de más de 46,000 niños. Tres cuartas partes de los niños son adolescentes; los otros tienen menos de 10 años. Aproximadamente el 20% de los niños que han perdido a sus padres son afroamericanos, aunque constituyen el 14% de la población.

“Existe esta pandemia en la sombra”, dijo Rachel Kidman, profesora asociada de la Universidad Stony Brook en Nueva York, que formó parte del equipo que encontró una manera de calcular el impacto de las muertes por covid. “Hay una gran cantidad de niños de luto”.

La administración Biden, que lanzó un programa para ayudar a pagar los costos de los funerales de las víctimas de covid, no respondió a las preguntas sobre la ayuda para estos niños.

No abordar la creciente cohorte de niños en duelo, ya sea en una sola familia o en general, podría tener efectos duraderos, dijeron investigadores. La pérdida de un padre en la infancia se ha relacionado con mayores riesgos de adicciones, problemas de salud mental, bajo rendimiento escolar, menor asistencia a la universidad, menor empleo y muerte prematura.


Robert Villegas co sus hijos Robert Jr., Nicholas y Ayden en diciembre de 2020, a pocas semanas de morir por covid.(Valerie Villegas)

“El duelo es el estrés más común y lo más estresante que las personas atraviesan en sus vidas”, dijo el psicólogo clínico Christopher Layne del Centro Nacional de Estrés Traumático Infantil de UCLA /Duke University. “Merece nuestro cuidado y preocupación”.

Es posible que entre el 10% y el 15% de los niños y otras personas en duelo por covid podrían cumplir con los criterios de un nuevo diagnóstico, el trastorno de duelo prolongado, lo que podría significar miles de niños con síntomas que requieren atención clínica. “Esta es literalmente una emergencia de salud pública nacional”, dijo Layne.

Aún así, Villegas y otros dicen que en gran medida se han quedado solos para navegar por un confuso mosaico de servicios comunitarios para sus hijos, mientras luchan con su propio dolor.

“Llamé a la consejera de la escuela. Me dio algunos pequeños recursos sobre libros y esas cosas”, dijo Villegas. “Llamé a una línea directa de crisis. Llamé a los lugares de asesoramiento, pero no pudieron ayudar porque tenían listas de espera y necesitaban seguro. Mis hijos perdieron su seguro cuando murió su padre”.

La interrupción social y el aislamiento causados ​​por la pandemia también abrumaron a los proveedores de atención del duelo. En todo el país, las agencias sin fines de lucro que se especializan en el duelo infantil dijeron que se han apresurado a satisfacer la necesidad y pasar de la participación en persona a la virtual.

“Fue un gran desafío; era algo muy ajeno a nuestra forma de trabajar”, dijo Vicki Jay, directora ejecutiva de la National Alliance for Grieving Children. “El trabajo de duelo se basa en las relaciones y es muy difícil establecer una relación con una sola pieza de la maquinaria”.


Valerie Villegas juega con sus hijos Robert Jr., Ayden y Nicholas, en el fondo de su casa de Portland Texas.(Scott Stephen Ball for KHN)

En Experience Camps, que cada año ofrece campamentos gratuitos de una semana a aproximadamente 1,000 niños de luto en todo el país, la lista de espera ha crecido más del 100% desde 2020, dijo Talya Bosch, asociada de Experience Camps. “Es algo que nos preocupa: muchos niños no reciben el apoyo que necesitan”, dijo.

Los consejeros privados también se han visto superados. Jill Johnson-Young, copropietaria de Central Counseling Services en Riverside, California, dijo que sus casi tres docenas de terapeutas han sido contratados sólidamente durante meses. “No conozco a ningún terapeuta en el área que no esté colmado en este momento”, dijo.

La doctora Sandra McGowan-Watts, de 47 años, médica familiar en Chicago, perdió a su esposo, Steven, a causa de covid en mayo de 2020. Se siente afortunada de haber encontrado un terapeuta en línea para su hija, Justise, quien le ayudó a entender por qué su hija de 12 años estaba tan triste por las mañanas: “Mi esposo era quien la despertaba para la escuela. La ayudaba a prepararse para la escuela”.


Valerie Villegas Celebrando el cumpleaños 45 de su esposo Robert, el 10 de noviembre de 2020, semanas antes de que murieran a causa de covid. “Fue un luchador mental y físico”, dijo Valerie. “Era un hombre muy fuerte”.(Valerie Villegas)

Justise también pudo obtener un lugar en una sesión de Experience Camps este verano. “Estoy nerviosa por ir al campamento, pero estoy emocionada por conocer nuevos niños que también han perdido a alguien cercano en su vida”, dijo.

Jamie Stacy, de 42 años, de San José, California, se conectó con un consejero en línea para su hija, Grace, de 8, y sus hijos gemelos, Liam y Colm, de 6, después de que su padre, Ed Stacy, muriera de covid en marzo de 2020 a los 52.

Solo entonces aprendió que los niños pueden sufrir de manera diferente a los adultos. Tienden a centrarse en preocupaciones concretas, como dónde vivirán y si sus juguetes o mascotas favoritos estarán allí. A menudo alternan períodos de juego con momentos de tristeza rápidamente para evitar confrontar sus sentimientos de pérdida.

“Los chicos jugarán con Legos, se lo pasarán en grande, y de repente te arrojarán una bomba: ‘Sé cómo puedo volver a ver a papá. Solo tengo que morir y volveré a ver a papá ‘”, dijo Stacy. “Y luego vuelven a jugar a Legos”.

Stacy dijo que la consejería ha sido crucial para ayudar a su familia a navegar en un mundo donde muchas personas están marcando el fin de la pandemia. “No podemos escapar del tema del= covid-19 ni siquiera por un día”, dijo. “Siempre está en nuestra cara, donde sea que vayamos, un recordatorio de nuestra dolorosa pérdida”.

Mientras tanto, Villegas, en Texas, ha regresado a su trabajo en cuidados paliativos y está comenzando a reconstruir su vida. Pero cree que debería haber ayuda formal y apoyo para familias en duelo como la suya, cuyas vidas han sido marcadas a fuego por el mortal virus.

“Ahora todos están volviendo a sus vidas normales”, dijo. “Pueden volver a sus vidas. Pero yo creo que mi vida nunca volverá a ser normal “.

KHN (Kaiser Health News) es la redacción de KFF (Kaiser Family Foundation), que produce periodismo en profundidad sobre temas de salud. Junto con Análisis de Políticas y Encuestas, KHN es uno de los tres principales programas de KFF. KFF es una organización sin fines de lucro que brinda información sobre temas de salud a la nación.

Esta historia fue producida por KHN, que publica California Healthline, un servicio editorialmente independiente de la California Health Care Foundation.

At Texas Border, Pandemic’s High Toll Lays Bare Gaps in Health and Insurance

EL PASO, Texas — Alfredo “Freddy” Valles was an accomplished trumpeter and a beloved music teacher for nearly four decades at one of the city’s poorest middle schools.

He was known for buying his students shoes and bow ties for their band concerts, his effortlessly positive demeanor and a suave personal style — “he looked like he stepped out of a different era, the 1950s,” said his niece Ruby Montana.

While Valles was singular in life, his death at age 60 in February was part of a devastating statistic: He was one of thousands of deaths in Texas border counties — where coronavirus mortality rates far outpaced state and national averages.

In the state’s border communities, including El Paso, not only did people die of covid-19 at significantly higher rates than elsewhere, but people under age 65 were also more likely to die, according to a KHN-El Paso Matters analysis of covid death data through January. More than 7,700 people died of covid in the border area during that period.

In Texas, covid death rates for border residents younger than 65 were nearly three times the national average for that age group and more than twice the state average. And those ages 18-49 were nearly four times more likely to die than those in the same age range across the U.S.

“This was like a perfect storm,” said Heide Castañeda, an anthropology professor at the University of South Florida who studies the health of border residents. She said a higher-than-normal prevalence of underlying health issues combined with high uninsurance rates and flagging access to care likely made the pandemic even more lethal for those living along the border than elsewhere.

That pattern was not as stark in neighboring New Mexico. Border counties there recorded covid death rates 41% lower than those in Texas, although the New Mexico areas were well above the national average as of January, the KHN-El Paso Matters analysis found. Texas border counties tallied 282 deaths per 100,000, compared with 166 per 100,000 in New Mexico.

That stark divide could be seen even when looking at neighboring El Paso County, Texas, and Doña Ana County, New Mexico. The death rate for residents under 65 was 70% higher in El Paso County.

Health experts said Texas’ refusal to expand Medicaid under the Affordable Care Act, a shortage of health care options and the state’s lax strategy toward the pandemic also contributed to a higher death rate at the border. Texas GOP leaders have opposed Medicaid expansion for a litany of economic and political reasons, though largely because they object to expanding the role or size of government.

“Having no Medicaid expansion and an area that is already underserved by primary care and preventive care set the stage for a serious situation,” Castañeda said. “A lot of this is caused by state politics.”

Texas was one of the first states to reopen following the nationwide coronavirus shutdown in March and April last year. Last June — even as cases were rising — Gov. Greg Abbott allowed all businesses, including restaurants, to operate at up to 50% capacity, with limited exceptions. And he refused to put any capacity restrictions on churches and other religious facilities or let local governments impose mask requirements.

In November, Texas Attorney General Ken Paxton filed an injunction to stop a lockdown order implemented by the El Paso county judge, the top administrative officer, at a time when El Paso hospitals were so overwhelmed with covid patients that 10 mobile morgues had to be set up at an area hospital to accommodate the dead.

Unlike Texas, New Mexico expanded Medicaid under the ACA and, as a result, has a much lower uninsured rate than Texas for people under age 65 — 12% compared with Texas’ 21%, according to Census figures. And New Mexico had aggressive rules for face masks and public gatherings. Still, that didn’t spare New Mexico from the crisis. Outbreaks in and around the Navajo reservation hit hard. Overall, its state death rate exceeded the state rate for Texas, but along the border New Mexico’s rates were lower in all age groups.

For some border families, the immense toll of the pandemic meant multiple deaths among loved ones. Ruby Montana lost not only her uncle to covid in recent months, but also her cousin Julieta “Julie” Apodaca, a former elementary school teacher and speech therapist.

Montana said Valles’ death surprised the family. He had been teaching remotely at Guillen Middle School in El Paso’s Segundo Barrio neighborhood, an area known as “the other Ellis Island” because of its adjacency to the border and its history as an enclave for Mexican immigrant families.


Alfredo “Freddy” Valles was an accomplished trumpeter and a beloved music teacher for nearly four decades in El Paso, Texas. He died of covid in February. (Ruby Montana)

When Valles first got sick with covid in December, Montana and the family were not worried, not only because he had no preexisting health conditions, but also because they knew his lungs were strong from practicing his trumpet daily over the course of decades.

In early January, he went to an urgent care center after his condition deteriorated. He had pneumonia and was told to go straight to the emergency room.

“When I took him to the [hospital], I dropped him off and went to go park,” said his wife, Elvira. But when she returned, she was not allowed inside. “I never saw him again,” she said.

Valles, a father of three, had been teaching one of his three grandchildren, 5-year-old Aliq Valles, to play the trumpet.

They “were joined at the hip,” Montana said. “That part has been really hard to deal with too. [Aliq] should have a whole lifetime with his grandpa.”

Hispanic adults are more than twice as likely to die of covid as white adults, according to the Centers for Disease Control and Prevention. In Texas, Hispanic residents died of covid at a rate four times as high as that of non-Hispanic white people, according to a December analysis by The Dallas Morning News.

Ninety percent of residents under 65 in Texas border counties are Hispanic, compared with 37% in the rest of the state. Latinos have high rates of chronic conditions like diabetes and obesity, which increases their risks of covid complications, health experts say.

Because they were more likely to die of covid at earlier ages, Latinos are losing the most years of potential life among all racial and ethnic groups, said Coda Rayo-Garza, an advocate for policies to aid Hispanic populations and a professor of political science at the University of Texas-San Antonio.

Expanding Medicaid, she said, would have aided the border communities in their fight against covid, as they have some of the highest rates of residents without health coverage in the state.

“There has been a disinvestment in border areas long before that led to this outcome that you’re finding,” she said. “The legislature did not end up passing Medicaid expansion, which would have largely benefited border towns.”

The higher death rates among border communities are “unfortunately not surprising,” said Rep. Veronica Escobar (D-El Paso).

“It’s exactly what we warned about,” Escobar said. “People in Texas died at disproportionate rates because of a dereliction on behalf of the governor. He chose not to govern … and the results are deadly.”

Abbott spokesperson Renae Eze said the governor mourns every life lost to covid.

“Throughout the entire pandemic, the state of Texas has worked diligently with local officials to quickly provide the resources needed to combat covid and keep Texans safe,” she said.

ErnestoCastañeda, a sociology professor at American University in Washington, D.C., who is not related to Heide Castañeda, said structural racism is integrally linked to poor health outcomes in border communities. Generations of institutional discrimination — through policing, educational and job opportunities, and health care — worsens the severity of crisis events for people of color, he explained.

“We knew it was going to be bad in El Paso,” Ernesto Castañeda said. “El Paso has relatively low socioeconomic status, relatively low education levels, high levels of diabetes and overweight [population].”

In some Texas counties along the border more than a third of workers are uninsured, according to an analysis by Georgetown University’s Center for Children and Families.

“The border is a very troubled area in terms of high uninsured rates, and we see all of those are folks put at increased risk by the pandemic,” said Joan Alker, director of the center.

In addition, because of a shortage of health workers along much of the border, the pandemic surge was all the deadlier, said Dr. Ogechika Alozie, an El Paso specialist in infectious diseases.

“When you layer on top not having enough medical personnel with a sicker-on-average population, this is really what you find happens, unfortunately,” he said.

The federal government has designated the entire Texas border region as both a health professional shortage area and a medically underserved area.

Jagdish Khubchandani, a professor of public health at New Mexico State University in Las Cruces, about 40 miles northwest of El Paso, said the two cities were like night and day in their response to the crisis.

“Restrictions were far more rigid in New Mexico,” he said. “It almost felt like two different countries.”

Manny Sanchez, a commissioner in Doña Ana County, credits the lower death rates in New Mexico to state and local officials’ united message to residents about covid and the need to wear masks and maintain physical distance. “I would like to think we made a difference in saving lives,” Sanchez said.

But, because containing a virus requires community buy-in, even El Paso residents who understood the risks were susceptible to covid. Julie Apodaca, who had recently retired, had been especially careful, in part because her asthma and diabetes put her at increased risk. As the primary caregiver for her elderly mother, she was likely exposed to the virus through one of the nurse caretakers who came to her mother’s home and later tested positive, said her sister Ana Apodaca.

Julie Apodaca had registered for a covid vaccine in December as soon as it was available but had not been able to get an appointment for a shot by the time she fell ill.

Montana found out that Apodaca had been hospitalized the day after her uncle died. One month later, and after 16 days on a ventilator, she too died on March 13.

She was 56.

This story was done in partnership with El Paso Matters, a member-supported, nonpartisan media organization that focuses on in-depth and investigative reporting about El Paso, Texas, Ciudad Juárez across the border in Mexico, and neighboring communities.

Methodology

To analyze covid deaths rates along the border with Mexico, KHN and El Paso Matters requested covid-related death counts by age group and county from Texas, New Mexico, California and Arizona. California and Arizona were unable to fulfill the requests. The Texas Department of State Health Services and the New Mexico Department of Health provided death counts as of Jan. 31, 2021.

Texas’ data included totals by age group for border counties as a group and for the state with no suppression of data. New Mexico provided data for individual counties, and small numbers were suppressed, totaling 1.6% of all deaths in the state. (Data on deaths is commonly suppressed when it involves very small numbers to protect individual identities.)

National death counts by age group were calculated using provisional death data from the Centers for Disease Control and Prevention, and included deaths as of Jan. 31, 2021.

Rates were calculated per 100,000 people using the 2019 American Community Survey.

The ethnic breakdown in Texas’ border counties comes from the Census Bureau’s 2019 population estimates.

Thousands of Young Children Lost Parents to Covid. Where’s Help for Them?

Five months after her husband died of covid-19, Valerie Villegas can see how grief has wounded her children.

Nicholas, the baby, who was 1 and almost weaned when his father died, now wants to nurse at all hours and calls every tall, dark-haired man “Dada,” the only word he knows. Robert, 3, regularly collapses into furious tantrums, stopped using the big-boy potty and frets about sick people giving him germs. Ayden, 5, recently announced it’s his job to “be strong” and protect his mom and brothers.

Her older kids — Kai Flores, 13, Andrew Vaiz, 16, and Alexis Vaiz, 18 — are often quiet and sad or angry and sad, depending on the day. The two eldest, gripped by anxiety that makes it difficult to concentrate or sleep, were prescribed antidepressants soon after losing their stepfather.

“I spend half the nights crying,” said Villegas, 41, a hospice nurse from Portland, Texas. She became a widow on Jan. 25, just three weeks after Robert Villegas, 45, a strong, healthy truck driver and jiujitsu expert, tested positive for the virus.

“My kids, they’re my primary concern,” she said. “And there’s help that we need.”

But in a nation where researchers calculate that more than 46,000 children have lost one or both parents to covid since February 2020, Villegas and other survivors say finding basic services for their bereaved kids — counseling, peer support groups, financial assistance — has been difficult, if not impossible.

“They say it’s out there,” Villegas said. “But trying to get it has been a nightmare.”

Interviews with nearly two dozen researchers, therapists and other experts on loss and grief, as well as families whose loved ones died of covid, reveal the extent to which access to grief groups and therapists grew scarce during the pandemic. Providers scrambled to switch from in-person to virtual visits and waiting lists swelled, often leaving bereft children and their surviving parents to cope on their own.

“Losing a parent is devastating to a child,” said Alyssa Label, a San Diego therapist and program manager with SmartCare Behavioral Health Consultation Services. “Losing a parent during a pandemic is a special form of torture.”

Children can receive survivor benefits when a parent dies if that parent worked long enough in a job that required payment of Social Security taxes. During the pandemic, the number of minor children of deceased workers who received new benefits has surged, reaching nearly 200,000 in 2020, up from an average of 180,000 in the previous three years. Social Security Administration officials don’t track cause of death, but the latest figures marked the most awards granted since 1994. Covid deaths “undoubtedly” fueled that spike, according to the SSA’s Office of the Chief Actuary.

And the number of children eligible for those benefits is surely higher. Only about half of the 2 million children in the U.S. who have lost a parent as of 2014 received the Social Security benefits to which they were entitled, according to a 2019 analysis by David Weaver of the Congressional Budget Office.

Counselors said they find many families have no idea that children qualify for benefits when a working parent dies, or don’t know how to sign up.


Valerie Villegas (left) holds Robert Jr. as her oldest son, Andrew Vaiz, ties Ayden’s shoes. Villegas says all six of her children have been affected by the grief of losing their father and stepfather.(Scott Stephen Ball for KHN)

In a country that showered philanthropic and government aid on the 3,000 children who lost parents to the 9/11 terror attacks, there’s been no organized effort to identify, track or support the tens of thousands of kids left bereaved by covid.

“I’m not aware of any group working on this,” said Joyal Mulheron, the founder of Evermore, a nonprofit foundation that focuses on public policy related to bereavement. “Because the scale of the problem is so huge, the scale of the solution needs to match it.”

Covid has claimed more than 600,000 lives in the U.S., and researchers writing in the journal JAMA Pediatrics calculated that for every 13 deaths caused by the virus, one child under 18 has lost a parent. As of June 15, that would translate into more than 46,000 kids, researchers estimated. Three-quarters of the children are adolescents; the others are under age 10. About 20% of the children who’ve lost parents are Black, though they make up 14% of the population.


Robert Villegas cuddled sons Robert Jr. (left), Nicholas and Ayden in December 2020, weeks before he fell ill with covid-19 and died. “You can go explain to my 1-, 3- and 5-year-old that their daddy is not coming home,” his widow, Valerie Villegas, told doctors.(Valerie Villegas)

“There’s this shadow pandemic,” said Rachel Kidman, an associate professor at Stony Brook University in New York, who was part of the team that found a way to calculate the impact of covid deaths. “There’s a huge amount of children who have been bereaved.”

The Biden administration, which launched a program to help pay funeral costs for covid victims, did not respond to questions about offering targeted services for families with children.

Failing to address the growing cohort of bereaved children, whether in a single family or in the U.S. at large, could have long-lasting effects, researchers said. The loss of a parent in childhood has been linked to higher risks of substance use, mental health problems, poor performance in school, lower college attendance, lower employment and early death.

“Bereavement is the most common stress and the most stressful thing people go through in their lives,” said clinical psychologist Christopher Layne of the UCLA/Duke University National Center for Child Traumatic Stress. “It merits our care and concern.”

Perhaps 10% to 15% of children and others bereaved by covid might meet the criteria of a new diagnosis, prolonged grief disorder, which can occur when people have specific, long-lasting responses to the death of a loved one. That could mean thousands of children with symptoms that warrant clinical care. “This is literally a national, very public health emergency,” Layne said.

Still, Villegas and others say they have been left largely on their own to navigate a confusing patchwork of community services for their children even as they struggle with their own grief.

“I called the counselor at school. She gave me a few little resources on books and stuff,” Villegas said. “I called some crisis hotline. I called counseling places, but they couldn’t help because they had waiting lists and needed insurance. My kids lost their insurance when their dad died.”


Valerie Villegas plays with her three youngest sons — Robert Jr., Ayden and Nicholas — at their Portland, Texas, home. Her husband, Robert Villegas, built the tire swing for the boys in 2020. In late December, 45-year-old Robert contracted covid-19. He died in January. (Scott Stephen Ball for KHN)

The social disruption and isolation caused by the pandemic overwhelmed grief care providers, too. Across the U.S., nonprofit agencies that specialize in childhood grief said they have scrambled to meet the need and to switch from in-person to virtual engagement.

“It was a huge challenge; it was very foreign to the way we work,” said Vicki Jay, CEO of the National Alliance for Grieving Children. “Grief work is based on relationships, and it’s very hard to get a relationship with a piece of machinery.”

At Experience Camps, which each year offers free weeklong camps to about 1,000 bereaved kids across the country, the waiting list has grown more than 100% since 2020, said Talya Bosch, an Experience Camps associate. “It is something that we are concerned about — a lot of kids are not getting the support they need,” she said.

Private counselors, too, have been swamped. Jill Johnson-Young, co-owner of Central Counseling Services in Riverside, California, said her nearly three dozen therapists have been booked solid for months. “I don’t know a therapist in the area who isn’t full right now,” she said.

Dr. Sandra McGowan-Watts, 47, a family practice doctor in Chicago, lost her husband, Steven, to covid in May 2020. She feels fortunate to have found an online therapist for her daughter, Justise, who helped explain why the 12-year-old was suddenly so sad in the mornings: “My husband was the one who woke her up for school. He helped her get ready for school.”


Valerie Villegas and her husband, Robert Villegas, celebrated his 45th birthday on Nov. 10, 2020, weeks before he died of covid-19. “He was a fighter, not only physically but mentally,” she says. “He was a very strong man.” (Valerie Villegas)

Justise was also able to get a spot at an Experience Camps session this summer. “I am nervous about going to camp, but I am excited about meeting new kids who have also lost someone close in their life,” she said.

Jamie Stacy, 42, of San Jose, California, was connected with an online counselor for her daughter, Grace, 8, and twin sons, Liam and Colm, 6, after their father, Ed Stacy, died of covid in March 2020 at age 52. Only then did she learn that children can grieve differently than adults. They tend to focus on concrete concerns, such as where they’ll live and whether their favorite toys or pets will be there. They often alternate periods of play with sadness, cycling rapidly between confronting and avoiding their feelings of loss.

“The boys will be playing Legos, having a great time, and all of a sudden drop a bomb on you: ‘I know how I can see Daddy again. I just have to die, and I’ll see Daddy again,’” she said. “And then they’re back to playing Legos.”

Stacy said counseling has been crucial in helping her family navigate a world where many people are marking the end of the pandemic. “We can’t escape the topic of covid-19 even for one day,” she said. “It’s always in our face, wherever we go, a reminder of our painful loss.”

Villegas, in Texas, has returned to her work in hospice care and is starting to reassemble her life. But she thinks there should be formal aid and grief support for families like hers whose lives have been indelibly scarred by the deadly virus.

“Now everybody’s lives are going back to normal,” she said. “They can get back to their lives. And I’m thinking my life will never be normal again.”

This story was produced by KHN (Kaiser Health News), a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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

Is Rand Paul Mixing Up the Vaccine Message for Covid Survivors?

Last week, Sen. Rand Paul (R-Ky.) posted a Twitter thread asserting that people who have survived a covid-19 infection were unlikely to be reinfected and have better immunity against variants than those who have been vaccinated against — but not infected by — SARS-CoV-2, the virus that causes covid.

The social media communication represented his latest salvo in the ongoing debate over whether natural immunity is equivalent or even better than vaccination.

While the science on the subject is still evolving, a look at the evidence behind Paul’s series of tweets seemed in order. After all, though almost 65% of Americans have received at least one dose of a covid vaccine, some people who have recovered from covid may not feel a need to get shot. Paul, who was the first senator to be diagnosed with the virus, is among them. Here’s a deeper look at what Paul said on Twitter, the studies he cited and how researchers characterized his comments.

Breaking Down the Twitter Thread

In his first tweet, Paul referenced a recent Cleveland Clinic study finding that among subjects who were unvaccinated but had already had covid-19, there were no re-infections in a five-month observation period: “Great news! Cleveland clinic study of 52,238 employees shows unvaccinated people who have had COVID 19 have no difference in re-infection rate than people who had COVID 19 and who took the vaccine.”

In subsequent tweets, the senator said: “The immune response to natural infection is highly likely to provide protective immunity even against the SARS-CoV-2 variants. … Thus, recovered COVID-19 patients are likely to better defend against the variants than persons who have not been infected but have been immunized with spike-containing vaccines only.” All three vaccines authorized for emergency use in the U.S. (Pfizer-BioNTech, Moderna and Johnson & Johnson) contain genetic instructions that tell our cells how to make a spike protein associated with the coronavirus. The presence of that spike protein then causes our bodies to make antibodies to protect against covid.

At the end of his final tweet, Rand then linked to a second study led by scientists at the Fred Hutchinson Cancer Research Center in Seattle to support his assertions.

Digesting the Scientific Papers

Paul referenced two scientific papers in his tweet thread — both of which are preprints, meaning they have not yet been published in scientific journals or been peer-reviewed.

One was a study from the Cleveland Clinic following four categories of health care workers: unvaccinated but previously infected; unvaccinated but not previously infected; vaccinated and previously infected; and vaccinated but not previously infected. The workers were followed for five months.

The researchers found that no one who was unvaccinated but had previously been infected with covid became infected again during the five-month study period. Infections were almost zero among those who were vaccinated, while there was a steady increase in infections among those who were unvaccinated and previously uninfected.

When asked whether he believed Paul’s tweet had interpreted his study results correctly, the study’s lead author, Dr. Nabin Shrestha, an infectious diseases specialist at Cleveland Clinic, said “it was an accurate interpretation of the study’s findings.”

However, Dr. George Rutherford, an epidemiologist at the University of California-San Francisco, wrote in an email that he would add one caveat to the wording of Paul’s tweet: “Note that in his tweet Senator Paul seems to suggest that the denominator of previously infected health care workers at the Cleveland Clinic was 52,238 — that was the total number in the whole study. There were 1,359 that were previously infected and never vaccinated, and there were no reinfections noted over a median follow up of 143 days. So, the tweet itself is accurate if read literally but the denominator is really 1,359.”

As for the other study Paul mentioned, researchers analyzed covid-19 immunity in those who had been infected with the covid virus and those who hadn’t and found that infection activated a range of immune cells and immunity lasted at least eight months.

In his last two tweets in the thread, Paul quotes directly from the study’s “discussion” section: “The immune response to natural infection is highly likely to provide protective immunity even against the SARS-CoV-2 variants. … Thus, recovered COVID-19 patients are likely to better defend against the variants than persons who have not been infected but have been immunized with spike-containing vaccines only.”

The lead study author, Kristen Cohen, a senior staff scientist in the Vaccine and Infectious Disease Division at the Fred Hutchinson Cancer Research Center in Seattle, acknowledged that Paul’s tweet was a direct quote from the study. Still, she said, in her view, the quote was taken out of context and presented to suit Paul’s objective — but does not accurately reflect the overall take-home message from the study’s findings.

That’s because, she said, Paul was quoting from the discussion section of the paper. The discussion is the final section of a scientific paper, and Cohen said its purpose here was to project what the study’s findings could imply for a broader scientific significance.

“We wrote that recovering covid patients are “likely” to better defend against variants than those who have just been immunized, but it’s not saying they do,” said Cohen. “It’s not saying they have been known to. It’s making a hypothesis or basically saying this could be the case.”

In fact, Cohen’s study did not include any subjects who had been vaccinated. The researchers were merely reasoning in the sentence Paul quoted that, based on the data showing the immune system’s broad natural response, those who recover from covid-19 and then receive a vaccine may be better protected against covid variants than those who had only vaccine-induced immunity.

“We did not intend to argue that infected people do not need to get vaccinated or that their immune responses are superior,” Cohen wrote in an email.

However, Cohen recognized the sentence was confusing when taken out of context and said she will eliminate it from the paper when it gets submitted for publication.

Cohen pointed us to another Fred Hutchinson-led study with which she was involved. It did show that people who previously had covid-19 benefited from also getting vaccinated, because there was a significant boost in immune response, especially against variants.

The Conventional Wisdom on Natural Immunity

So, what’s known from these two studies is that surviving a covid infection confers a significant amount of immunity against the virus. Other studies also support this assertion.

“Existing literature does show natural immunity provides protection against COVID-19,” said Shane Crotty, a professor at the Center for Infectious Disease and Vaccine Research at the La Jolla Institute for Immunology who has published numerous peer-reviewed studies on natural immunity against covid-19. He said such immunity particularly protects against hospitalizations and severe illness.

In Crotty’s own recent study, the largest yet to measure the molecules and cells involved in immune protection, his team found that natural immunity against covid lasted at least eight months. Based on projections, it could last up to a couple of years.

While that is good news, Crotty said, there are three points of caution.

First, though natural immunity appears to be very effective against the current dominant U.S. variant (known as alpha), it also appears weaker than vaccine immunity against some of the variants circulating, such as the delta variant, first detected in India. That means if those variants eventually become dominant in the U.S., people relying on natural immunity would be less protected than those who are vaccinated.

Second, there is a lack of data about whether natural immunity prevents asymptomatic transmission and infection. Several other studies, though, show vaccines do.

Third, Crotty said his studies have shown that levels of natural immunity can vary widely in individuals. His team even found a hundredfold difference in the number of immune cells among people.

“If you thought about the immune system as a basketball game and you thought about that as a team scoring 1 point, and another team scoring 100 points, that’s a big difference,” said Crotty. “We’re not so confident that people at the low end of immunity levels would be as protected against covid-19.”

But those who receive a vaccine shot have a much more consistent number of immune cells, since everyone receives the same dose amount, said Crotty.

With all that in mind, the Centers for Disease Control and Prevention recommends that those who previously had covid-19 should get vaccinated and receive both doses of a vaccine, whether it’s the Pfizer-BioNTech or Moderna vaccine. Fauci, the nation’s leading infectious disease expert, reiterated this message during a White House covid-19 briefing last month.

Hospitals, Insurers Invest Big Dollars to Tackle Patients’ Social Needs

PHILADELPHIA — When doctors at a primary care clinic here noticed many of its poorest patients were failing to show up for appointments, they hoped giving out free rides would help.

But the one-time complimentary ride didn’t reduce these patients’ 36% no-show rate at the University of Pennsylvania Health System clinics.

“I was super surprised it did not have any effect,” said Dr. Krisda Chaiyachati, the Penn researcher who led the 2018 study of 786 Medicaid patients.

Many of the patients did not take advantage of the ride because they were either saving it for a more important medical appointment or preferred their regular travel method, such as catching a ride from a friend, a subsequent study found.

It was not the first time that efforts by a health care provider to address patients’ social needs — such as food, housing and transportation — failed to work.

In the past decade, dozens of studies funded by state and federal governments, private hospitals, insurers and philanthropic organizations have looked into whether addressing patients’ social needs improves health and lowers medical costs.

But so far it’s unclear which of these strategies, focused on so-called social determinants of health, are most effective or feasible, according to several recent academic reports by experts at Columbia, Duke and the University of California-San Francisco that evaluated existing research.

And even when such interventions show promising results, they usually serve only a small number of patients. Another challenge is that several studies did not go on long enough to detect an impact, or they did not evaluate health outcomes or health costs.

“We are probably at a peak of inflated expectations, and it is incumbent on us to find the innovations that really work,” said Dr. Laura Gottlieb, director of the UCSF Social Interventions Research and Evaluation Network. “Yes, there’s a lot of hype, and not all of these interventions will have staying power.”

With health care providers and insurers eager to find ways to lower costs, the limited success of social-need interventions has done little to slow the surge of pilot programs — fueled by billions of private and government dollars.

Paying for Health, Not Just Health Care

Across the country, both public and private health insurance programs are launching large initiatives aimed at improving health by helping patients with unmet social needs. One of the biggest efforts kicks off next year in North Carolina, which is spending $650 million over five years to test the effect of giving Medicaid enrollees assistance with housing, food and transportation.

California is redesigning its Medicaid program, which covers nearly 14 million residents, to dramatically increase social services to enrollees.

These moves mark a major turning point for Medicaid, which, since its inception in 1965, largely has prohibited government spending on most nonmedical services. To get around this, states have in recent years sought waivers from the federal government and pushed private Medicaid health plans to address enrollees’ social needs.

The move to address social needs is gaining steam nationally because, after nearly a dozen years focused on expanding insurance under the Affordable Care Act, many experts and policymakers agree that simply increasing access to health care is not nearly enough to improve patients’ health.

That’s because people don’t just need access to doctors, hospitals and drugs to be healthy, they also need healthy homes, healthy food, adequate transportation and education, a steady income, safe neighborhoods and a home life free from domestic violence — things hospitals and doctors can’t provide, but that in the long run are as meaningful as an antibiotic or an annual physical.

Researchers have known for decades that social problems such as unstable housing and lack of access to healthy foods can significantly affect a patient’s health, but efforts by the health industry to take on these challenges didn’t really take off until 2010 with the passage of the ACA. The law spurred changes in how insurers pay health providers — moving them away from receiving a set fee for each service to payments based on value and patient outcomes.

As a result, hospitals now have a financial incentive to help patients with nonclinical problems — such as housing and food insecurity — that can affect health.

Temple University Health System in Philadelphia launched a two-year program last year to help 25 homeless Medicaid patients who frequently use its emergency room and other ERs in the city by providing them free housing, and caseworkers to help them access other health and social services. It helps them furnish their apartments, connects them to healthy delivered meals and assists with applications for income assistance such as Social Security.

To qualify, participants had to have used the ER at least four times in the previous year and had at least $10,000 in medical claims that year.

Temple has seen promising results when comparing patients’ experiences before the study to the first five months they were all housed. In that time, the participants’ average number of monthly ER visits fell 75% and inpatient hospital admissions dropped 79%.

At the same time, their use of outpatient services jumped by 50% — an indication that patients are seeking more appropriate and lower-cost settings for care.

Living Life as ‘Normal People Do’

One participant is Rita Stewart, 53, who now lives in a one-bedroom apartment in Philadelphia’s Squirrel Hill neighborhood, home to many college students and young families.

“Everyone knows everyone,” Stewart said excitedly from her second-floor walk-up. It’s “a very calm area, clean environment. And I really like it.”

Before joining the Temple program in July and getting housing assistance, Stewart was living in a substance abuse recovery home. She had spent a few years bouncing among friends’ homes and other recovery centers. Once she slept in the city bus terminal.

In 2019, Stewart had visited the Temple ER four times for various health concerns, including anxiety, a heart condition and flu.

Stewart meets with her caseworkers at least once a week for help scheduling doctor appointments, arranging group counseling sessions and managing household needs.

“It’s a blessing,” she said from her apartment with its small kitchen and comfy couch.

“I have peace of mind that I am able to walk into my own place, leave when I want to, sleep when I want to,” Stewart said. “I love my privacy. I just look around and just wow. I am grateful.”

Stewart has sometimes worked as a nursing assistant and has gotten her health care through Medicaid for years. She still deals with depression, she said, but having her own home has improved her mood. And the program has helped keep her out of the hospital.

“This is a chance for me to take care of myself better,” she said.

Her housing assistance help is set to end next year when the Temple program ends, but administrators said they hope to find all the participants permanent housing and jobs.

“Hopefully that will work out and I can just live my life like normal people do and take care of my priorities and take care of my bills and things that a normal person would do,” Stewart said.

“Housing is the second-most impactful social determinant of health after food security,” said Steven Carson, a senior vice president at Temple University Health System. “Our goal is to help them bring meaningful and lasting health improvement to their lives.”


Temple University Health System helped Rita Stewart get a one-bedroom apartment in Philadelphia’s Squirrel Hill neighborhood. Stewart and other patients in Temple’s housing assistance program have avoided unnecessary ER visits. Program caseworkers arrange preventive health appointments, meal delivery and can help outfit a new home with basic needs.(Kimberly Paynter / WHYY)

Success Doesn’t Come Cheap

Temple is helping pay for the program; other funding comes from two Medicaid health plans, a state grant and a Pittsburgh-based foundation. A nonprofit human services organization helps operate the program.

Program organizers hope the positive results will attract additional financing so they can expand to help many more homeless patients.

The effort is expensive. The “Housing Smart” program cost $700,000 to help 25 people for one year, or $28,000 per person. To put this in perspective, a single ER visit can cost a couple of thousands of dollars. And “frequent flyer” patients can tally up many times that in ER visits and follow-up care.

If Temple wants to help dozens more patients with housing, it will need tens of millions of dollars more per year.

Still, Temple officials said they expect the effort will save money over the long run by reducing expensive hospital visits — but they don’t yet have the data to prove that.

The Temple program was partly inspired by a similar housing effort started at two Duke University clinics in Durham, North Carolina. That program, launched in 2016, has served 45 patients with unstable housing and has reduced their ER use. But it’s been unable to grow because housing funding remains limited. And without data showing the intervention saves on health care costs, the organizers have been unable to attract more financing.

Often there is a need to demonstrate an overall reduction in health care spending to attract Medicaid funding.

“We know homelessness is bad for your health, but we are in the early stages of knowing how to address it,” said Dr. Seth Berkowitz, a researcher at the University of North Carolina-Chapel Hill.

Results Remain to Be Seen

“We need to pay for health not just health care,” said Elena Marks, CEO of the Houston-based Episcopal Health Foundation, which provides grants to community clinics and organizations to help address the social needs of vulnerable populations.

The nationwide push to spend more on social services is driven first by the recognition that social and economic forces have a greater impact on health than do clinical services like doctor visits, Marks said. A second factor is that the U.S. spends far less on social services per capita compared with other large, industrialized nations.

“This is a new and emerging field,” Marks said when reviewing the evaluations of the many social determinants of health studies. “The evidence is weak for some, mixed for some, and strong for a few areas.”

But despite incomplete evidence, Marks said, the status quo isn’t working either: Americans generally have poorer health than their counterparts in other industrialized countries with more robust social services.

“At some point we keep paying you more and more, Mr. Hospital, and people keep getting less and less. So, let’s go look for some other solutions” Marks said.

The covid-19 pandemic has shined further light on the inequities in access to health services and sparked interest in Medicaid programs to address social issues. Over half of states are implementing or expanding Medicaid programs that address social needs, according to a KFF study in October 2020. (The KHN newsroom is an editorially independent program of KFF.)

The Medicaid interventions are not intense in many states: Often they involve simply screening patients for social needs problems or referring them to another agency for help. Only two states — Arizona and Oregon — require their Medicaid health plans to directly invest money into pilot programs to address the social problems that screening reveals, according to a survey by consulting firm Manatt.

The Centers for Medicare & Medicaid Services, which is funding a growing number of efforts to help Medicaid patients with social needs, said it “remains committed” to helping states meet enrollees’ social challenges including education, employment and housing.

On Jan. 7, CMS officials under the Trump administration sent guidance to states to accelerate these interventions. In May, under President Joe Biden, a CMS spokesperson told KHN: “Evidence indicates that some social interventions targeted at Medicaid and CHIP beneficiaries can result in improved health outcomes and significant savings to the health care sector.”

The agency cited a 2017 survey of 17 state Medicaid directors in which most reported they recognized the importance of social determinants of health. The directors also noted barriers to address them, such as cost and sustainability.

In Philadelphia, Temple officials now face the challenge of finding new financing to keep their housing program going.

“We are trying to find the magic sauce to keep this program running,” said Patrick Vulgamore, project manager for Temple’s Center for Population Health.

Sojourner Ahebee, health equity fellow at WHYY’s health and science show, “The Pulse,” contributed to this report.

This story is part of a partnership that includes WHYY, NPR and KHN.

Hemmed In at Home, Nonprofit Hospitals Look for Profits Abroad

Across the street from the Buckingham Palace Garden and an ocean away from its Ohio headquarters, Cleveland Clinic is making a nearly $1 billion bet that Europeans will embrace a hospital run by one of America’s marquee health systems.

Cleveland Clinic London, scheduled to open for outpatient visits later this year and for overnight stays in 2022, will primarily offer elective surgeries and other profitable treatments for the heart, brain, joints and digestive system. The London strategy attempts to attract a well-off, privately insured population: American expatriates, Europeans drawn by the clinic’s reputation, and Britons impatient with the waits at their country’s National Health Service facilities. The hospital won’t offer less financially rewarding business lines, like emergency services.

“There are very few people out there in the world who would not choose to have Cleveland Clinic as their health care provider,” said chief executive Dr. Tomislav Mihaljevic.

Facing the prospect of stagnant or declining revenues at home, around three dozen of America’s elite hospitals and health systems are searching with a missionary zeal for patients and insurers able to pay high prices that will preserve their financial successes.

For years, a handful of hospitals have partnered with foreign companies or offered consulting services in places like Dubai, where Western-style health care was rare and money plentiful. Now a few, like the clinic, are taking on a bigger risk — and a potentially larger financial reward.

These foreign forays prompt questions about why American nonprofit health systems, which pay little or no taxes in their hometowns, are indulging in such nakedly commercial ventures overseas. The majority of U.S. hospitals are exempt from taxes because they provide charity care and other benefits to their communities. Nonprofit hospitals routinely tout these contributions, though studies have found they often amount to less than the tax breaks.

Despite their tax designation, nonprofit hospitals are as aggressive as commercial hospitals in seeking to dominate their health care markets and extract prices as high as possible from private insurers. Though they do not pay dividends, some nonprofits amass large surpluses most years even as more and more patients are covered by Medicare and Medicaid, the U.S. government’s insurance programs for the elderly, disabled and poor, which pay less than commercial insurance. Cleveland Clinic, one of the wealthiest, ran an 11% margin in the first three months of this year and paid Mihaljevic $3.3 million in 2019, the most recent salary disclosed.

The advantages of international expansion for their local communities are tenuous. Venturing overseas does not provide Americans with the direct or trickle-down benefits that investing locally does, such as construction work and health care jobs. Even when hospitals abroad add to the bottom line, the profits funneled home are minimal, according to the few financial documents and tax returns that disclose details of the operations.

“It’s a distraction from the local mission at a minimum,” said Paul Levy, a former chief executive at Boston’s Beth Israel Deaconess Medical Centerand now a consultant. “People get into them at the beginning, thinking this is easy money. The investment bankers get involved because they get the financing, and the senior faculty get on board and say, ‘This is great; it means I can go to Italy for two years’ — and there’s not a real business plan.”

There are financial hazards. For instance, Cleveland Clinic has warned bondholders that its performance could suffer if its London project does not launch as planned. There are also risks to a system’s reputation if a foreign venture goes awry.

Finance experts temper expectations that operations of overseas hospitals will have a major bearing on a system’s balance sheet. “Even though they do well, they’re small hospitals — they’re never part of the overall picture,” said Olga Beck, a senior director at Fitch Ratings. “It does help [the U.S. operations] because it gives a global name and presence in other markets.”

Hospital executives say their foreign ventures provide an additional source of revenue, thus adding stability, and benefit the care of their hometown patients.

“As we go to different areas around the world, we learn and we continuously improve for all our patients,” said Dr. Brian Donley, CEO of Cleveland Clinic London. He said the clinic has learned from U.K. practices more efficient ways to sterilize surgical instruments and perform X-rays.

For decades, wealthy foreigners — who are willing to pay the list prices for specialized surgeries and cancer care that domestic insurers bargain down — have been appealing targets for U.S. hospitals. Hospitals like MedStar Health’s Georgetown University Hospital in Washington, D.C., solicit and assist foreign patients with special offices staffed by people with job titles such as “international services coordinator” and “international services finance administrator.”

Between July 2019 and June 2020, U.S. hospitals treated more than 53,000 foreign patients, charging them more than $2.8 billion, according to a survey of members by the Chicago-based U.S. Cooperative for International Patient Programs. In addition, instead of just importing patients, 37 of 51 health systems in the survey said they offer international advisory or consulting services abroad.

“‘Send us your patients’ is pretty much a dying approach,” said Steven Thompson, a consultant who has spearheaded international programs for Baltimore’s Johns Hopkins Medicine and Boston’s Brigham and Women’s Hospital. “People see it on both sides for what it is: a one-way relationship.”

One of the oldest foreign ventures is the organ transplant program the Pittsburgh-based nonprofit system UPMC has run in Palermo, Italy, since 1997, when Sicily’s government and Italian insurers realized it would be cheaper to perform those procedures there than continue to send patients to the U.S. Since then, UPMC’s Palermo facility has performed more than 2,300 transplants.

In this initial expansion, the U.S. hospital was providing a highly specialized type of surgery — one that UPMC is renowned for — that was not available locally. But UPMC, one of the most entrepreneurial U.S. health systems, didn’t stop there. In Ireland, UPMC owns a cancer center and provides care for concussions through sports medicine clinics. Since 2018, the system has acquired hospitals in Waterford, Clane and Kilkenny. They are staffed mostly by independent Irish physicians, but UPMC regularly sends over its leading U.S. specialists to lend expertise, according to Wendy Zellner, a UPMC spokesperson.

UPMC has company in Ireland: in 2019, Bon Secours Mercy Health, a Roman Catholic system with hospitals in Eastern states, merged with a five-hospital Catholic system there.

Over the past two decades, UPMC did advisory and consulting work in 15 countries but ultimately decided to narrow its involvement to four: Italy, Ireland, China and Kazakhstan, where UPMC is helping a university develop a medical teaching hospital. Charles Bogosta, president of UPMC International, said UPMC wanted to focus its efforts where it was confident it could improve the quality of care, bolster UPMC’s reputation and earn profit margins greater than its U.S. hospitals do.

UPMC officials said the economics are favorable abroad because labor is cheaper and the mix of patients is heavily tilted toward those with commercial insurance, which pays better than government programs.

“What we’ve been doing overseas has been really helpful in addressing what everyone in the U.S. is trying to do, which is come up with diversified revenue sources,” Bogosta said.

Even so, that extra revenue remains a small part of UPMC’s earnings. The health system’s foreign hospital business generated gross revenues of $96 million, or 1% of UPMC’s $9.3 billion total hospital revenues in 2019, according to a KHN analysis of a UPMC financial disclosure. Since that figure is before accounting for the costs of running the hospitals, taxes and other expenses, the actual profits the foreign hospitals might send back to Pittsburgh are much smaller. In Ireland, where corporations are required to disclose audited financial statements, UPMC Investments Ltd., an umbrella group that owns the Waterford hospital operation and property, reported net profits of about a half-million dollars in 2019 on more than $47 million in gross revenues.

In an email, Zellner said the Ireland statements “do not give you the totality of the picture in Ireland or International, where our results are far better than these documents would suggest.” UPMC declined to provide more detailed financial data.

Like other systems, UPMC has expanding ambitions in China. In 2019 it signed an agreement with the multinational corporation Wanda Group to help manage several “world-class” hospitals, starting with one opening in Chengdu next year.

But foreign ventures can misfire. “These partnerships can turn into nightmares, as Hopkins has learned,” Thompson wrote in a 2012 article for the Harvard Business Review that described his observations as the founder and first CEO of Johns Hopkins Medicine International, a for-profit venture jointly owned by Johns Hopkins Medicine and Johns Hopkins University.

Anadolu Medical Center, which Hopkins helped establish in Istanbul in 2005, was “plagued by quality problems,” including overbooked operating rooms and physicians who refused to follow evidence-based procedures and quality protocols, he wrote. Thompson attributed the problem to the Turkish mandate that the hospital be run by a Turkish citizen and wrote that the problems did not dissipate until Hopkins was allowed to install its own manager in the second-highest position and dissolve the top position to get around the citizenship requirement “while remaining in technical compliance with the law.”

While “the project is now thriving,” he warned that “lending the Hopkins name to a hospital that delivers unimpressive care could significantly damage our 135-year-old brand — and that’s a real danger in developing areas, especially in a project’s early days.”

Hopkins has remained skittish about outright ownership or even management responsibilities. Instead, it has affiliations with hospitals and health systems in 13 countries, including Vietnam, China, Turkey, Lebanon, Brazil and Saudi Arabia. Hopkins does not run any of the hospitals but helps develop hospital master plans and clinical programs, trains doctors, and advises on patient safety and infection control.

Even so, in 2014 it created a joint venture with the oil and gas company Saudi Aramco to provide health care to 255,000 employees and their dependents and retirees. Hopkins, which owns a fifth of the venture, said all foreign net revenue is returned to the system’s parent organizations to fund research, expansion of care and scholarships. But its public records report meager income from its foreign subsidiary, just $7 million in 2018 — a tenth of a percent of the health system’s $7 billion revenues.

Charles Wiener, the current president of Johns Hopkins Medicine International, focused on other benefits. “If we can put in robust quality and safety at one of our affiliates, their patients do better,” he said. “If we can export our education and training models, we believe that allows our people to benefit from learning from other cultures, and some of their people come here to train.”

Cleveland Clinic London is unusual in that U.S. health systems rarely build a hospital abroad from scratch without a local partner. The clinic chose that more cautious approach with Cleveland Clinic Abu Dhabi, a 364-bed hospital owned by the Mubadala Investment Co. that the clinic manages. It also has a consulting practice that is helping a Singapore health care company build a hospital in Shanghai.

Foreign enterprises appeal to the clinic because it has limited growth opportunities in Ohio, where the population is growing slowly and aging, meaning more patients are leaving high-paying commercial insurers for lower-paying Medicare. The clinic has expanded in Florida, acquiring five hospitals to take advantage of population increases and wealthier patients there.

The London project will have 184 beds and eight operating rooms. Donley said it will be staffed primarily by U.K. physicians, including ones who also work for the National Health Service.

“The clinic has a long track record of being able to execute on its strategies,” said Lisa Martin, an analyst at the bond rating agency Moody’s Investors Service. “The London project is obviously the biggest venture and the biggest financial risk that they’ve made abroad.”

In a Murky Sea of Mental Health Apps, Consumers Left Adrift

In the eyes of the tech industry, mental health treatment is an area ripe for disruption.

In any given year, 1 in 5 adults in the U.S. experience a form of mental illness, according to federal estimates. And research indicates only about half of them receive treatment in a system that is understaffed and ill distributed to meet demand.

For tech startups looking to cash in on unmet need, that translates into more than 50 million potential customers.

Venture capital firms invested more than $2.4 billion in digital behavioral health apps in 2020 — more than twice the amount invested in 2019 — touting support or treatment for issues from burnout and depression to ADHD and bipolar disorder. At least seven mental health app companies have achieved “unicorn” status and are valued at more than $1 billion.

But even as industry hype mounts, researchers and companies are scrambling to prove these apps actually work. Of the estimated 20,000 mental health apps available for download on personal computers and smartphones, just five have been formally vetted and approved by the Food and Drug Administration, which largely has taken a hands-off approach to regulating the space.

“Development has really outpaced the science,” said Stephen Schueller, a clinical psychologist at the University of California-Irvine who specializes in the development and evaluation of digital mental health products.

Type “depression” or “anxiety” into an app store, and you’ll be met with a dizzying list of results. There are thousands of “wellness” apps like Headspace that counsel people on breathing exercises and other techniques to help them feel more mindful. Apps such as Woebot and TalkLife profess to help manage conditions like anxiety and postpartum depression using games, mood journaling or text exchanges with peers or automated bots.

Some apps are meant to be used alongside in-person therapy, and others on their own. Several of the most popular, like Talkspace, BetterHelp and Ginger, promise access to treatment with a licensed therapist over text message, phone or video. Others, including Brightside and Cerebral, connect users to psychiatrists who can prescribe antidepressants.

Most products make their money by charging consumers a monthly or annual fee, with the option to purchase extras like video sessions with a therapist. Others contract directly with employers or insurers.

And, yes, a small portion of these apps have promising research to back them up. Several studies, for example, have found that cognitive behavioral therapy, a mainstay of treatment for depression and anxiety that seeks to help patients change negative thought patterns, is as effective when delivered using web-based platforms as when done in person by a licensed professional. And the pandemic has bolstered claims that patients are willing to trade in-person visits for the ease of online connection.

“Digital mental health can be viewed as a way to extend the mental resources that we have,” said David Mohr, who directs the Center for Behavioral Intervention Technologies at the Northwestern University Feinberg School of Medicine. A step-care model, for example, would allow patients with milder symptoms to be treated via technology while reserving in-person care for patients who need something more.

The challenge for consumers is separating the apps that might help from those that offer little more than distraction — or could actually do harm.

Some companies offering mental health treatment had recently been doing something totally different — for example, an online seller of erectile dysfunction and hair loss treatments has started offering psychiatric evaluations and prescribing and selling antidepressants.

Tech companies are by nature for-profit and, in the rush to compete in a saturated market, many are selling a product with an appealing user interface but little evidence of effectiveness. A 2020 analysis by Australian researchers reviewing nearly 300 apps for anxiety and depression found just 6% of the companies that boasted an evidence-based framework in the app store description for their products had published any evidence.

Nor do star ratings and download totals offer much context: An April study from Beth Israel Deaconess Medical Center and Harvard Medical School found little correlation between app store metrics and treatment quality.

“No one is competing based on privacy, safety or evidence. They’re competing on aesthetics, in part, on page ranking, marketing on brand awareness,” said Dr. John Torous, director of the digital psychiatry division at Beth Israel Deaconess Medical Center and one of the authors of the April study. “There’s an implicit assumption that the app is better than nothing. But what if it isn’t better than nothing?”

One problem, said Dr. Ipsit Vahia, a geriatric psychiatrist and medical director of the McLean Institute for Technology in Psychiatry, is that randomized control studies of the kind that might prove an app’s effectiveness can take years, far slower than the rapid innovation in tech. “In general, the health care industry and the technology industry work at very different paces,” Vahia said.

Dr. David Mou, a psychiatrist at Massachusetts General Hospital who is chief medical officer at Cerebral, said he agrees that everything new in health care must be done deliberately and conservatively to avoid patient harm. But he said some people in the mental health field are painting all companies with the same brush and failing to differentiate those that are data-driven from those trying to grow at any cost.

“They look at us and say we’re all VC-backed bros in a basement trying to redesign health care. And that’s not true. It may have been true 10 years ago, but it isn’t true today,” said Mou. The long-term winners, he said, will be those that are “evidence-based and measure quality like crazy.”

Cerebral offers online therapy and medication management and delivery for a range of mental illnesses. The monthly subscription fees range from $29 to $325, depending on the level and frequency of care, as well as insurance coverage. Mou said Cerebral is already able to demonstrate some advantages. While many top hospital systems might have a months-long wait for care, he said, someone in crisis can reach a Cerebral provider almost immediately. “Within minutes you are able to talk with someone with one of our instant live visits. That in itself is a huge win.”

Even critics of the tech explosion are quick to acknowledge that the current brick-and-mortar system of mental health is dated and inadequate. In recent years, the issues surrounding mental illness and lack of access to treatment have infiltrated public dialogue. Brain illnesses that many families once squirreled away from view have become the stuff of celebrity culture and dinner-table chatter.

Yet even as advocates have made strides in acceptance, truly improving the lives of people with mental illness has proven stubbornly difficult. Over the past several decades — while the U.S. successfully lowered death rates for cancer, heart disease and other major illnesses — deaths by suicide and drug overdose have continued to climb.

Federal law theoretically requires insurance companies to cover brain illness as they would any other illness. But finding affordable care remains a challenge, largely because of a shortage of licensed mental health professionals and ongoing inequities in insurance coverage.

In a nation where huge swaths of the population lack a primary care doctor and health insurance — but most everyone has a cellphone — connecting people to treatment via mobile apps would seem a logical solution. And, for some, the opportunity to talk about their mental health challenges anonymously makes online treatment an attractive alternative.

Still, many of the experts who welcome the potential for innovation in mental health treatment acknowledge that consumers are getting little guidance in how to choose a reputable option. “Wellness” apps that promote a healthy lifestyle or apps that help people manage their disease without providing specific treatment suggestions can avoid FDA regulation. But even those that offer patient-specific diagnoses and treatment recommendations that would seem to fall squarely under the FDA’s authority do not seem to garner the agency’s attention, according to industry experts.

“The FDA has been really, really lax on enforcing in digital health for reasons that are not entirely clear to me,” said Bradley Merrill Thompson, a lawyer at Epstein Becker Green who advises companies on FDA regulations. “Anybody could spend 20 minutes on the app store and find dozens of examples of apps that make medical device claims, and that have been doing so for some time, without any effort by the FDA to rein them in.”

In response to questions from KHN about its approach to regulating mental health apps, the FDA sent a brief statement. “As circumstances change and new needs arise, FDA is ready to meet and address these challenges, especially in the areas of mental health,” the statement reads in part. “We would like to see more evidence-based products in this area, which is why we remain committed to facilitating the development of additional safe and effective therapies for patients who rely on these products.”

Dr. Tom Insel, a psychiatrist and neuroscientist, has a unique view of the evolving landscape. In 2015, Insel left his job as director of the National Institute of Mental Health, a post he had held since 2002, trading the halls of government for the open floor plans of Silicon Valley to work in digital mental health. He started at Google’s Verily, then co-founded Mindstrong Health, a startup researching how smartphone technology could be used to predict and diagnose mental health crises. He has since left to advise California officials on behavioral health issues.

Insel said he believes in the promise of digital mental health but that it will take time to find its highest and best use. He noted, for example, that most of the apps on the market focus on the problem of access: They make care more convenient. But they’re overlooking a more basic problem: quality. Unlike most fields of medicine, mental health providers rarely measure whether the care they provide makes patients better.

“A lot of what we need is not just more access. It’s not just recreating the brick-and-mortar system and letting people do it by phone or Zoom,” Insel said. Instead, he argued, digital health should focus on measuring whether treatments improve people’s lives.

“I have no doubt that this field will transform mental health treatment and diagnosis,” Insel said, “but we’re in the first act of a five-act play. I don’t think we’re anywhere near the kinds of solutions that we need in the real world.”

Una misión: voluntarios ofrecen atención médica a refugiados hacinados en la frontera

TIJUANA, México.- El Chaparral Plaza alguna vez estuvo repleto de turistas, vendedores ambulantes y taxis esperando clientes. Pero este lugar en las afueras de San Ysidro, el punto de entrada fronterizo del lado mexicano, ahora es un campo de refugiados en expansión donde los migrantes de México, Centroamérica y Haití esperan en el limbo mientras buscan asilo en los Estados Unidos.

La doctora Hannah Janeway, médica de emergencias en un hospital de Los Ángeles y voluntaria en la frontera, estima que al menos 2,000 personas viven apretujadas en carpas y lonas, sin agua potable ni electricidad.

La supervivencia es la preocupación apremiante, no covid.

“El campamento sigue creciendo día a día”, dijo Janeway.

Un número récord de migrantes está realizando el largo viaje hacia la frontera. La Oficina de Aduanas y Protección Fronteriza de Estados Unidos detuvo a 180,034 personas en la frontera sur en mayo, un aumento del 78% desde febrero. En comparación, los agentes fronterizos detuvieron a unas 144,000 personas en mayo de 2019.

Las nuevas pautas emitidas en febrero por la administración Biden requieren que los migrantes que buscan asilo se registren en línea o por teléfono desde sus países de origen, se hagan la prueba de covid en México, y luego vayan a un punto entrada a los Estados Unidos en un día específico para sus entrevistas de asilo.

El objetivo es reducir la cantidad de personas que hacen la peligrosa travesía y aliviar la espera en pueblos fronterizos como Tijuana, pero la gente sigue presentándose sin pasar por el proceso.

“Mientras conducía, vi dos autobuses que dejaban a un grupo de migrantes”, dijo Janeway. “¿A dónde van a ir?”.

Debido a que los refugios para migrantes ya estaban llenos antes de la afluencia de migrantes de este año, muchos terminan en el campamento de El Chaparral, donde los alimentos y la atención médica son escasos, y hay poco acceso a instalaciones sanitarias, más allá de estaciones para lavarse las manos y baños portátiles.

Janeway, codirectora de Refugee Health Alliance, una organización sin fines de lucro que brinda atención médica a los migrantes en la frontera entre Estados Unidos y México en Tijuana, visita el campamento dos o tres veces al mes para atender a los pacientes y difundir información sobre la clínica cercana que abrió en 2018, ubicada a pocas cuadras de la plaza.

La clínica, Resistencia en Salud, brinda atención gratuita, y depende de donaciones y de un personal en su mayoría voluntario para permanecer abierta.


Migrantes y unos pocos residentes de Tijuana esperan para ser atendidos en la clínica Resistencia en Salud.(Heidi de Marco / California Healthline)

“Creo que las personas a las que estoy sirviendo merecen recibir atención médica y sufrir menos”, dijo Janeway.

La clínica es pequeña y básica, tiene dos salas de examen. El personal coordina con el sistema de salud pública de México para atender a los pacientes que necesitan atención más especializada, como cirugía o quimioterapia.

Un jueves reciente, Janeway caminó a lo largo del borde del campamento, lleno de tiendas de campaña, lonas convertidas en refugios improvisados y montones de basura, para verificar el suministro de agua del tanque que proporciona su organización. Dijo que el gobierno mexicano no está ofreciendo mucho en cuanto a atención médica o provisiones esenciales, como agua.

La Secretaría de Salud de Baja California no respondió a múltiples solicitudes de comentarios.

“Es responsabilidad del gobierno, pero no quiero polemizar con ellos sobre el agua”, dijo. “Es fundamental. Hay niños con enfermedades [gastrointestinales]”.

En la clínica, Janeway y su personal “lo ven todo”, dijo: problemas cardíacos, dolor de espalda, cáncer, lesiones por agresión. Además de tratamiento médico, Resistencia en Salud brinda servicios de salud mental y apoyo a la comunidad LGBTQ.

Para cuando abrieron las puertas a las 10:30 am, una fila de personas estaba esperando para registrarse. No pudieron atender a todos porque la clínica alcanzó su capacidad máxima. Octavio Alfaro y su hijo de 12 años, a quien le dolían las rodillas, estuvieron entre los afortunados.

El hombre de 53 años de Villanueva, Cortés, en Honduras, ha estado esperando asilo durante dos años y medio.

“Mi historia es cruel”, dijo.

Alfaro salió de Honduras con sus tres hijos, huyendo de la violencia de las pandillas. “En Honduras, no puedes arriesgarte a iniciar un negocio porque si no pagas lo que te cobran las pandillas, te van a poner bajo tierra”, dijo. “Querían llevarse a mi hijo y estaban listos para secuestrar a mi hija para hacer lo que les hacen a las niñas”.


La doctora Hannah Janeway habla con uno de los cerca de una docena de pacientes a los que atiende en la clínica Resistencia en Salud.(Heidi de Marco / California Healthline)

Historias como la suya son frecuentes en el campamento, dijo. “Por eso venimos. Por una vida mejor para estos niños”.

Alfaro conoció a Janeway en el campamento de El Chaparral a fines de mayo. Janeway escribió una carta de defensa en apoyo de la solicitud de asilo de su hija Brenda, de 14 años. Brenda tiene un soplo cardíaco que requiere cirugía inmediata en los Estados Unidos. “Necesita que la vea un especialista”, dijo Janeway. “No puede recibir ese tipo de atención aquí”.

Janeway dijo que muchos pacientes como Alfaro y su familia solo están tratando de sobrevivir en los campamentos y refugios abarrotados de Tijuana, donde temen ser asaltados o robados. La pandemia de covid es algo secundario.

La clínica solo ha atendido a un puñado de pacientes con covid, dijo Janeway, y, hasta donde ella sabe, nadie está vacunando a los migrantes.

La enfermera Luz Elena Esquivel dijo que intenta educar a los pacientes sobre cómo mantener la distancia y usar máscaras, “pero a veces parece imposible”, dijo. “No es su prioridad. Su prioridad es cruzar”.

Ese día, una docena de miembros del personal de la clínica atendieron a 55 personas en unas seis horas.

Se movieron en sincronía de paciente a paciente, tratando de tratar a la mayor cantidad posible, incluido un niño de 3 años de Honduras que era tan pequeño que parecía tener 6 meses, una mujer transexual mexicana que necesitaba terapia hormonal, y un hombre haitiano que se quejaba de dolor en el pecho. En medio de todo eso, asistieron a un hombre que colapsó en la sala de espera.


La doctora Hannah Janeway y el doctor Christian Armenta discuten el diagnóstico de un paciente.(Heidi de Marco / California Healthline)

La última ola de migrantes ha puesto a prueba la clínica, que necesita más dinero, más voluntarios y otro médico. “Las condiciones laborales no son tan buenas. Y los salarios que podemos ofrecer tampoco”, dijo Janeway. “Pero las personas que están aquí, están aquí porque están muy dedicadas a ayudar a esta población. Es una misión”.

El doctor Christian Armenta, médico de familia de la clínica, nació y se crió en Tijuana. Comenzó a trabajar en la clínica en medio de la pandemia. “Al principio fue muy aterrador, pero me adapté rápidamente”, dijo. “Como médico y tijuanense, tengo que generar algún tipo de impacto para mejorar mi ciudad”.

Alrededor del 95% de los pacientes son migrantes, dijo. El resto son tijuanenses que viven en la calle o en albergues. “El entorno en el que viven crea la tormenta perfecta para generar problemas de salud”, dijo.

Alfaro, trabajador de la construcción de oficio, fue asaltado más de una vez. “Aquí me han maltratado”, dijo. “Me robaron mis herramientas dos veces”.

Aun así, Alfaro dijo que se siente un nativo de Tijuana. “Las personas que he conocido aquí son como mi familia”.

En medio de su turno, Janeway salió de la clínica para darle buenas noticias a Alfaro.

“Acabo de hablar con los abogados y me dijeron que tienes una fecha para cruzar”, dijo.

“Gloria a Dios”, respondió Alfaro. “Estoy tan feliz. Si he aprendido una cosa aquí, es a tener paciencia”.

‘It’s a Mission’: Volunteers Treat Refugees Massing at the Border

TIJUANA, Mexico — El Chaparral Plaza once teemed with tourists, street vendors and idling taxis. But the plaza, just outside the San Ysidro port of entry on the Mexican side of the border, now serves as a sprawling refugee camp where migrants from Mexico, Central America and Haiti wait in limbo while they seek asylum in the U.S.

Dr. Hannah Janeway, an emergency medicine physician who works in a Los Angeles hospital but volunteers at the border, estimates at least 2,000 people are jammed into tents and repurposed tarps here, living without running water and electricity.

Survival is the pressing concern, not covid.

“The encampment just keeps growing day by day,” Janeway said.


Migrants and a few Tijuana locals wait to be seen at the Resistencia en Salud clinic. (Heidi de Marco / California Healthline)

A record number of migrants are making the often long and perilous journey to the border. U.S. Customs and Border Protection apprehended 180,034 people at the southern border in May, a 78% increase since February. By comparison, border agents apprehended about 144,000 people in May 2019.

New guidelines issued in February by the Biden administration require migrants seeking asylum to register online or via phone from their home countries, get tested for the coronavirus in Mexico and then come to a U.S. port of entry on a specific day for their asylum interviews. The goal is to reduce the number of people making the dangerous trek and alleviate the waiting in border towns like Tijuana — but people continue to show up without going through the process.

“As I was driving here, I just saw two buses drop off a group of migrants,” Janeway said. “Where are they going to go?”

Because migrant shelters were already at capacity before this year’s influx of migrants, many end up at the El Chaparral camp, where food and medical care are scarce and there is little access to sanitation facilities — other than hand-washing stations and portable toilets.


A handful of portable toilets and hand-washing stations are available for the roughly 2,000 migrants at the El Chaparral encampment. (Heidi de Marco / California Healthline)

The migrant camp at El Chaparral Plaza overflows with trash and debris. (Heidi de Marco / California Healthline)

Janeway, who co-directs the Refugee Health Alliance, a nonprofit organization that provides medical care to migrants at the U.S.-Mexico border in Tijuana, visits the camp two to three times a month to tend to patients and spread the word about the nearby clinic she opened in 2018, located a few blocks from the plaza.

The clinic, Resistencia en Salud, provides free care and depends on donations and a mostly volunteer staff to keep the doors open.

“I believe that the people that I’m serving deserve to have health care and a reduction to their suffering,” Janeway said.

The clinic is small and basic, with two exam rooms. Staffers coordinate with Mexico’s public health system to handle patients who need more specialized care, such as surgery or chemotherapy.


Dr. Hannah Janeway consults with one of more than a dozen patients she treated at Resistencia en Salud on a recent Thursday. (Heidi de Marco / California Healthline)

On a recent Thursday, Janeway made her way along the edge of the camp — lined with tents, tarps fashioned into makeshift shelters and mounds of trash — to check on the water tank supply her organization provides. She said the Mexican government is not providing much in the way of health care or essential provisions, like water.

The office of Baja California’s secretary of health (Secretaría de Salud de Baja California) did not respond to multiple requests for comment.

“It’s the government’s responsibility, but I don’t want to play a game of chicken with them about water,” she said. “It’s critical. There are all these kids here with [gastrointestinal] illnesses.”

At the clinic, Janeway and her staff “see it all,” she said: heart problems, back pain, cancer, assault injuries. In addition to medical treatment, Resistencia en Salud provides mental health services and support to the LGBTQ community.


Clinic staff perform an electrocardiogram on a Haitian man with chest pain. (Heidi de Marco / California Healthline)

By the time doors opened at 10:30 a.m., a line of people were waiting to sign up. Some were turned away because the clinic hit capacity. Octavio Alfaro and his 12-year-old son, whose knees had been hurting, were among the hopefuls.

The 53-year-old from Villanueva, Cortés, in Honduras, had been waiting for asylum for 2½ years.

“My story is cruel,” he said.

Alfaro left Honduras with his three children, fleeing gang violence. “In Honduras, you cannot risk starting a business because if you don’t pay what the gangs charge you, they will put you in the ground,” he said. “They wanted to take my son and were ready to kidnap my daughter to do what they do to young girls.”

Stories like his are common in the encampment, he said. “That’s why we come. For a better life for these kids.”

Alfaro met Janeway at the El Chaparral encampment in late May. She quickly wrote an advocacy letter in support of his 14-year-old daughter Brenda’s asylum claim. Brenda has a cardiac murmur that requires immediate surgery in the U.S. “She needs to be seen by a specialist,” Janeway said. “She can’t get that type of care here.”


For the growing number of migrants trying to cross into the U.S. at the southern border, survival is a pressing concern than covid-19.(Heidi de Marco / California Healthline)

Janeway said many patients like Alfaro and his family are just trying to survive in Tijuana’s encampments and overcrowded shelters, where they fear being assaulted or robbed. Navigating the pandemic is secondary.

The clinic has seen only a handful of covid patients, Janeway said, and, as far as she knows, no one is vaccinating migrants.

Nurse Luz Elena Esquivel said she tries to educate patients about maintaining distance and wearing masks, “but sometimes it seems impossible,” she said. “It’s not their priority. Their priority is crossing.”

On this day, a dozen clinic staff members saw 55 people in about six hours. They moved in synchrony from patient to patient, attempting to treat as many as possible, including a 3-year-old child from Honduras who was so small he appeared 6 months old, a Mexican transgender woman in need of hormone therapy and a Haitian man complaining of chest pain. In the middle of it all, they rushed to treat a man who collapsed in the waiting area.


By the time clinic doors opened at 10:30 a.m. on a recent Thursday, a line of people were waiting to sign up. Some were turned away because the clinic hit capacity.  (Heidi de Marco / California Healthline)

The clinic is small and basic, with two exam rooms. Staffers coordinate with Mexico’s public health system to handle patients who need more specialized care, such as surgery or chemotherapy. (Heidi de Marco / California Healthline)

The latest wave of migrants has put a strain on the clinic, which needs more money, more volunteers and another doctor. “The working conditions aren’t that good. And the salaries we can offer aren’t either,” Janeway said. “But the people who are here are here because they are very dedicated to helping this population. It’s a mission.”

Dr. Christian Armenta, a family physician at the clinic, was born and raised in Tijuana. He started working at the clinic in the midst of the pandemic. “It was very scary in the beginning, but I adapted quickly,” he said. “As a doctor and a Tijuanense, I have to generate some sort of impact to better my city.”

About 95% of the patients are migrants, he said. The rest are people from Tijuana who live on the streets or in shelters. “The environment in which they are living creates the perfect storm to generate health problems,” he said.


Drs. Hannah Janeway and Christian Armenta discuss a patient. (Heidi de Marco / California Healthline)

Alfaro, a construction worker by trade, was robbed more than once. “I’ve been mistreated here,” he said. “My tools have been stolen twice.”

Even so, Alfaro said he feels like a child of Tijuana. “The people I have met here are like my family.”

In the middle of her shift, Janeway stepped out of the clinic to deliver some good news to Alfaro.

“I just talked to the lawyers and they told me that you have a date to cross on June 8,” she said.

“Glory to God,” Alfaro said. “I’m so happy. If I’ve learned one thing here, it’s to have patience.”


Resistencia en Salud depends on donations and a mostly volunteer staff to keep the doors open. (Heidi de Marco / California Healthline)

Nurse Luz Elena Esquivel says she tries to educate patients about maintaining distance and wearing masks during the pandemic, but “it’s not their priority,” she says. “Their priority is crossing.” (Heidi de Marco / California Healthline)

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

Nurses and Docs at Long Beach Center ‘Consider It an Honor’ to Care for Migrant Children

The 5-year-old had nodded off while waiting for her 10-year-old brother to be treated for scabies at the clinic in the Long Beach Convention & Entertainment Center, which she currently calls home. Nurse Chai-Chih Huang asked if she wanted to be taken back to her dormitory to sleep.

“She looked so sad and didn’t say anything,” Huang recalled. The girl’s brother explained that they had been separated for a week during their journey. His sister cried every day without him, he said. Now, she wanted to stick close at all times.

“This has been pretty hard,” Huang told KHN later. She knew few details of the siblings’ story, but many of the children at the center had trekked across hundreds of miles of dangerous lands guided by a smuggler.

The siblings, not named for privacy reasons, are among the hundreds of children, mostly from Central America, attempting to cross the U.S. border alone from Mexico each day. After brief detention by the Border Patrol, they are sent to shelters run by the Department of Health and Human Services while officials seek to unite them with relatives or other sponsors in the United States.

Long Beach offered housing at its convention center as part of a Biden administration effort to move children more quickly from the forbidding border housing where they are held initially. Those harsh settings, where at least five children died in 2018 and 2019, provoked a backlash against the Trump administration’s immigration policies.

The Long Beach location is one of more than a dozen temporary homes the federal government has set up for a massive influx of children. On June 14, it housed 115 children — a mix of girls up to age 17 and boys up to 12, out of consideration for their privacy and safety, an HHS official said — and had connected 755 others with relatives or sponsors since the first children arrived on April 22. Federal officials, citing the safety and privacy of the children, have not allowed KHN or other news media to enter the facility currently.

The children arrive at the Long Beach facility by bus, scared and timid but “very well behaved,” said Huang, director of pediatric nursing at Mattel Children’s Hospital of UCLA Health, who is doing temporary duty at the shelter. “They warm up to the staff here and when they get to know you and start talking to you, it melts your heart.”

DRC Emergency Services, a government contractor that typically performs jobs like debris removal after hurricanes, subcontracted with UCLA Health, UCI Health, Children’s Hospital of Orange County and other providers to care for the children.

“We can imagine they have been through a lot,” said Jennie Sierra, nursing director in the neonatal intensive care unit at the Orange County hospital. “They’re very grateful, and they’re an amazing, resilient group.”

“Most of my nurses here come from immigrant families, and we consider it an honor and privilege to serve in this capacity,” she said.

Before this year’s surge of migrants at the U.S. border, HHS ran about 200 such facilities in 22 states and has announced plans to double capacity by adding about 18,500 emergency beds this year. It has signed $400 million in contracts to provide services for unaccompanied children. The federal government is paying about $35 million to house and care for the children at the Long Beach convention center through Aug. 2.

“Border Patrol stations were never designed to be places for minors to be held for any period of time,” said Border Patrol spokesperson Matthew Dyman. The cells were intended for “single adult males to be quickly turned around — and not for families or children.”

The Border Patrol can legally hold the children 72 hours before putting them in the custody of HHS’ Office of Refugee Resettlement, which looks for relatives or sponsors in the U.S. pending immigration hearings.

On a recent day, June 14, HHS was caring for 15,365 children at facilities around the country and discharged 412 into communities. HHS Secretary Xavier Becerra said in May that the agency had reduced time spent in the emergency shelters to an average of 29 days, down from 40 days in late January.

Within two days of their arrival at Long Beach, the children get a health assessment at a pediatric clinic set up by UCLA Health.

Many come with chronic headaches and stomachaches. Some have rough or broken skin, swollen and infected feet, or rashes caused by filth and clothes rubbing against skin on long marches. Some have colds — or covid; as of Monday, two cases were recorded among children at the convention center. The children stay in isolation and receive appropriate care.

While mental health therapy is limited, visibly sad or anxious children can get counseling and children can take part in weekly group discussions overseen by clinicians, said David Kosub, a federal spokesperson for the Long Beach site. Referrals are provided in the communities to which they are moving, he said.

Caring for the kids “has been very moving and meaningful, even life-changing,” said Dr. Charles Golden, a pediatrician and executive medical director of Children’s Hospital of Orange County’s primary care network.

The doctors and nurses feel loved by their charges, he said. One day, Golden saw a group of children sitting in a circle, playing games. “They came over and gave me a big hug.”

UCLA staffers painted murals for the children, who have access to classrooms, indoor and outdoor play spaces and TVs, soccer nets, hula hoops and ample board games.

They have books, and music from their homelands: punta, marimba, merengue, cumbia and bachata, said UCLA Health child life specialist Tracy Reyes Serrano. Performers have played for the children, too, she said.

“When the kids hear songs they recognize, it lifts their spirits; they’re quick to get up and dance and sing, and we’re happy to join them,” she said.

The Long Beach Community Foundation launched a Migrant Children Support Fund that has raised $200,000, said foundation president and CEO Marcelle Epley. The money has gone to educational programs and toys, as well as gift cards that HHS can distribute once the children are settled with families. Long Beach residents have donated books, toys and personalized notes in Spanish.

Sierra recalled a girl who said she wanted to learn English and become a pediatrician.

“I told her, ‘This is a great country with great opportunities. You’re going to be an amazing doctor,’” Sierra said.

U.S. Rep. Nanette Diaz Barragán (D-Calif.), who represents North Long Beach and the Port of Los Angeles, visited the center May 6 and met children who “seemed to be in a state of hope, smiling and anxious to talk,” including a young boy from Honduras.

“He was very happy until I asked about his home country and he looked like he wanted to cry,” she said. “Someone in our group said, ‘It’s beautiful there,’ and he said ‘No, it’s bad,’ and talked about gangs and violence. He was willing to disagree with an adult.”

The children’s histories are mostly a mystery to their temporary caretakers, said Jennifer Sablan Panopio, a nurse manager in UCI Health’s neonatal intensive care unit who has been the health system’s lead nurse in Long Beach. “We can at least help give them a positive experience here, a good start.”

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

Montana Tribe Welcomes Back Tourists After Risky Shutdown Pays Off

Millions of people will flock to Montana’s Glacier National Park this summer after last year’s pandemic-caused tourism skid, and they will once more be able sightsee and camp nearby on the recently reopened Blackfeet Indian Reservation.

The tourists’ return is a relief to the owners of the restaurants, campgrounds and hotels forced to shut down last summer when Blackfeet tribal leaders closed the roads leading to the eastern side of the popular park.

Those closures fed worries that a major economic driver for residents on the reservation would be crippled. But the tribe’s priority was protecting its elders and stemming the spread of the coronavirus. It worked: The closures and the tribe’s strictly enforced stay-at-home orders and mask mandate led to a low daily case rate held up as an example by federal health officials. Now, boasting one of the highest vaccination rates in the nation, the reservation is back open for business.

On a recent day at the Two Sisters Café, a stone’s throw from Glacier National Park’s eastern boundary, workers stacked dishes and stocked freezers in preparation for a busy season as demand soars for the wide-open spaces national parks can offer during the lingering pandemic.

Susan Higgins, co-owner of the cafe, said she’s seen more traffic whiz past her door than she’s seen at this time of year in nearly three decades. Some passersby stopped and poked their heads through the front door of the restaurant known for fresh huckleberry pies, only to leave disappointed because the restaurant didn’t open for the season until mid-June.

The situation is nothing like last year, when Higgins and sister Beth worried they would rack up massive debt just to survive. With the help of government loans and other grants, they were able to cover their bills and maintain their savings to expand the business.

“When everything happened, we were initially, of course, just concerned about just making it to this year,” Susan Higgins said.

Despite the uncertainty of the past year, Higgins said she supported the stringent measures taken by Blackfeet tribal leaders. The pandemic has disproportionately affected Native Americans, something Higgins is keenly aware of.

“With such a vulnerable population, I would have hated to see what would have happened last year if we had been open, especially with the issue of getting people to mask up,” Higgins said.


Susan Higgins, co-owner of Two Sisters Café near the eastern boundary of Glacier National Park, trains one of her staff members to make pies as she gears up for the 2021 tourism season. (Aaron Bolton for KHN)

Last year, the number of Glacier visitors plunged to 1.7 million after a record 3 million people visited in 2019. Those who did come stayed and spent their money in non-Blackfeet communities on the western side of the Continental Divide.

The measures the tribe took slowed but didn’t stop the spread of covid. Daily cases surged in September, after the Northwest Montana Fair and Rodeo in August and Labor Day weekend, leading to a strictly enforced stay-at-home order, the tribe’s third, issued Sept. 28.

Daily cases then dropped from a peak of 6.4 per 1,000 per day on Oct. 5 to 0.19 on Nov. 7, a 33-fold drop that the Centers for Disease Control and Prevention held up as an example that such restrictions work.

Out of roughly 10,000 reservation residents, fewer than 50 Blackfeet tribal members have died of covid to date. Kimberly Boy, Blackfeet department of revenue director and a member of the incident command team that leads the tribe’s pandemic response, said she is certain their actions saved lives.

“It was the toughest job I’ve had so far in my life,” Boy said. “We had moved aggressively and extremely restrictive[ly] only due to the fact that our primary goal was to save as many lives as we can.”

The efforts bought time until the covid vaccines became available. Then, the tribe mounted a serious campaign that has resulted in about 85% of the total population — over 90% of adults — being fully vaccinated, according to tribal officials. The national average is about 44%, according to the CDC.

The Blackfeet’s vaccination campaign then stretched into Canada when tribal officials set up a clinic at the border for their counterparts in the Blackfoot Confederacy. The Blackfoot Confederacy, of which the Montana Blackfeet nation is a part, includes affiliated First Nations tribes who live on the Canadian side of the border.

The idea for the makeshift clinic was conceived after U.S. and Canadian officials denied requests to ship vaccines over the border, Blackfoot Confederacy Health Director Bonnie Healy said.

“We were joking, and I said that we’ll just have the Canadians from the confederacy stand on one side of the border and you guys vaccinate us over the fence and we’ll get it done,” Healy said.

Healy said that’s exactly happened in a sense, and the clinic was aptly named the “medicine line vaccine clinic,” referencing what the Blackfeet and Blackfoot call the U.S.-Canadian border that separates the different bands of the tribe.

Mark Pollock, a member of the Blackfeet Tribal Business Council, and others said the strong vaccination rate on the reservation in Montana is giving the tribe the confidence to open to tourists this summer.

Pollock hopes the season will go smoothly and covid can be eliminated among tribal members or cases remain very low. However, if cases rise, he said, the tribe could reduce the current 75% capacity limit on dine-in restaurants and bars, as well as reintroduce restrictive measures like curfews and limits on gatherings.

“Whatever it takes to get that number back down, get a handle on it,” Pollock said.

Jackie Conway owns the Heart of Glacier Campground near Glacier’s east gate with her husband, Steve, a tribal member. Conway said even with all 40 of her RV and camping sites booked for the season, she still can’t make up for last year’s 100% loss. Government relief helped the business survive over the past year.

She’s happy there will be a tourism season this summer but knows in the back of her mind that tribal leaders could shut things down anytime.

“The tribe gets spooked pretty easy. So, you just don’t know,” she said.


Angelika Harden-Norman holds a parfleche box made by her late husband, Darrell Norman. Harden-Norman made both traditional and modern Blackfeet artwork. Parfleche boxes are painted containers made from animal hide. They were used by Native Americans to carry items as they traveled.(Aaron Bolton for KHN)

Angelika Harden-Norman owns the Lodgepole Gallery & Tipi Village just outside Browning, the reservation’s largest city. Standing in the gallery full of artwork by her late husband, Darrell Norman, and other Blackfeet tribal members, she said it’s up to business owners to keep guests safe and make sure this pandemic tourist season goes smoothly.

She used grant money to move her art gallery from the center of her home to another room with better ventilation. She’s also renovated the bathrooms of the two cabins for overnight guests so they are no longer shared.

“I will do my best to take the responsibility … by asking people to wear a mask when they come indoors to check in, to have hand sanitizers,” she explained.

At Two Sisters Café, Susan Higgins stood inside an unfinished drive-thru coffee stand just outside the restaurant. Higgins said she and her sister had thought about building a coffee stand in the past, but it was the uncertainty of how this season would go that pushed them to do it.

Higgins added she is requiring her workers to be vaccinated and hopes that will allow her to avoid shutting down her business this summer. So, for now, the coffee stand will serve as an addition to her business, but it’s also a Plan B should there be another shutdown.

“Primarily it is to assure ourselves of a continued cash flow should we get shut down again,” she explained.

What It Means When Celebrities Stay Coy About Their Vaccine Status

When two St. Louis Blues hockey players were sidelined because of covid-19 just days before this year’s NHL playoffs, the team said young defenseman Jake Walman had been vaccinated against the deadly illness. But it was mum about the vaccination status of a more well-known player: star forward David Perron.

It wasn’t until 10 days later — and after the Colorado Avalanche buried the team, without Perron touching the ice in any of the series’ four games — that he begrudgingly acknowledged he had been vaccinated.

“I don’t want to talk about that anymore,” Perron, the team’s leading scorer, said at a press conference.

While fans often know intricate details about athletes’ knee joints and concussions, covid vaccinations are another story. Reticence is common among professional athletes. Vaccination status is also a point of secrecy among some Republican lawmakers, other public figures and even many regular people.

Public health leaders say that people in the limelight do not have an obligation to announce or answer media questions about their vaccination status, but many add that they hoped more well-known names would become role models for getting the vaccines.

Instead, they say, the politicization of the shots, misinformation and flawed public messaging from the federal government have made the vaccines controversial and something some public figures are reluctant to endorse, which then ripples across society.

President Joe Biden is trying to get at least 70% of the nation vaccinated by July 4. So far, according to the Centers for Disease Control and Prevention, 53% of Americans have received at least one dose.

“I continue to be hopeful that celebrities will share their vaccination status and use their platform to encourage people to get vaccinated,” said Thomas LaVeist, a sociologist and the dean of the School of Public Health and Tropical Medicine at Tulane University. “But I haven’t seen a lot of celebrities really embrace that role.”

LaVeist and others in public health hoped someone would step up as Elvis Presley did in 1956 to help increase the low rate of polio vaccinations. He received his shot on “The Ed Sullivan Show.”

But that occurred years after the polio vaccine was developed, whereas the covid vaccines became available less than a year after the onset of the pandemic.

“We still have not done a good enough job of explaining to people how and why it is that we were able to have a vaccine developed so quickly, and a lot of people have questions about whether corners were cut,” said LaVeist, who criticized the Trump administration’s decision to call its vaccine development program Operation Warp Speed.

Former President Donald Trump also hurt vaccination efforts among Republicans when he received his vaccine privately rather than in a public setting like Biden and other former presidents, said Gregory Zimet, a behavioral scientist who studies vaccination at Indiana University School of Medicine.

When CNN conducted a survey of congressional lawmakers in May, 95 of the 212 Republican House members said they had received the vaccines and 112 Republican offices did not respond at all. (All congressional Democrats said they had received the vaccines.)

“For some individuals, particularly if their social circle is very anti-vaccine or skeptical of the vaccine, it can feel very uncomfortable to come out and say, ‘I got vaccinated,’” Zimet said.

Sports stars, who are often asked about their health, could change public perceptions of the vaccines, said Nancy Berlinger, a bioethicist at the Hastings Center, a research institute in Garrison, New York.

“In the worst days of HIV-AIDS, the fact that Magic Johnson was willing to talk about being HIV-positive changed public conversation in this country,” Berlinger said. “Not everyone is able to step into that role.”

Basketball king LeBron James, when asked if he planned to get a covid vaccine, told reporters in March, “That’s a conversation that my family and I will have. Pretty much keep that to a private thing.”

Jennifer Reich, a sociologist at the University of Colorado-Denver who has studied vaccine hesitancy, thinks that James and other NBA stars could be reluctant to promote the vaccines because of the way athletes have been castigated in recent years for taking stands on hot-button issues.

But James has expressed support for the Black Lives Matter movement and called for the prosecution of police officers who shot and killed Breonna Taylor, a Black medical worker, in her Kentucky apartment.

“It’s not like he is someone who has been a shrinking violet and has not stepped into the public arena to make very strong statements about inequities and problems in our society,” Zimet said. “So, it’s a little hypocritical that he would now say, ‘This is a private issue.’”

Not everyone in public health is convinced, though, that what James, Perron and other celebrities say is crucial to vaccination efforts.

Sandra Crouse Quinn, a professor of family science at University of Maryland, studied the role of communication in vaccine acceptance during events such as the 2009 H1N1 pandemic. She found that while public figures’ disclosures can make a difference, they are not as important as endorsements from “people we care about and people who care about us,” she said.

“If Beyoncé came out with a vaccine video, would people watch it? Yes,” Quinn said. “Is it entertainment? Yes. Does it move somebody? Not necessarily, because her life is so dramatically different” than that of an ordinary person.

But Timothy Caulfield, a law professor at the University of Alberta and the author of a book on vaccine myths, believes celebrities can make a big difference, pointing to actor Jenny McCarthy’s role in the anti-vaccine movement.

“The role that pop culture can play in normalization is a constructive role,” Caulfield said. “We are getting close to that hesitancy hurdle in jurisdictions where you are getting 60-65% of people vaccinated, so this messaging may seem trivial, but it matters when you are talking about trying to get another 2% or 3% of the population vaccinated.”

During the time when Perron was quiet during the playoff series, sportswriters and fans speculated about his vaccination status. At the press conference where he revealed his vaccination after being questioned about it, Perron said, “I don’t know why it’s a big deal.” He pointed out that he and two other players had gotten covid despite being vaccinated.

“It’s unfortunate and shows that it’s not perfect,” he said, adding that, among his teammates, “I can tell you that we support each individual to make their own decision.”

Even if Perron had declined a vaccine or not revealed his status, some fans would likely not have held it against him.

Thomas Welch, who hosts a hockey podcast, “Locked On Blues,” quickly decided to get vaccinated because his father and brother have Crohn’s disease, which means they could face a greater risk from the coronavirus. But Welch said he understands that for some people the vaccines might not make sense for various reasons.

“As much as we love talking about these players and breaking down the analytics of the sport, at the end of the day, each of these players are people,” said Welch, who lives in Jefferson County, outside St. Louis. “We lose sight of that a lot.”

Journalists Follow Up on Unused Vaccines and For-Profit Medical Schools

KHN correspondent Rachana Pradhan discussed the politics of unused Johnson & Johnson covid vaccines and the FDA’s potential announcement that their shelf life can be extended on Newsy on June 11.


KHN reporter Victoria Knight discussed for-profit medical schools on Montana Public Radio on June 10.

KHN’s ‘What the Health?’: The ACA Lives


Can’t see the audio player? Click here to listen on SoundCloud. You can also listen on Spotify, Apple Podcasts, Stitcher, Pocket Casts or wherever you listen to podcasts.


For the third time in nine years, the Affordable Care Act has survived a constitutional challenge at the Supreme Court. In a 7-2 decision, the court ruled that the states and individuals who filed the latest challenge lacked standing to sue.

Meanwhile, Democratic lawmakers are looking for ways to expand health benefits as they pull together spending plans on Capitol Hill. And criticism is growing of the Food and Drug Administration, which approved a controversial drug to treat Alzheimer’s disease over the recommendation of its own expert outside advisers.

This week’s panelists are Julie Rovner of KHN, Joanne Kenen of Politico, Mary Ellen McIntire of CQ Roll Call and Rachel Cohrs of Stat.

Among the takeaways from this week’s episode:

  • The ACA decision Thursday was a signal that the Supreme Court is moving beyond Republican arguments that the landmark health law is unconstitutional or should be overturned. At least one other challenge is still working its way through the court system, and the Supreme Court may still be called on to settle questions about specific provisions or aspects of implementation. But it appears that legal challenges are no longer an existential threat to the overall law.
  • The first major ACA case that made its way to the Supreme Court was one brought by business groups. But over time, industry has come to accept the ACA and most businesses do not want to see more challenges that threaten the entire law.
  • The court’s decision leaves Republicans in a tough position. Their opposition to the law has become a standard part of the party’s identity, yet Republican lawmakers never put forward a strong vision for a replacement or a path to meeting the country’s health care needs if the ACA were overturned. Because health care policy issues are not front and center on Capitol Hill at the moment, Republicans have time to formulate a new strategy. But they may need a message when Democrats move soon to make permanent the enhanced insurance subsidies for plans on the ACA marketplace.
  • The congressional clock is ticking as Democrats strategize on a variety of policies, including infrastructure and those health premium subsidies. If bipartisan deals are not made soon, Democratic leaders will likely push to use a complicated process called budget reconciliation that allows some types of bills to be passed by a simple majority in the Senate and not be subjected to a filibuster. Health provisions could be part of such a bill, such as lowering the eligibility age for Medicare, establishing higher insurance subsidies and allowing Medicare to negotiate drug prices.
  • One of the most popular options Democrats would like to add to a reconciliation bill would be expanding Medicare benefits to cover dental, vision and hearing care.
  • As the country continues to transition to a new normal as the covid pandemic eases, some employers are mandating that workers be vaccinated — but, in some instances, workers are refusing. The issue has already led to a legal fight over a Houston hospital’s mandate and is likely to spread. Workers argue that the vaccine has not yet been formally approved by federal regulators, having received only emergency authorization. That could change soon, though, because at least two vaccine makers are asking for a former approval from the FDA.

Also this week, Rovner interviews Andy Slavitt, who ran Medicare and Medicaid in the Obama administration and most recently helped head up the covid response effort for President Joe Biden.

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

Julie Rovner: Politico Magazine’s “How the Anti-Abortion Movement Used the Progressive Playbook to Chip Away at Roe v. Wade,” by Mary Ziegler and Robert L. Tsai

Joanne Kenen: The Atlantic’s “The Texans Challenging Obamacare Have No Standing,” by Nicholas Bagley

Rachel Cohrs: KHN’s “In Alleged Health Care ‘Money Grab,’ Nation’s Largest Hospital Chain Cashes In on Trauma Centers,” by Jay Hancock

Mary Ellen McIntire: The New York Times’ “Many Post-Covid Patients Are Experiencing New Medical Problems, Study Finds,” by Pam Belluck

Also: Roll Call’s “CDC Issues Guidance for Treating ‘Long COVID’ Patients,” by Mary Ellen McIntire


To hear all our podcasts, click here.

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Pandemia eleva el número de beneficiarios de Medicaid a más de 80 millones

Las últimas cifras de inscripción al Medicaid muestran que creció de 71,3 millones de miembros en febrero de 2020, cuando la pandemia comenzaba en los Estados Unidos, a 80,5 millones en enero, según un análisis de KFF de datos federales.

La recesión causada por la pandemia y un requisito federal de que los estados mantuvieran inscritos a los beneficiarios de Medicaid hasta que terminara la emergencia nacional aumentó el grupo de personas en el programa en más de 9 millones durante el año pasado, indica el nuevo informe.

En 2013, justo antes de que muchos estados expandieran Medicaid bajo la Ley de Cuidado de Salud a Bajo Precio (ACA), el número de beneficiarios era de 56 millones.

Medicaid, que alguna vez se consideró el “patito feo” en comparación con el popular y políticamente poderoso programa Medicare, ahora cubre a casi 1 de cada 4 estadounidenses.

Juntos, Medicaid y Medicare ofrecen atención médica al 43% de los estadounidenses.

Desde 2014, más de tres docenas de estados han utilizado miles de millones en fondos de ACA para expandir la cobertura más allá de las poblaciones tradicionales de Medicaid, cubriendo a adultos con ingresos por debajo del 138% del nivel federal de pobreza (es decir un individuo que gana alrededor de $17,800 al año).

Los estados que han visto al menos un aumento del 80% en la inscripción en Medicaid desde 2013 son Kentucky (157%), Nevada (129%), Alaska (94%), Colorado (92%), Montana (88%), Oregon (85%) y Nuevo México (80%).

Aunque a menudo se ha criticado a Medicaid por tener muy pocos médicos que acepten sus bajas tasas de reembolso, funcionarios estatales dicen que han transitado el aumento con pocas quejas de los beneficiarios sobre el acceso a los servicios de salud.

Una razón clave es la dramática caída en el número de personas que buscaron atención médica durante la pandemia por temor a contagiarse el coronavirus. Además, los médicos pudieron incorporar a más pacientes de manera eficiente a través de citas de telemedicina, luego que las reglas federales expandieran el reembolso por esos servicios.

“No tenemos problemas de acceso”, dijo Karen Kimsey, directora de Medicaid de Virginia. Desde marzo de 2020, Virginia Medicaid ha sumado a 308,000 nuevos miembros, un aumento del 20%, dijeron funcionarios estatales. Con la excepción de la escasez de algunos proveedores de salud mental, dijeron que tienen suficientes proveedores para manejar el aumento de la demanda.

Por lo general, un aumento en la inscripción a Medicaid puede paralizar los presupuestos estatales, pero el paquete de ayuda por covid aprobado por el Congreso el año pasado aumentó la participación federal en el financiamiento para Medicaid en 6.2 puntos porcentuales.

Antes de la pandemia, Washington pagaba en promedio alrededor del 56% de los costos de Medicaid, y los estados más pobres obtenían una mayor parte de los fondos federales.

Sin embargo, el aumento de fondos requería que los estados no retiraran a nadie del programa durante la emergencia de salud pública a menos que murieran o se mudaran fuera del estado.

El aumento en las contribuciones federales no se aplica a los beneficiarios cubiertos por la expansión de Medicaid bajo ACA. El gobierno federal ya paga al menos el 90% de sus gastos.

Entre los grandes ganadores de las listas ampliadas de Medicaid se encuentran los planes de salud privados, que la mayoría de los estados utilizan para cubrir a sus afiliados.

Los planes de salud como los administrados por los titanes de la atención administrada UnitedHealthcare, Molina Healthcare y Centene Corp. reciben un pago de los estados cada mes, en base a la inscripción. Eso significa que estas aseguradoras pueden beneficiarse si controlan los costos, pero pierden dinero si los gastos para tratar a los afiliados son demasiado altos.

“Estamos viendo que los ingresos de los planes aumentan y el uso de los servicios de salud disminuye, lo que es una receta para aumentar las ganancias”, dijo Massey Whorley, experto en Medicaid de la firma consultora Avalere.

Debido a la forma en que se les paga, las aseguradoras de salud se beneficiaron económicamente durante la pandemia en comparación con otros sectores importantes de la industria de la salud, como hospitales, médicos y hogares de adultos mayores, que se vieron obligados a estirar los presupuestos para dotación de personal adicional y equipo de protección para los trabajadores mientras sus ingresos se reducían debido a la baja de la demanda.

La mayoría de los expertos en salud esperan que la administración Biden mantenga el estado de emergencia sanitaria de la nación al menos hasta fin de año.

Los funcionarios de la administración han dicho que avisarán a los estados con al menos 60 días de anticipación antes de finalizar la emergencia para que los estados puedan prepararse para determinar quién sigue siendo elegible para Medicaid, y ayudar a quienes dejan el programa en la transición a otra cobertura.

La decisión de la administración Biden de reabrir los mercados de seguros de ACA desde marzo hasta el 15 de agosto impulsó la inscripción a Medicaid. Aproximadamente 331,000 personas que aplicaron como parte de esa inscripción especial fueron elegibles para Medicaid o el Programa de Seguro Médico para Niños (CHIP).

Matt Salo, director ejecutivo de la Asociación Nacional de Directores de Medicaid, dijo que algunos estados están considerando reducir las tarifas que pagan a las aseguradoras por persona.

A medida que más personas se vacunen por completo, dijo Salo, los estados esperan un aumento de beneficiarios que buscan atención médica que pospusieron durante la pandemia, lo que aumentará los costos. “Habrá mucha demanda contenido que podría explotar en un futuro cercano”, dijo.

Varios planes de salud les han dicho a los inversionistas de Wall Street que la pandemia ha sido buena para su salud financiera.

El director ejecutivo de Molina, Joseph Zubretsky, dijo en abril que la inscripción de la compañía en Medicaid a fines de marzo era de 3.9 millones de miembros, un aumento de 260,000 desde diciembre. Desde que comenzó la pandemia, estima la compañía, ha sumado a más de 700,000 miembros de Medicaid, sin una meseta a la vista.

“Por cada mes que se extienda la emergencia nacional por covid, produciría alrededor de $150 millones de ingresos para nuestro total anual”, dijo.

Zubretsky predijo, además, que muchos permanecerán en Medicaid por más tiempo.

“La economía de servicios de bajos salarios, las sandwicherías, los restaurantes, las tintorerías no están regresando muy rápido, y todavía creo que habrá una cantidad significativa de esa membresía que estará en Medicaid por un período prolongado de tiempo”, agregó.

The Hard Realities of a ‘No Jab, No Job’ Mandate for Health Care Workers

Christopher Richmond keeps a running tab on how many workers at the ManorCare skilled nursing facility he manages in western Pennsylvania have rolled up their sleeves for a covid-19 vaccine.

Although residents were eager for the shots this year, he’s counted only about 3 in 4 workers vaccinated at any one time. The excuses, among its staff of roughly 100, had a familiar ring: Because covid vaccines were authorized only for emergency use, some staffers worried about safety. Convenience mattered. In winter, shots were administered at work through a federal rollout. By spring, though, workers had to sign up online through a state program — a time-sucking task.

ManorCare urges every worker to be immunized against covid but turnover has vexed that effort. Managers at ProMedica, a nonprofit health system that operates ManorCare and senior care facilities in 26 states, faced a workforce conundrum familiar to all manner of providers during the pandemic: how to persuade essential workers to get vaccinated — and in a way that didn’t drive them away. Raises and bonuses, costing millions of dollars, did not move the needle to 100%.

Animus toward the vaccine created turmoil for some providers. Dr. Eric Berger, a pediatrician in Philadelphia who opened his practice more than a dozen years ago, enforced mandatory shots in May and saw six of his 47 staff members walk out. Berger said he worked for months to educate resistant workers. In April, he learned that several, women in their 20s and 30s, had attended a private karaoke party. Within days, four staffers were infected with covid.

Berger, who had seen in-office costs for protective equipment soar, then set a deadline for shots. He looks back with steely resolve over the last-minute “I quit” texts he received — and the hassle of finding a new receptionist and billing and medical assistants.

“Fortunately, we had some wonderful people who put in extra time,” he said. “It’s been stressful, but I think we did the right thing.”

Brittany Kissling, 33 and a mother of four, was one of the hesitant workers at Berger’s practice who decided — largely for financial reasons — to get vaccinated. The clinic manager couldn’t afford to lose her job. But she said she was nervous and that most of the workers who left recoiled at being told vaccinations were not negotiable. “I was a no-show my first time,” Kissling said about her first vaccine appointment. “I was scared. There were a lot of unknowns.”

But Kissling said Berger’s practice has spent “thousands and thousands and thousands of dollars” on masks and even paid workers for five days a week when they worked only two during the pandemic’s worst months. She said she understood how and why the karaoke episode prompted a mandate. “I get it from the business side,” said Kissling, about the requirement. “I do think it’s fair. I do think it is tough.”

Berger saw no other choice. “Vaccines are fundamental to our practices. That’s what we do,” he said. “Some got it in their heads that it could cause infertility; some had other reasons. It’s frustrating … [and] I don’t think it was political. If anything, most of these people are apolitical.”

At ManorCare, managers decided money could make a difference. Bonuses — up to $200 per employee — were added as an incentive, which in Pennsylvania alone cost ProMedica $3 million, said Luke Pile, vice president and general manager for ProMedica Senior Care skilled nursing centers.

Richmond, at ManorCare, said the resident council has been pivotal in keeping the focus on the risks of covid to the elderly — and no one there needs a reminder about the stress of the past year. According to Medicare records, the facility had 107 cases of covid among staffers and residents — and 14 deaths among residents beginning in March 2020.

“I constantly wear a mask. Not out of fear, but I don’t want to spread it by being asymptomatic,” Richmond said. “I tell people here: Whatever is happening in the community, that is what is happening in the community. But we are a health care institution and caring for the elderly. We need to be constantly vigilant.”

Richmond and other administrators admit it can be a struggle to understand why some health workers are unmoved by the science.

“Everything has been so polarized this past year. I don’t know that there is a single reason that individuals don’t get the vaccine,” Pile said. “In trying to educate people, personally and professionally, we talk about the history and science. Unfortunately, individual opinions don’t always align with that.”


Medical workers and pedestrians cross an intersection outside the Houston Methodist Hospital on June 9 in Houston. A judge dismissed a lawsuit this month from more than 100 hospital system staffers who objected to its compulsory vaccination.(Brandon Bell / Getty Images)

Mandating vaccines is a step that ProMedica has yet to take, even as more businesses, universities and health care providers do so. A few long-term care operators, such as Atria Senior Living, operating in the United and Canada, and Juniper Communities, announced mandates. Some have been met with lawsuits from workers aligned with conservative groups. In May, more than 100 staffers at Houston Methodist Hospital filed suit to dispute and derail the hospital system’s compulsory vaccination. A judge dismissed the challenge this month on the grounds that the hospital’s requirement did not violate state or federal law or public policy.

Last week, the U.S. Labor Department issued a temporary emergency standard for health care workers, saying they face “grave danger” in the workplace when “less than 100 percent of the workforce is fully vaccinated.”

In Pennsylvania, whose population ranks among the oldest according to 2019 census data, statistical snapshots published in April underscored the need for vigilance. Two state agencies overseeing skilled nursing care and personal care homes reported that only half of their workers were vaccinated. Covid was notably devastating to long-term care facilities nationwide in 2020; some of Pennsylvania’s deadliest outbreaks were reported by local media in places shown later to have low staff vaccination rates.

A survey by the Delphi Group, begun in March 2020 with over 700,000 Facebook respondents ages 18 to 64, recently was analyzed by researchers from Carnegie Mellon and the University of Pittsburgh, who found that health care workers were largely leading the vaccine uptake. But there were notable differences over the winter among people working, side by side, in health care settings.

Pharmacists, physicians and registered nurses were the least hesitant to get vaccinated. Home health care aides, EMTs and nursing assistants showed the highest hesitancy among front-line health workers. Overall hesitancy across professions decreased from January to March 2021, as much as 5 percentage points, as vaccinations expanded, according to the analysis by the university researchers.

University of Pittsburgh researcher Wendy King said people indicated they were receptive to the vaccine if they were familiar with its science. Educators, overall, displayed the least hesitancy; workers in construction, mining and oil/gas extraction showed the greatest. Half of those who were hesitant cited possible side effects — a fear that could be eased by education, King said. A third among the hesitant gave other reasons: They didn’t believe they needed the vaccine. They didn’t trust the government. Or they didn’t trust the covid-19 vaccines.

“We expected hesitancy to vary by group, but how much they varied was surprising,” King said. “These were not people who were anti-vaccine, but they were worried about the effect of the vaccine.”

Still, King said the percentage who didn’t trust the government was alarming. “If somebody doesn’t understand the vaccine, that’s one thing. If you don’t trust that government, that is a much more difficult issue to address.”

That may change as two prominent vaccine makers approach full approval by the Food and Drug Administration. Pfizer and BioNTech applied for approval in May; Moderna applied in early June. A recent KFF poll found nearly a third of unvaccinated adults said they would be more likely to get a vaccine once it was fully approved by the FDA.

At ProMedica, Pile described a multipronged approach in such states as Florida and Pennsylvania, home to large elderly populations. On-site counseling in groups, with familiar doctors and staff, helped persuade some who were reluctant, he said. Short videos on why and how the vaccine worked were readied. ProMedica senior medical staff flew to Florida to advise as the National Guard arrived at its facility in Pinellas County, the health system’s first to receive the vaccine.

Falon Blessing, a nurse, manages other practitioners at ManorCare Health Services Center throughout the Tampa region. She recounted how employees had wondered aloud how such newly created vaccines could be safe.

“I think people at first just wanted to know: I’m not going to grow a tail in five years,” she said. “But then there was a momentum. It wasn’t so much ‘Are you going to get vaccinated?’ but rather ‘Of course, I’m going to get vaccinated.’”

During three vaccinations sessions ended in January, though, the facility reached about the same rate as Pennsylvania overall — about 76% of its workers were vaccinated. That rate has fallen to 62% this month because of attrition. An education effort continues, a ProMedica spokesperson said.

“My takeaway was it mattered to have one-on-one discussions,” Pile said. “If you talk to 10 people, why they wouldn’t get the vaccine, you’d get 10 different reasons.”

“And there were political opinions — what they heard on Facebook — and then they’d say: I want to see how it goes,” he said.

The questions and qualms about vaccines came at the end of a deeply distressing pandemic year for health care workers, and facilities are now finding fewer applicants for essential care.

By spring, ProMedica had 1,500 job postings in Pennsylvania alone, compared with a typical 400 openings. Pile said ProMedica raised wages in dozens of locations, though he declined to provide wage ranges or rates. It spent $4.5 million in Pennsylvania from March through last week — and still supplemented its workforce across the U.S. by hiring through staffing agencies.

“In 2020, we spent over $32 million on staffing agencies,” he said. Through this spring, ProMedica was on course to spend $66 million on staffing agencies for 2021, said Pile, who has worked in the care sector for 18 years.

“I have less employees than ever before,” he said. “I have never seen anything like it.”

The Pennsylvania Health Care Association, an advocacy group, surveyed members in April to better understand vaccine reluctance. Zachary Shamberg, the group’s president, said it found that defining “hesitancy is not that simple.”

Shamberg said PHCA focused on why people had yet to be immunized and the characteristics of the workforce were telling: About 92% of all its workers are women; 65% are between ages 16 and 44. Among them, some worried early on about possible infertility from the new vaccine, he said, and some wanted to wait for the single-shot Johnson & Johnson vaccine. Others were sick with covid and were advised, once recovered, not to get a vaccine for 90 days.

Shamberg was also critical of the state data. Those surveys, taken in March and released in April, reflected a time when the vaccine was new to many people.

Pennsylvania, a battleground state in recent presidential elections, remains politically charged, and Shamberg noted that politics likely plays a role among holdouts. In recent months, PHCA enlisted churches and doctors’ consortiums to change minds. Keeping residents and workers safe should be a priority in a state that, in a few years, will face a “silver tsunami” of residents in their 80s, Shamberg said.

In recent weeks, there has been clear momentum among the general population for shots in Pennsylvania. The state now ranks among the top 10 states in the nation to administer first doses of vaccines, according to data from the Centers for Disease Control and Prevention.

“Pennsylvania is a big and diverse state,” Shamberg said. “And it’s interesting why some of our staff in western Pennsylvania were hesitant versus workers in the city of Philadelphia.”

“The vast majority of workers in Philadelphia are female and, among them, minority populations that have some inherent distrust based on historical experience. Then you go out west and you have a more conservative viewpoint — and a distrust of government today and a distrust of government vaccine.”

More Than 100 Missouri Schools Have Bought ‘Often Unproven’ Air-Cleaning Technology

When the coronavirus pandemic hit, Scott Dulle scoured the internet for ways to safely get kids back into St. Thomas More School, a private pre-K-8 school in Kansas City, Missouri, where he works as the director of building and grounds.

When Dulle found air-purifying ionization technology that marketing materials said would inactivate over 99% of the virus that causes covid-19 in minutes, he had to have it. Parishioners who support the parochial school, some of whom were out of work, raised roughly $22,000 to buy the devices. 


LISTEN: Audio story by Sarah Fentem, St. Louis Public Radio

Once the units were added to the school’s air system last summer, Dulle was confident he had made the right decision.

“I knew in my heart, I knew on paper, that we were probably one of the most protected schools in Kansas City,” Dulle said.

More than 100 public and private schools in Missouri are installing air-cleaning technology to try to ease the covid fears of staff members and parents, KHN and St. Louis Public Radio found through a review of school board notes, school websites and news reports. From Dulle’s Kansas City school to the Clayton district west of St. Louis to the Jefferson City School District in central Missouri, the review found schools across the state are collectively spending over $3.5 million on devices that claim to reduce the covid virus.

But in April, a covid-19 commission task force for top medical journal The Lancet, composed of international health, education and air quality experts, called various air-cleaning technologies — ionization, plasma and dry hydrogen peroxide — “often unproven” with a potential to create “harmful secondary pollutants.”

School officials need to be cautious when considering installing the devices, said Yang Wang, an assistant professor in environmental engineering who studies aerosols and air quality at the Missouri University of Science and Technology. He and other air quality experts worry that some versions of the cleaners may emit byproducts such as ozone that can make people sick.

“It’s some schools influencing other schools, and they’ve heard about this thing, and they think this is quite fancy, and maybe they will make the children’s parents feel safer,” he said. “We shouldn’t easily just devote all of our resources onto this device before we know clearly what’s happening.”

At a federal regulatory level, air-purifying devices that use ionization or UV light count as devices that kill pests such as bacteria and viruses, but they do not face the same scrutiny as more traditional pesticides, said Patrick Jones, president of the Association of American Pesticide Control Officials and four lawyers who specialize in pesticide law.


Ron Orr, Pattonville School District’s chief financial officer, isn’t completely sold that the technology will keep students safer from covid-19. “I will say, it makes our environment safer and healthier, because we’re filtering out more from the air than we otherwise would be,” he says. (Sarah Fentem / St. Louis Public Radio)

Pratim Biswas, who spent years leading the Energy, Environmental and Chemical Engineering Department at Washington University in St. Louis, said not enough peer-reviewed evidence shows the devices are effective at preventing covid spread — or better than using a multilayered approach that includes low-cost solutions such as opening a window. He added that much of the testing conducted so far has occurred in laboratories, not in a classroom environment.

“People try to sell some of these devices, but there’s no shortcut,” said Biswas, now the University of Miami’s incoming dean of engineering.

Instead, Biswas, Wang and others typically recommend schools install high-quality air filters such as HEPA or more advanced MERV 13 filters, and increase the amount of outdoor air inside a room.

Even so, over 2,000 schools across 44 states have installed ion-blasting or other air-purifying technology, a KHN investigation found in May. To pay the bill, many schools have tapped into a flood of taxpayer money — roughly $193 billion in federal funds sent to schools to pay for anything from salaries to personal protective equipment.

In Kansas City, St. Thomas More School received about $11,000 in taxpayer funds to reimburse the school for half the cost of the devices it installed, Dulle said. St. Louis University High School, a private Catholic school, also used federal funds to pay for ionization technology, according to the school website and its student newspaper. St. Louis University High School did not respond to multiple attempts for comment.

In the St. Louis suburbs, Rockwood School District is spending more than $685,000 to install ionizing units across its campus. “The federal funding that has been made available absolutely was a game changer,” said Chris Freund, Rockwood’s director of facilities. “That’s really what kind of tipped the scales.”

For some larger districts, the costs add up. The public Jefferson City School District has budgeted $1.1 million, not from federal pandemic funding, to install ionization units in its schools, according to district spokesperson Ryan Burns. That could buy more than 3,600 Samsung Chromebook laptops for students.

The “iWave” devices that Kansas City’s Dulle purchased rely on technology from Global Plasma Solutions. The air-purifying company’s marketing materials for its various products explain how they are designed to work: They emit charged ions into the air. Those ions “seek out” particles, like dust or pollen, and make them cluster together. Those clusters are more easily trapped inside a filter in a building’s HVAC system. The North Carolina-based company also says on its website that the ions inactivate pathogens.

The company, which has made products also being installed in Jefferson City Public Schools, St. Louis University High School and other schools in Missouri, is facing a federal lawsuit filed by a consumer who bought one of its devices, alleging the company “continues to defraud consumers by concealing material information regarding the true performance” of its products.

Company spokesperson Kevin Boyle pointed to the company’s motion to dismiss the suit. In those court documents, Global Plasma Solutions said of the lawsuit: “It is devoid of any concrete, specific allegations plausibly alleging that GPS made even a single false or deceptive statement about its products.”

Boyle said peer-reviewed research on the company’s products doesn’t exist yet for the virus that causes covid-19, but his confidence in the technology stems from the company’s testing, stories from customers and the general peer-reviewed research on the benefits of ionization.

“This technology is safe and effective,” he said, noting he was glad it was in his children’s schools. “This is not a silver bullet. This is part of a multilayered solution. And when this technology is used, it absolutely delivers incremental benefits.”

He said the ionizers from Global Plasma Solutions do not emit “harmful volumes of ozone.”


Pattonville School District spent over $330,000 to install Global Plasma Solutions air-purifying devices. (Sarah Fentem / St. Louis Public Radio)

One school district in California turned off its devices when it learned of the lawsuit. Although Dulle’s Kansas City school is aware of the Global Plasma Solutions lawsuit, he said, school officials decided “we’re going to wait and see where this is going.” He said that doctors’ offices and other trusted institutions had bought the technology. And when the school bought the devices last summer, he said, school officials were “every day learning something new about the virus and how to kill it.”

In north St. Louis County, Pattonville School District has installed Global Plasma Solutions technology made possible by federal relief funds, spending over $330,000.

Ron Orr, chief financial officer for the district, noted the appeal of buying devices that fight more than the virus that causes covid-19, as makers of air-purifying devices often tout their ability to curb the spread of viruses that cause colds, flu and other illnesses. He is such a fan, he bought a unit to help with dirt and dander in his home — where he lives with his wife, son and three dogs.

Orr isn’t completely sold on the claims of the devices when it comes to keeping kids safe from covid: “What I will say, it makes our environment safer and healthier, because we’re filtering out more from the air than we otherwise would be.”

He said the price also was hard to beat compared with replacing the district’s entire HVAC systems with a higher filtration option.

“Is there any way that we can get to that standard, without having to replace $40 million in heating and cooling equipment, which just physically wasn’t something that was going to be possible?” Orr asked. “And so that’s what kind of led us down this road.”

Pandemic Swells Medicaid Enrollment to Record 80 Million People

The pandemic-caused recession and a federal requirement that states keep Medicaid beneficiaries enrolled until the national emergency ends swelled the pool of people in the program by more than 9 million over the past year, according to a report released Thursday.

The latest figures show Medicaid enrollment grew from 71.3 million in February 2020, when the pandemic was beginning in the U.S., to 80.5 million in January, according to a KFF analysis of federal data. (KHN is an editorially independent program of KFF.)

That’s up from about 56 million in 2013, just before many states expanded Medicaid under the Affordable Care Act. And it’s double the 40 million enrolled in 2001.

Medicaid, once considered the ugly duckling compared with the politically powerful and popular Medicare program, now covers nearly 1 in 4 Americans. In New Mexico, the ratio is more than 1 in 3.

Together, Medicaid and Medicare cover 43% of Americans.

More than three dozen states since 2014 have used billions in ACA funding to expand coverage beyond traditional Medicaid populations to cover adults with incomes below 138% of the federal poverty level, or about $17,800. At the end of 2020, 14.8 million newly eligible adults were enrolled in Medicaid because of the ACA.

States that have seen at least an 80% increase in Medicaid enrollment since 2013 are Kentucky (157%), Nevada (129%), Alaska (94%), Colorado (92%), Montana (88%), Oregon (85%) and New Mexico (80%).

Although Medicaid has often been criticized for having too few physicians who accept its low reimbursement rates, state officials say they have weathered the surge with few complaints from enrollees about accessing health services. One key reason is the dramatic downturn in people seeking medical care during the pandemic because they were mitigating their risks of contracting covid. Also, doctors were able to fit in more patients efficiently through telehealth appointments after federal rules expanded reimbursement for those services.

“We have no access issues,” said Karen Kimsey, Virginia’s Medicaid director. Since March 2020, Virginia Medicaid has added 308,000 members, a 20% increase, state officials said. With the exception of a shortage of some licensed mental health providers, state officials said they have enough providers to handle the increased demand.

Typically, a surge in Medicaid enrollment can cripple state budgets, but a covid relief package passed by Congress last year boosted the federal share of its funding for traditional Medicaid by 6.2 percentage points. Before the pandemic, Washington paid on average about 56% of Medicaid costs, with poorer states getting a larger share of federal funding.

However, the funding hike required states to not remove anyone from the program during the public health emergency unless they die or move out of state.

The increase in federal contributions does not apply to enrollees covered by the ACA Medicaid expansion. The federal government already pays for at least 90% of their expenses.

Among the big winners from the enlarged Medicaid rolls are private health plans, which most states use to cover their enrollees. Health plans such as those run by managed-care titans UnitedHealthcare, Molina Healthcare and Centene Corp. receive a payment from states each month based on enrollment. That means these insurers can profit if they control costs, but they lose money if expenses to treat enrollees are too high.

“We are seeing plans’ revenues go up and utilization of health services decline, which is a recipe for increased profits,” said Massey Whorley, a Medicaid expert with the consulting firm Avalere.

Because of the way they are paid, health insurers benefited financially during the pandemic compared with other major health industry sectors, such as hospitals, physicians and nursing homes forced to stretch budgets for extra staffing and protective gear for workers while their revenues shrank due to waning demand.

Most health experts expect the Biden administration to maintain the nation’s health emergency status until at least the end of the year. Administration officials have said they will give states at least 60 days’ notice before ending the emergency so states can prepare to determine who is still eligible for Medicaid and help those who leave the program transition to other coverage.

“What we are seeing now is the high-water mark for Medicaid enrollment,” Massey said.

Helping to drive Medicaid enrollment this year was the Biden administration’s decision to reopen the ACA insurance marketplace from March until Aug. 15. About 331,000 people who applied as part of that special enrollment were eligible for Medicaid or the Children’s Health Insurance Program.

Anthony Fiori, an analyst with the consulting firm Manatt Health, said some states likely have adjusted payments to health plans when annual contracts were negotiated to account for a drop in health care use. He noted many states have limits on how much health plans can make in profits.

Matt Salo, executive director of the National Association of Medicaid Directors, said some states are considering lowering the rates they pay insurers per person.

As more people get fully vaccinated, Salo said, states expect an uptick in enrollees seeking care that they have put off during the pandemic, which will increase costs. “There will be a lot of pent-up demand that might explode in the near future,” he said.

Several health plans have told Wall Street investors that the pandemic has been good for their financial health.

Molina CEO Joseph Zubretsky said in April that the company’s Medicaid enrollment at the end of March was 3.9 million members, an increase of 260,000 since December. Since the pandemic started, the company estimates, it has added more than 700,000 Medicaid members with no plateau in sight.

“For every month the national covid emergency gets extended, it would produce about $150 million of revenue to our annual total,” he said.

Zubretsky predicted many will remain on Medicaid longer.

“The low-wage service economy, the sandwich shops, the restaurants, the dry cleaner shops aren’t coming back real fast, and I still think there will be a significant amount of that membership that will be on Medicaid for an extended period of time,” he said.

Corte Suprema se niega a revocar ACA, por tercera vez

La Corte Suprema se negó por tercera vez a revocar la Ley de Cuidado de Salud a Bajo Precio (ACA) el jueves 17 de junio, desestimando una demanda presentada por un grupo de fiscales generales estatales republicanos que alegaban que un cambio realizado por el Congreso en 2017 había vuelto inconstitucional a toda la ley.

Por 7 a 2 votos, los jueces ni siquiera llegaron a los méritos del caso, resolviendo que los estados e individuos demandantes, dos personas de Texas cuentapropistas, carecían de “argumentos” para llevar el caso a los tribunales.

“No procederemos más allá”, escribió el juez Stephen Breyer. “Ni los individuos ni los demandantes estatales han demostrado que el daño que sufrirán o hayan sufrido sea ‘razonablemente atribuible’ a la ‘conducta supuestamente ilegal’ de la que se quejan”.

Los dos jueces disidentes, Samuel Alito y Neil Gorsuch, no estuvieron de acuerdo. “Los estados han demostrado claramente que sufren daños económicos concretos y particulares que se pueden atribuir a la conducta del gobierno federal”, escribió Alito. “ACA los carga con obligaciones costosas y onerosas, y el gobierno federal las hace cumplir. Eso es suficiente para establecer una posición”.

El fallo representó una victoria no solo para los defensores de la ley de salud en general, sino también para el secretario de Salud y Servicios Humanos, Xavier Becerra. Como fiscal general de California, Becerra lideró a los estados demócratas que defendían ACA después que la administración Trump apoyara la demanda de los estados republicanos.

Fue la tercera vez en nueve años que se le ofreció al tribunal la oportunidad de poner fin de manera efectiva a la ley de salud, y la tercera vez que se negó.

Los demócratas se apresuraron a declarar victoria. “La Corte Suprema acaba de fallar: ACA está aquí para quedarse”, dijo el líder de la mayoría del Senado, Chuck Schumer. La presidenta de la Cámara de Representantes, Nancy Pelosi, agregó: “Nunca olvidaremos cómo los líderes republicanos presentaron esta monstruosa demanda para arrebatar la atención médica de millones de estadounidenses en medio de una pandemia mortal”.

El caso, California vs. Texas, surgió como resultado de una disposición del proyecto de ley de reducción de impuestos aprobada por el Congreso controlado por los republicanos en 2017. Como parte de ese proyecto de ley, el Congreso redujo a cero la multa de ACA por no tener seguro médico.

El requisito de cobertura, también llamado mandato individual, se incorporó a la ley para aumentar el número de clientes de las aseguradoras, a las que ahora se les exige que cubran a personas con afecciones médicas. Los republicanos han atacado durante mucho tiempo la disposición como una extralimitación del gobierno.

En su demanda, los fiscales republicanos argumentaron que solo la existencia de esa sanción, que los magistrados consideraron un impuesto, fue lo que permitió que la Corte Suprema dictaminara en 2012 que la ley sí era constitucional. Al reducir la multa por no tener seguro a cero, los republicanos dijeron que no solo el mandato de tener cobertura era inconstitucional, sino también el resto de la ley.

En los argumentos orales del caso, en noviembre pasado, varios de los jueces conservadores dejaron en claro que no estaban de acuerdo con el argumento de los republicanos.

Sobre la falta de argumentos para sostener el caso, el presidente de la Corte, John Roberts, se preguntó si alguien podría demandar para revocar una ley que requiriera que propietarios corten el césped, incluso si esa ley no tuviera ninguna sanción. Su clara sugerencia fue que esa persona no tendría ningún caso.

También estaba en discusión la cuestión de si el resto de la ley podía mantenerse si los jueces creían que quienes presentaban el caso tenían legitimación, y si el requisito de tener un seguro médico era inconstitucional. Incluso algunos de los miembros más conservadores de la corte, incluido el juez Brett Kavanaugh, sugirieron que el Congreso no tenía la intención de que el resto de la ley se desmoronara si el mandato individual se declaraba inconstitucional.

La ley, promulgada en 2010, ha brindado cobertura a cerca de 31 millones de estadounidenses. Pero cientos de millones más han visto su atención médica y su cobertura impactadas por disposiciones de la ley tan amplias como cambios en los copagos de medicamentos de Medicare, requisitos de recuento de calorías en los menús, y una vía para la aprobación de copias genéricas de medicamentos biológicos costosos.

Y, quizás, lo más importante políticamente: protecciones para personas con afecciones preexistentes y la prohibición de imponer límites de cobertura de por vida.

La administración Trump tomó varias posiciones sobre el caso. En un momento afirmó que la eliminación del mandato individual requería que toda la ley fuera declarada nula, y en otro momento sugirió que la ley de salud podría invalidarse solo en los estados controlados por los republicanos involucrados en la demanda.

Antes de la muerte de la jueza Ruth Bader Ginsburg, en septiembre pasado, la mayoría de los observadores de la corte pensaban que era muy poco probable que el caso resultara en la anulación de toda la ley. Eso se debe a que Roberts votó para defender la ley en 2012, y nuevamente cuando fue impugnada de una manera menos radical en 2015. Pero la jueza conservadora Amy Coney Barrett reemplazó a Ginsburg, lo que pareció crear una plataforma de mayor inseguridad para sostener la ley.