From Health Care

Social Media Image About Mask Efficacy Right In Sentiment, But Percentages Are ‘Bonkers’

A popular social media post that’s been circulating on Instagram and Facebook since April depicts the degree to which mask-wearing interferes with the transmission of the novel coronavirus. It gives its highest “contagion probability” — a very precise 70% — to a person who has COVID-19 but interacts with others without wearing a mask. The lowest probability, 1.5%, is when masks are worn by all.

The exact percentages assigned to each scenario had no attribution or mention of a source. So we wanted to know if there is any science backing up the message and the numbers — especially as mayors, governors and members of Congress increasingly point to mask-wearing as a means to address the surges in coronavirus cases across the country.

Doubts About The Percentages

As with so many things on social media, it’s not clear who made this graphic or where they got their information. Since we couldn’t start with the source, we reached out to the Centers for Disease Control and Prevention to ask if the agency could point to research that would support the graphic’s “contagion probability” percentages.

“We have not seen or compiled data that looks at probabilities like the ones represented in the visual you sent,” Jason McDonald, a member of CDC’s media team, wrote in an email. “Data are limited on the effectiveness of cloth face coverings in this respect and come primarily from laboratory studies.”

McDonald added that studies are needed to measure how much face coverings reduce transmission of COVID-19, especially from those who have the disease but are asymptomatic or pre-symptomatic.

Other public health experts we consulted agreed: They were not aware of any science that confirmed the numbers in the image.

“The data presented is bonkers and does not reflect actual human transmissions that occurred in real life with real people,” Peter Chin-Hong, a professor of medicine at the University of California-San Francisco, wrote in an email. It also does not reflect anything simulated in a lab, he added.

Andrew Lover, an assistant professor of epidemiology at the University of Massachusetts Amherst, agreed. He had seen a similar graphic on Facebook before we interviewed him and done some fact-checking on his own.

“We simply don’t have data to say this,” he wrote in an email. “It would require transmission models in animals or very detailed movement tracking with documented mask use (in large populations).”

Because COVID-19 is a relatively new disease, there have been only limited observational studies on mask use, said Lover. The studies were conducted in China and Taiwan, he added, and mostly looked at self-reported mask use.

Research regarding other viral diseases, though, indicates masks are effective at reducing the number of viral particles a sick person releases. Inhaling viral particles is often how respiratory diseases are spread.

One recent study found that people who had different coronaviruses (not COVID-19) and wore a surgical mask breathed fewer viral particles into their environment, meaning there was less risk of transmitting the disease. And a recent meta-analysis study funded by the World Health Organization found that, for the general public, the risk of infection is reduced if face masks are worn, even if the masks are disposable surgical masks or cotton masks.

The Sentiment Is On Target

Though the experts said it’s clear the percentages presented in this social media image don’t hold up to scrutiny, they agreed that the general idea is right.

“We get the most protection if both parties wear masks,” Linsey Marr, a professor of civil and environmental engineering at Virginia Tech who studies viral air droplet transmission, wrote in an email. She was speaking about transmission of COVID-19 as well as other respiratory illnesses.

Chin-Hong went even further. “Bottom line,” he wrote in his email, “everyone should wear a mask and stop debating who might have [the virus] and who doesn’t.”

Marr also explained that cloth masks are better at outward protection — blocking droplets released by the wearer — than inward protection — blocking the wearer from breathing in others’ exhaled droplets.

“The main reason that the masks do better in the outward direction is that the droplets/aerosols released from the wearer’s nose and mouth haven’t had a chance to undergo evaporation and shrinkage before they hit the mask,” wrote Marr. “It’s easier for the fabric to block the droplets/aerosols when they’re larger rather than after they have had a chance to shrink while they’re traveling through the air.”

So, the image is also right when it implies there is less risk of transmission of the disease if a COVID-positive person wears a mask.

“In terms of public health messaging, it’s giving the right message. It just might be overly exact in terms of the relative risk,” said Lover. “As a rule of thumb, the more people wearing masks, the better it is for population health.”

Public health experts urge widespread use of masks because those with COVID-19 can often be asymptomatic or pre-symptomatic — meaning they may be unaware they have the disease, but could still spread it. Wearing a mask could interfere with that spread.

Our Ruling 

A viral social media image claims to show “contagion probabilities” in different scenarios depending on whether masks are worn.

Experts agreed the image does convey an idea that is right: Wearing a mask is likely to interfere with the spread of COVID-19.

But, although this message has a hint of accuracy, the image leaves out important details and context, namely the source for the contagion probabilities it seeks to illustrate. Experts said evidence for the specific probabilities doesn’t exist.

We rate it Mostly False.

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Pruebas para el VPH y el cáncer cervical podrían hacerse en casa

Pasa un pequeño hisopo por la vagina para recoger células. Luego lo colocas en un kit de detección y lo envías por correo.

Una prueba sencilla como ésta, que se puede hacer en casa, ayudaría a los Estados Unidos a acercarse a la erradicación del cáncer de cuello uterino o cáncer cervical.

El año que viene, el Instituto Nacional del Cáncer (NCI) lanzará un estudio en diferentes localidades que involucrará a unas 5,000 mujeres para evaluar si la autoprueba casera puede equivaler a la que realiza el médico en un consultorio.

Casi 14,000 estadounidenses este año serán diagnosticadas con un cáncer que es prevenible, y más de 4,000 morirán. Las mujeres que no tienen seguro o que no pueden acceder a servicios médicos regulares tienen más probabilidades de no hacerse pruebas de detección que salvan vidas, dijo Vikrant Sahasrabuddhe, de la División de Prevención del Cáncer del NCI.

Sin salir de sus casas, las mujeres podrían recolectar células vaginales y cervicales para analizarlas en la detección del virus del papiloma humano (VPH), que causa virtualmente todos los cánceres cervicales, de la misma manera que las muestras de heces en casa pueden usarse para detectar el cáncer de colon, añadió.

“Sigue existiendo un número constante de mujeres que padece cáncer cervical cada año”, explicó Sahasrabuddhe, que supervisa los estudios sobre los cánceres relacionados con el VPH. “Y ese número no va a bajar”.

Las autoridades federales esperan que la investigación acelere un test aprobado por la Administración de Alimentos y Medicamentos (FDA) que podría formar parte de las directrices de evaluación si se demuestra que tomar la muestra en casa es eficaz, señaló Sahasrabuddhe.

En lugar de esperar a que las empresas que realizan las pruebas de VPH para los médicos hagan estudios de automuestreo, los funcionarios federales se unirán a empresas, instituciones académicas y otros en una asociación público-privada, explicó. Los funcionarios del NCI, que esperan gastar unos $6 millones en fondos federales, supervisarán los datos y el análisis del estudio.

“Queremos acelerar ese proceso”, indicó Sahasrabuddhe.

El automuestreo del VPH, existente en países como Australia y los Países Bajos, es uno de los enfoques de los investigadores del cáncer cervical en los Estados Unidos. Otra estrategia clave consiste en vacunar a las adolescentes contra el VPH, que se transmite a través de la actividad sexual. En 2018, casi el 54% de las niñas habían sido vacunadas al llegar a los 17 años, al igual que casi el 49% de los niños, según los datos federales más recientes.

Los países que han tenido más éxito en la reducción del cáncer cervical —un análisis predice que Australia está en vías de eliminar la enfermedad— han hecho hincapié en la vacunación contra el VPH en adolescentes.

Las autoridades siguen aconsejando a las mujeres vacunadas que se sometan regularmente a pruebas de detección, ya que la vacuna no protege contra todas las cepas que causan el cáncer de cuello uterino.

Sin embargo, a veces es un desafío.

Para algunas, el acceso o el costo puede ser un problema. La mayoría de los planes médicos cubren los exámenes y también hay algunos programas públicos, pero las mujeres sin seguro que no los conocen tienen que pagar por la consulta y la prueba.

Además, las mujeres no siempre salir del trabajo o encontrar una guardería, o pueden haber tenido “emociones o experiencias negativas en el pasado con los exámenes pélvicos”, señaló Rachel Winer, profesora de epidemiología de la Escuela de Salud Pública de la Universidad de Washington que estudia el automuestreo del VPH.

Invertir la tendencia

Unas 4 de cada 5 mujeres se someten regularmente a pruebas de detección de cáncer cervical, pero los índices alcanzaron su punto máximo alrededor del año 2000 y han disminuido ligeramente desde entonces, según datos federales.

Otro análisis de registros médicos de 27,418 mujeres de Minnesota, de entre 30 y 65 años, encontró que casi el 65% se había hecho la prueba en 2016, según publicó el año pasado el Journal of Women’s Health.

“Lamentablemente, creo que nuestros datos probablemente reflejan mejor lo que está sucediendo con los índices de evaluación en nuestro país”, expresó la doctora Kathy MacLaughlin, autora del estudio e investigadora de la Clínica Mayo en Rochester, Minnesota.

Un obstáculo para la prueba podría ser la complejidad de las directrices, dijo MacLaughlin. En lugar de un examen anual fácil de recordar, las evaluaciones ocurren en intervalos de más de un año. La edad de la mujer ayuda a determinar cuándo se recomienda la prueba de VPH o la citología vaginal (el Papanicolau), que recoge células del cuello uterino para buscar cambios precancerosos.

“El reto es cómo recordar que debemos hacer algo cada tres o cada cinco años”, comentó MacLaughlin.

Logística en casa

Si bien el NCI aún no ha decidido el tipo de automuestreo que utilizará, la técnica generalmente requiere que la mujer inserte un pequeño hisopo en su vagina y lo rote varias veces para recolectar las células.

Luego desliza el hisopo en un contenedor de muestras que tiene una solución conservante y devuelve el kit para el análisis del VPH.

Según un informe publicado en 2018 en la revista médica BMJ, la precisión de la identificación del VPH era similar cuando las muestras eran recogidas por las mujeres en casa que cuando lo hacía un médico.

También se estudia una prueba de VPH en orina, que podría resultar más fácil de realizar para las mujeres, dijo Jennifer Smith, profesora de epidemiología de la Escuela Gillings de Salud Pública Global de la Universidad de Carolina del Norte.

Antes que las compañías puedan aplicar para pruebas caseras aprobadas por la FDA, el automuestreo de las mujeres debe ser comparable en la detección del VPH, aunque no sea tan preciso, como cuando lo hace un médico, señaló Sahasrabuddhe.

Los funcionarios del NCI aún están ultimando los detalles del estudio. Pero el plan es invitar a participar a cuatro compañías que ya fabrican pruebas de VPH para médicos, dijo Sahasrabuddhe.

Las empresas pagarán el costo de las pruebas y las futuras tarifas relacionadas con la solicitud de licencias a través de la FDA. Sahasrabuddhe espera que los resultados del estudio estén disponibles para 2024, si no antes.

Si una mujer da positivo en las pruebas de VPH podría necesitar una biopsia, para buscar células anormales o cáncer cervical, indicó Sahasrabuddhe.

Si se desarrolla un test casero aprobado por la FDA, es crucial que las mujeres sin seguro y otras que no tienen acceso fácil a la atención médica puedan conseguirlo, enfatizó Smith.

“Porque no se envían kits al azar a los hogares”, dijo Smith, “y nadie se asegura que tengan a alguien con quien hablar sobre los resultados y que puedan tener un seguimiento”.

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A pesar del aumento de casos, California frena fondos multimillonarios para pruebas de COVID

En abril, el gobernador Gavin Newsom lanzó una iniciativa estatal multimillonaria para que las pruebas de COVID-19 llegaran a las personas y a los lugares con menos acceso: pueblos rurales y vecindarios desfavorecidos del centro de la ciudad.

Pero ahora, citando costos, California está frenando esta expansión, incluso cuando el estado está teniendo devastadores récords de nuevas infecciones y aumentos de dos dígitos en las hospitalizaciones.

El estado ya no financiará nuevos sitios de prueba, a pesar de las súplicas de los condados para obtener asistencia adicional. También ha cerrado algunos espacios y los ha trasladado a otros lugares.

Y el gobierno ha amenazado con cerrar los sitios subutilizados, de acuerdo con casi dos docenas de entrevistas con funcionarios de salud pública de los condados.

Aunque es pronto para evaluar, han surgido algunos ganadores y perdedores: el condado de El Dorado, al este de Sacramento, perdió uno de sus sitios de prueba en la ciudad de Shingle Springs en junio por no agendar suficientes citas, mientras que el condado de Fresno ganó un sitio que había sido retirado de otra parte, dijo el doctor Rais Vohra, su oficial de salud.

Sin embargo, el condado de San Mateo ha pedido tres veces a los funcionarios estatales un segundo lugar de pruebas financiado por el estado para abordar las brechas en las pruebas en los vecindarios de minorías de raza negra y de trabajadores agrícolas, pero se le ha “dicho que no repetidamente”, dijo Justin Mates, subdirector del condado.

Por eso, el condado transformó su único sitio estatal en una unidad de prueba itinerante.

“La equidad es ciertamente una preocupación para nosotros”, dijo Mates. “Realmente necesitamos ayuda con el acceso a pruebas si vamos a llegar a nuestros residentes latinos y lugares como East Palo Alto”, una ciudad diversa cuya población es principalmente latina, afroamericana, asiática y de nativos de las Islas del Pacífico.

California ha comprometido hasta $132 millones en contratos con dos compañías privadas de pruebas para COVID-19, Verily Life Sciences y OptumServe, para ofrecer pruebas gratuitas en más de 100 sitios que la administración de Newsom ha identificado como “desérticos para pruebas”.

La expansión ha elevado drásticamente los números de pruebas generales del estado, que aumentaron de 16,000 por día en abril a 105,000 el lunes 29 de junio.

Las pruebas también están disponibles en ubicaciones financiadas por condados, farmacias privadas, hospitales y clínicas comunitarias.

Mark Ghaly, secretario estatal de Salud y Servicios Humanos, confirmó que el estado está retirando los sitios de los condados que no están generando números lo suficientemente altos y cortando fondos para nuevos espacios.

“Lo que quieres es que el dinero vaya a donde más se necesita”, dijo Ghaly. “No sería prudente o sabio mantener el gasto en un lugar donde no se están utilizando los recursos”.

El propio Newsom ha expresado su preocupación por los precios, dados los déficits presupuestarios “sin precedentes”. “Hay un gran costo asociado con las pruebas”, dijo a fines de junio.

Un funcionario de la administración de Newsom confirmó que el estado quiere ver que los condados llenen al menos el 80% de las citas para pruebas en cada ubicación. Y si las pruebas caen por debajo del 50% durante unos días o más, se les advierte que los sitios podrían transferirse a otro lugar.

Los condados argumentan que existe un beneficio para la salud pública al mantener abiertas las ubicaciones de bajo rendimiento, simplemente para garantizar que las pruebas estén disponibles para las comunidades rurales y postergadas.

En todo el estado, están luchando para salvar sitios financiados por el estado, incluso cuando están siendo abrumados por los crecientes casos de coronavirus vinculados en gran medida a reuniones sociales.

“Es cómo podemos identificar rápidamente dónde está el virus y si hay puntos calientes”, dijo la doctora Olivia Kasirye, oficial de salud del condado de Sacramento, donde celebraciones familiares y reuniones con alto consumo de alcohol están elevando las tasas de infección.

El condado de Contra Costa vio caer sus números de pruebas en junio y corría el riesgo de perder un sitio financiado por el estado hasta que demostrara que podía cumplir con las citas a cerca del 80% de su capacidad, dijo el doctor Chris Farnitano, su oficial de salud.

Al condado de Riverside se le advirtió el 16 de junio de que un sitio financiado por el estado al norte de Temecula sería “trasladado a otro condado” si no cubría el 50% de sus citas, según un correo electrónico del grupo de trabajo de pruebas del estado.

Lo mismo se le dijo al condado de Mendocino, que podría perder su sitio financiado por el estado, la única prueba gratuita disponible a dos horas de manejo para algunos residentes de áreas rurales.

El condado de Alameda se sintió tan frustrado con los requisitos estatales que emprendió una expansión de pruebas por cuenta propia.

“Nos dimos cuenta que no podíamos depender del estado, especialmente para llegar a nuestras comunidades vulnerables”, dijo la doctora Jocelyn Freeman Garrick, doctora de la sala de emergencias del Hospital Highland en Oakland, quien lidera la fuerza de pruebas del condado.

El condado de El Dorado, que perdió su sitio, hasta ahora ha mantenido un recuento relativamente bajo de casos de COVID-19.

Ghaly dijo que el estado está trabajando con los condados en peligro de perder sitios para darles la oportunidad de llenar los espacios de prueba. Los funcionarios estatales se negaron a decir cuántos condados han perdido sitios, pero a medida que las nuevas infecciones se han disparado, los números de las pruebas están comenzando a recuperarse.

La lista de condados en riesgo de perder un sitio ha disminuido de alrededor de una docena a principios de junio a unos pocos la última semana de junio.

Expertos en salud pública dicen que enfocándose tan intensamente en los números de las pruebas y no en las pruebas adecuadas en los vecindarios de minorías, se corre el riesgo de abandonar las comunidades que ya enfrentan enormes barreras para la atención médica como el racismo y la pobreza.

“Si ignoras estas comunidades, seguiremos viendo las mismas urgencias que estamos viendo ahora”, dijo el doctor Tony Iton, ex alto funcionario de salud del condado de Alameda y ahora vicepresidente senior de California Endowment, que está trabajando con los condados para expandir las pruebas en vecindarios desatendidos.

Las barreras socioeconómicas arraigadas también hacen que sea difícil obtener y mantener los números de prueba. Por ejemplo, las personas que desean hacerse la prueba en sitios estatales a menudo necesitan acceso a Internet y una dirección de correo electrónico. La mayoría son al paso, por lo que deben tener un vehículo.

Muchas personas de bajos ingresos no pueden cumplir con esos requisitos, y los inmigrantes indocumentados temen que proporcionar información personal para obtener una prueba pueda exponerlos a los funcionarios de inmigración, dijo el doctor Marty Fenstersheib, ex funcionario de salud del condado de Santa Clara que lidera el programa de pruebas.

“Si las personas tienen miedo de venir y hacerse la prueba, no habrá ningún beneficio”, dijo.

Los contratos estatales que financian los sitios de prueba se extendieron en junio, pero expirarán el 31 de agosto, y los funcionarios de la administración no han dicho a los condados si el estado continuará financiándolos, dijo Mimi Hall, presidenta de la Asociación de Ejecutivos de Salud del Condado de California y directora de salud pública del condado de Santa Cruz.

“Es difícil planificar cuando no sabemos cuánto tiempo podremos mantenerlos”, expresó Hall.

Esta historia de KHN fue publicada primero en California Healthline, un servicio de la California Health Care Foundation.

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Among Those Disrupted By COVID-19: The Nation’s Newest Doctors

July 1 is a big day in medical education. It’s traditionally the day newly minted doctors start their first year of residency. But this year is different. Getting from here to there — from medical school to residency training sites — has been complicated by the coronavirus.

“We were all really freaking out,” said Dr. Christine Petrin, who just graduated from medical school at Tulane University in New Orleans and is starting a combined residency in internal medicine and pediatrics at MedStar Georgetown University Hospital in Washington, D.C. Students “matched” — the term for finding out where they will spend their next several years training — in March, just as everything was shutting down because of the pandemic.

After getting the news of their placements, Petrin said, some of her friends were worried about being able to enter states that were closing their borders. They “just rapidly picked up and moved. Found an apartment, packed up the car, and went.”

Petrin said she was lucky. Although she shopped apartments online, her sister, who lives in Washington, could check them out in person. Dr. Erin Fredrickson was not as fortunate. She graduated in May from Campbell University School of Osteopathic Medicine near Raleigh, North Carolina, and matched in a family practice residency at the University of Washington in Seattle.

She and her partner were already planning to drive across the country with their dog, but the trip turned out to be much different than the leisurely journey they had envisioned. “We were going to visit friends in different places along the way,” she said. “We were going to camp, but a lot of places to camp were closed. We ended up staying in Airbnb guest houses” in an effort to minimize contact with anyone else.

Meanwhile, she said, she was forced to pick out housing remotely. “I did a lot of FaceTime tours of apartments” in Seattle, she said.

Dr. Janis Orlowski, chief health care officer for the Association of American Medical Colleges, agreed this has been a year like no other. “It’s been really messy,” she said. “But it looks like it’s coming together.”

Among other things, graduates traveling from states that are or have been hot spots are being asked to quarantine for 14 days upon arrival. That has required more flexibility than usual from administrators used to starting programs at an exact time.

“Everyone is pretty much going to start July 1 — or a little after,” she said.

In some instances, the medical students graduating this year — some of whom graduated early to help in the hospitals attached to their medical schools — have it easier than students directly behind them.

Almost from the start of the outbreak, third- and fourth-year students who would typically spend much or all of their time in the hospital were shut out to avoid being exposed to the coronavirus. Even the newly graduated doctors were generally kept away from COVID-19 patients.

The restrictions were intended not only for their own safety, said Orlowski, but also to help protect patients. “If you have a COVID patient, you don’t need 14 people marching into the room,” she said. “We wanted to decrease the team size.” And shortages of personal protective equipment made smaller care teams necessary.

For most of the graduating seniors, required rotations were generally finished by the time the virus had upset their plans. Those that were not could be made up.

But for third-year students, the time out of the hospital will be more difficult to recoup as the pandemic drags on — and continues to spread. For the moment, most students are also barred from rotations at hospitals other than their own. (Students frequently work at hospitals that have programs their home hospital does not offer.)

At the same time, those soon-to-be fourth-year students who normally would be traveling around the country to interview for residencies will be limited to online visits only. That’s a real shame, said Petrin, because being on-site in some cases “changed my perception for better or worse.”

But right now it’s about safety, Orlowski said. “We’re trying to cut down on any travel,” she said. “But we’re also trying to make it fair. We don’t want some students to have in-person interviews and others not.”

For those starting residency this week, one of the hardest things, said Fredrickson, is getting through all the errands she won’t have time for later. “I moved to a new state and I need a new driver’s license and license plates,” she said. “And the DMV is still closed.”

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Un sistema de salud pública devastado enfrenta más recortes en medio del virus

El sistema de salud pública de los Estados Unidos ha subsistido en la precariedad durante décadas y carece de los recursos necesarios para enfrentar la peor crisis de salud en un siglo.

Mientras enfrentan juntos una pandemia que ha enfermado al menos a 2.3 millones de personas en el país, y matado a más de 120,000, y que ha costado millones de empleos y $3 mil millones en dinero de rescate federal, a los trabajadores de salud de los gobiernos estatales y locales a veces se les paga tan poco que califican para ayuda pública. Rastrean al coronavirus en registros compartidos por fax. Trabajando los siete días de la semana por meses, temiendo que se congelen sus salarios, que los despidan, e incluso la reacción negativa del público.

Desde 2010, el gasto para los departamentos de salud pública estatales ha disminuido un 16% per cápita, y el gasto para los departamentos de salud locales ha bajado un 18%, según un análisis de KHN y Associated Press. Al menos 38,000 empleos de salud pública locales y estatales han desaparecido desde la recesión de 2008, dejando en algunos lugares una fuerza laboral esquelética.

KHN y AP entrevistaron a más de 150 trabajadores de salud pública, legisladores y expertos, analizaron registros de gastos de cientos de departamentos de salud estatales y locales, e indagaron en las legislaturas estatales. La investigación reveló que, a todo nivel, el sistema está amenazado por la falta de financiación y medios.

A lo largo del tiempo, los departamentos de salud estatales y locales han recibido tan poco apoyo que se encontraron sin dirección, ignorados e incluso vilipendiados.

En medio de la recesión económica causada por la pandemia, los estados, las ciudades y los condados han comenzado a cesantear y despedir al personal, aun cuando los estados están reabriendo y comienzan a aumentar los casos de COVID.

“No le decimos al departamento de bomberos, ‘lo siento. No hubo incendios el año pasado, por lo que vamos a quitarle el 30% de su presupuesto’. Eso sería una locura, ¿verdad?”, dijo el doctor Gianfranco Pezzino, oficial de salud en el condado de Shawnee, en Kansas. “Pero lo hacemos con la salud pública, día tras día”.

El Departamento de Salud del condado de Toledo-Lucas, en Ohio, gastó solo $40 por persona en 2017. Cuando atacó el coronavirus, tenía tan poco personal que las tareas de Jennifer Gottschalk, supervisora ​​de salud ambiental, incluían supervisar las inspecciones de campamentos y piscinas, y el control de roedores, además de la preparación para brotes.

Cuando Gottschalk, de 42 años, y cinco colegas se enfermaron con COVID-19, se encontró respondiendo llamadas de trabajo desde su cama del hospital. “Tienes que hacer lo que tienes que hacer para que el trabajo se haga”, expresó.

Casi dos tercios de los estadounidenses viven en condados que gastan más del doble en vigilancia policial que en la atención médica no hospitalaria, que incluye la salud pública.

La subvaloración de la salud pública contrasta con su papel multidimensional. A diferencia del sistema de atención médica que está dirigido a las personas, el de salud pública se centra en la salud de las comunidades en general. Las agencias están legalmente obligadas a proporcionar una amplia gama de servicios esenciales.

Jennifer Gottschalk, supervisora de salud del medio ambiente del Departamento de Salud del condado de Toledo-Lucas, en su oficina en Toledo, Ohio. “La semana pasada los gritos de los residentes por dos horas seguidas sobre regulaciones que no puedo controlar me dejaron completamente agotada”, dijo a mediados de junio.(AP Photo/Paul Sancya)

“A la salud pública le encanta decir: cuando hacemos nuestro trabajo, no pasa nada. Pero nadie nos da una medalla por eso”, dijo Scott Becker, director ejecutivo de la Asociación de Laboratorios de Salud Pública. “Les hacemos pruebas al 97% de los bebés de los Estados Unidos para detectar trastornos metabólicos, y otros problemas. Testeamos el agua. ¿Te gusta nadar en el lago y no te gusta que tenga excremento? Piensa en nosotros”.

El público no ve los desastres que se evitan. Y es fácil no prestar atención a lo que no vemos.

Una historia de privaciones

Las promesas ocasionales del gobierno federal de apoyar los esfuerzos locales de salud pública han sido efímeras.

Por ejemplo, la Ley de Cuidado de Salud a Bajo Precio (ACA) estableció el Fondo de Prevención y Salud Pública, que se suponía alcanzaría los $2 mil millones anuales para 2015. Pero la administración Obama y el Congreso lo postergaron por otras prioridades, y ahora la administración Trump está presionando para derogar ACA, lo cual lo eliminaría.

Si no se hubiera tocado, los departamentos de salud estatales y locales hubieran recibido eventualmente un monto adicional de $12.4 mil millones, lo que los hubiera fortalecido frente a la actual pandemia.

Los líderes locales y estatales tampoco lograron priorizar la salud pública. En Carolina del Norte, por ejemplo, la fuerza laboral de salud pública del condado de Wake se redujo de 882 personas en 2007 a 614 una década después, incluso cuando la población creció un 30%.

Años de recortes financieros dejaron frágil a esta fuerza laboral predominantemente femenina. En 2017, más de una quinta parte de los trabajadores de salud pública en los departamentos locales o regionales fuera de las grandes ciudades ganaron $35,000 o menos al año, según una investigación realizada por la Asociación de Oficiales de Salud Territoriales y Estatales y la Fundación Beaumont.

Casi la mitad de los trabajadores de salud pública planean retirarse o irse de sus organizaciones en los próximos cinco años, y la razón que encabeza la lista es una remuneración deficiente.

María Fernanda rastrea contactos de personas con COVID en el Departamento de Salud del condado de Miami-Dade, en su oficina de El Doral, en Florida, en mayo. En los estados, los departamentos de salud locales, encargados de realizar este trabajo de detectives tienen una fuerza laboral mucho menor de la que se requiere para esta tarea.(AP Photo/Lynne Sladky)

Hace dos años, Julia Crittendon, ahora de 46 años, aceptó un trabajo en el departamento de salud estatal de Kentucky. Pasaba sus días reuniendo información sobre las parejas sexuales de las personas para combatir la propagación del VIH y la sífilis. Ganaba tan poco que calificó para Medicaid, el programa de salud federal gerenciado por los estados para los estadounidenses de bajos recursos. Al no ver oportunidades de crecimiento, renunció.

Desde que comenzó la pandemia, líderes de salud pública estatales y locales han renunciado en masa. Desde abril, al menos 32 presentaron su renuncia, se retiraron o fueron despedidos en 16 estados, según una revisión de KHN/AP.

De mal en peor

Scott Lockard, director de salud pública para el Departamento de Salud del distrito Kentucky River, en Appalachia, está luchando contra el virus con un servicio celular 3G, registros en papel y un tercio de los empleados comparado con los que tenía el departamento hace 20 años.

En la zona rural de Missouri, Melanie Hutton, administradora del Centro de Salud Pública del condado de Cooper, dijo que su estado le dio $18,000 al servicio de ambulancias local para combatir COVID y proporcionó máscaras a los departamentos de bomberos y policía.

“Para nosotros, ni una moneda de cinco centavos, ni una máscara”, contó. “Obtuvimos [cinco] galones de desinfectante de manos casero hecho por prisioneros”.

La Asociación de Oficiales de Salud Territoriales y Estatales dijo que, desde que comenzó la pandemia, el gobierno federal ha asignado más de $13 mil millones para actividades de los departamentos de salud estatales y locales, incluyendo rastreo de contactos, control de infecciones y actualizaciones tecnológicas.

En el condado de Fairfax, en Virginia, las pruebas para COVID-19 han estado disponibles sin costo y sin una orden del doctor. El día de la foto, el 23 de mayo, de 10 am a 6 pm, oficiales planeaban hacerle la prueba a unas 1,000 personas, mientras cientos hacían fila en autos y a pie, en este sitio de pruebas al paso en Annandale.(AP Photo/Jacquelyn Martin)

Pero al menos 14 estados ya han recortado los presupuestos o los empleos del departamento de salud, o estuvieron considerando activamente estos recortes en junio, según una revisión de KHN/AP.

Las reducciones amenazan con limitar programas cruciales como clínicas de inmunización, control de mosquitos, diabetes y programas de nutrición para adultos mayores. Estos recortes pueden hacer que las comunidades ya vulnerables lo sean aún más, dijo E. Oscar Alleyne, jefe de programas y servicios de la Asociación Nacional de Oficiales de Salud del Condado y la Ciudad.

Las personas que han pasado sus vidas trabajando en la salud pública temen estar viendo un patrón que les resulta familiar: los funcionarios descuidan esta infraestructura y luego, cuando surge una crisis, responden con una rápida inyección de efectivo.

Si bien ese dinero temporal es necesario para combatir la pandemia, expertos en salud pública dicen que no solucionará la base erosionada, que es la encargada de proteger la salud de la nación mientras miles continúan muriendo.

Contribuyeron con este informe: los escritores de Associated Press Mike Stobbe en Nueva York; Mike Householder en Toledo, Ohio; Lindsay Whitehurst en Salt Lake City, Utah; Brian Witte en Annapolis, Maryland; Jim Anderson en Denver; Sam Metz en Carson City, Nevada; Summer Ballentine en Jefferson City, Missouri; Alan Suderman en Richmond, Virginia; Sean Murphy en Oklahoma City, Oklahoma; Mike Catalini en Trenton, New Jersey; David Eggert en Lansing, Michigan; Andrew DeMillo en Little Rock, Arkansas; Jeff Amy en Atlanta; Melinda Deslatte en Baton Rouge, Louisiana; Morgan Lee en Santa Fe, New Mexico; Mark Scolforo en Harrisburg, Pennsylvania; y el escritor de Economía de AP Christopher Rugaber, en Washington, D.C.

Hollowed-Out Public Health System Faces More Cuts Amid Virus

The U.S. public health system has been starved for decades and lacks the resources to confront the worst health crisis in a century.

Marshaled against a virus that has sickened at least 2.6 million in the U.S., killed more than 126,000 people and cost tens of millions of jobs and $3 trillion in federal rescue money, state and local government health workers on the ground are sometimes paid so little that they qualify for public aid.

They track the coronavirus on paper records shared via fax. Working seven-day weeks for months on end, they fear pay freezes, public backlash and even losing their jobs.

Since 2010, spending for state public health departments has dropped by 16% per capita and spending for local health departments has fallen by 18%, according to a KHN and Associated Press analysis of government spending on public health. At least 38,000 state and local public health jobs have disappeared since the 2008 recession, leaving a skeletal workforce for what was once viewed as one of the world’s top public health systems.

KHN and AP interviewed more than 150 public health workers, policymakers and experts, analyzed spending records from hundreds of state and local health departments, and surveyed statehouses. On every level, the investigation found, the system is underfunded and under threat, unable to protect the nation’s health.

Dr. Robert Redfield, the director of the Centers for Disease Control and Prevention, said in an interview in April that his “biggest regret” was “that our nation failed over decades to effectively invest in public health.”

So when this outbreak arrived — and when, according to public health experts, the federal government bungled its response — hollowed-out state and local health departments were ill-equipped to step into the breach.

Over time, their work had received so little support that they found themselves without direction, disrespected, ignored, even vilified. The desperate struggle against COVID-19 became increasingly politicized and grew more difficult.

States, cities and counties in dire straits have begun laying off and furloughing members of already limited staffs, and even more devastation looms, as states reopen and cases surge. Historically, even when money pours in following crises such as Zika and H1N1, it disappears after the emergency subsides. Officials fear the same thing is happening now.

“We don’t say to the fire department, ‘Oh, I’m sorry. There were no fires last year, so we’re going to take 30% of your budget away.’ That would be crazy, right?” said Dr. Gianfranco Pezzino, the health officer in Shawnee County, Kansas. “But we do that with public health, day in and day out.”

Ohio’s Toledo-Lucas County Health Department spent $17 million, or $40 per person, in 2017.

Jennifer Gottschalk, 42, works for the county as an environmental health supervisor. When the coronavirus struck, the county’s department was so short-staffed that her duties included overseeing campground and pool inspections, rodent control and sewage programs, while also supervising outbreak preparedness for a community of more than 425,000 people.

When Gottschalk and five colleagues fell ill with COVID-19, she found herself fielding calls about a COVID-19 case from her hospital bed, then working through her home isolation. She stopped only when her coughing was too severe to talk on calls.

“You have to do what you have to do to get the job done,” Gottschalk said.

Now, after months of working with hardly a day off, she said the job is wearing on her. So many lab reports on coronavirus cases came in, the office fax machine broke. She faces a backlash from the community over coronavirus restrictions and there are countless angry phone calls.

Things could get worse; possible county budget cuts loom.

But Toledo-Lucas is no outlier. Public health ranks low on the nation’s financial priority list. Nearly two-thirds of Americans live in counties that spend more than twice as much on policing as they spend on non-hospital health care, which includes public health.

Jennifer Gottschalk, environmental health supervisor of the Toledo-Lucas County Health Department, works in her office in Toledo, Ohio. “Being yelled at by residents for almost two hours straight last week on regulations I cannot control left me feeling completely burned out,” she said in mid-June.(AP Photo/Paul Sancya)

More than three-quarters of Americans live in states that spend less than $100 per person annually on public health. Spending ranges from $32 in Louisiana to $263 in Delaware, according to data provided to KHN and AP by the State Health Expenditure Dataset project.

That money represents less than 1.5% of most states’ total spending, with half of it passed down to local health departments.

The share of spending devoted to public health belies its multidimensional role. Agencies are legally bound to provide a broad range of services, from vaccinations and restaurant inspections to protection against infectious disease. Distinct from the medical care system geared toward individuals, the public health system focuses on the health of communities at large.

“Public health loves to say: When we do our job, nothing happens. But that’s not really a great badge,” said Scott Becker, chief executive officer of the Association of Public Health Laboratories. “We test 97% of America’s babies for metabolic or other disorders. We do the water testing. You like to swim in the lake and you don’t like poop in there? Think of us.”

But the public doesn’t see the disasters they thwart. And it’s easy to neglect the invisible.

We don’t say to the fire department, ‘Oh, I’m sorry. There were no fires last year, so we’re going to take 30% of your budget away.’ That would be crazy, right? But we do that with public health, day in and day out.

Dr. Gianfranco Pezzino, health officer in Shawnee County, Kansas

A History of Deprivation

The local health department was a well-known place in the 1950s and 1960s, when Harris Pastides, president emeritus of the University of South Carolina, was growing up in New York City.

“My mom took me for my vaccines. We would get our injections there for free. We would get our polio sugar cubes there for free,” said Pastides, an epidemiologist. “In those days, the health departments had a highly visible role in disease prevention.”

The United States’ decentralized public health system, which matches federal funding and expertise with local funding, knowledge and delivery, was long the envy of the world, said Saad Omer, director of the Yale Institute for Global Health.

“A lot of what we’re seeing right now could be traced back to the chronic funding shortages,” Omer said. “The way we starve our public health system, the way we have tried to do public health outcomes on the cheap in this country.”

A stack of paperwork detailing positive COVID-19 test results sits in a box at the Toledo-Lucas County Health Department offices. Since 2010, spending for state public health departments has dropped by 16% per capita and spending for local health departments has fallen by 18%, according to an analysis of government spending on public health by KHN and The Associated Press.(AP Photo/Paul Sancya)

In Scott County, Indiana, when preparedness coordinator Patti Hall began working at the health department 34 years ago, it ran a children’s clinic and a home health agency with several nurses and aides. But over time, the children’s clinic lost funding and closed. Medicare changes paved the way for private services to replace the home health agency. Department staff dwindled in the 1990s and early 2000s. The county was severely outgunned when rampant opioid use and needle sharing sparked an outbreak of HIV in 2015.

Besides just five full-time and one part-time county public health positions, there was only one doctor in the outbreak’s epicenter of Austin. Indiana’s then-Gov. Mike Pence, now leading the nation’s coronavirus response as vice president, waited 29 days after the outbreak was announced to sign an executive order allowing syringe exchanges. At the time, a state official said that only five people from agencies across Indiana were available to help with HIV testing in the county.

The HIV outbreak exploded into the worst ever to hit rural America, infecting more than 230 people.

At times, the federal government has promised to support local public health efforts, to help prevent similar calamities. But those promises were ephemeral.

Two large sources of money established after Sept. 11, 2001 — the Public Health Emergency Preparedness program and the Hospital Preparedness Program — were gradually chipped away.

The Affordable Care Act established the Prevention and Public Health Fund, which was supposed to reach $2 billion annually by 2015. The Obama administration and Congress raided it to pay for other priorities, including a payroll tax cut. The Trump administration is pushing to repeal the ACA, which would eliminate the fund, said Carolyn Mullen, senior vice president of government affairs and public relations at the Association of State and Territorial Health Officials.

Former Iowa Sen. Tom Harkin, a Democrat who championed the fund, said he was furious when the Obama White House took billions from it, breaking what he said was an agreement.

“I haven’t spoken to Barack Obama since,” Harkin said.

If the fund had remained untouched, an additional $12.4 billion would eventually have flowed to local and state health departments.

But local and state leaders also did not prioritize public health over the years.

In Florida, for example, 2% of state spending goes to public health. Spending by local health departments in the state fell 39%, from a high of $57 in inflation-adjusted dollars per person in the late 1990s to $35 per person last year.

In North Carolina, Wake County’s public health workforce dropped from 882 in 2007 to 614 a decade later, even as the population grew by 30%.

In Detroit, the health department had 700 employees in 2009, then was effectively disbanded during the city’s bankruptcy proceedings. It’s been built back up, but today still has only 200 workers for 670,000 residents.

Many departments rely heavily on disease-specific grant funding, creating unstable and temporary positions. The CDC’s core budget, some of which goes to state and local health departments, has essentially remained flat for a decade. Federal money currently accounts for 27% of local public health spending.

Years of such financial pressure increasingly pushed workers in this predominantly female workforce toward retirement or the private sector and kept potential new hires away.

More than a fifth of public health workers in local or regional departments outside big cities earned $35,000 or less a year in 2017, as did 9% in big-city departments, according to research by the Association of State and Territorial Health Officials and the de Beaumont Foundation.

Maria Fernanda works on COVID contact tracing at the Florida Department of Health in Miami-Dade County in Doral, Florida, in May. In state after state, local health departments charged with doing the detective work of running down the contacts of coronavirus patients are falling well short of the number of people needed to do the job.(AP Photo/Lynne Sladky)

Even before the pandemic, nearly half of public health workers planned to retire or leave their organizations for other reasons in the next five years. Poor pay topped the list of reasons.

Armed with a freshly minted bachelor’s degree, Julia Crittendon took a job two years ago as a disease intervention specialist with Kentucky’s state health department. She spent her days gathering detailed information about people’s sexual partners to fight the spread of HIV and syphilis. She tracked down phone numbers and drove hours to pick up reluctant clients.

The mother of three loved the work but made so little money that she qualified for Medicaid, the federal-state insurance program for America’s poorest. Seeing no opportunity to advance, she left.

“We’re like the redheaded stepchildren, the forgotten ones,” said Crittendon, 46.

Public health loves to say: When we do our job, nothing happens. But that’s not really a great badge. We test 97% of America’s babies for metabolic or other disorders. We do the water testing. You like to swim in the lake and you don’t like poop in there? Think of us.

Scott Becker, chief executive officer of the Association of Public Health Laboratories

Such low pay is endemic, with some employees qualifying for the nutrition program for new moms and babies that they administer. People with the training for many public health jobs, which can include a bachelor’s or master’s degree, can make much more money in the private health care sector, robbing the public departments of promising recruits.

Dr. Tom Frieden, a former CDC director, said the agency “intentionally underpaid people” in a training program that sent early-career professionals to state and local public health departments to build the workforce.

“If we paid them at the very lowest level at the federal scale,” he said in an interview, “they would have to take a 10-20% pay cut to continue on at the local health department.”

As low pay sapped the workforce, budget cuts sapped services.

In Alaska, the Division of Public Health’s spending dropped 9% from 2014 to 2018 and staffing fell by 82 positions in a decade to 426. Tim Struna, chief of public health nursing in Alaska, said declines in oil prices in the mid-2010s led the state to make cuts to public health nursing services. They eliminated well-child exams for children over 6, scaled back searches for the partners of people with certain sexually transmitted infections and limited reproductive health services to people 29 and younger.

Living through an endless stream of such cuts and their aftermath, those workers on the ground grew increasingly worried about mustering the “surge capacity” to expand beyond their daily responsibilities to handle inevitable emergencies.

When the fiercest of enemies showed up in the U.S. this year, the depleted public health army struggled to hold it back.

A Decimated Surge Capacity

As the public health director for the Kentucky River District Health Department in rural Appalachia, Scott Lockard is battling the pandemic with 3G cell service, paper records and one-third of the employees the department had 20 years ago.

He redeployed his nurse administrator to work round-the-clock on contact tracing, alongside the department’s school nurse and the tuberculosis and breastfeeding coordinator. His home health nurse, who typically visits older patients, now works on preparedness plans. But residents aren’t making it easy on them.

“They’re not wearing masks, and they’re throwing social distancing to the wind,” Lockard said in mid-June, as cases surged. “We’re paying for it.”

In Virginia’s Fairfax County, COVID-19 testing was available at no cost and without a doctor’s order. Officials had planned on testing about 1,000 people from 10 a.m. to 6 p.m. on May 23, as hundreds lined up in cars and on foot at this site in Annandale.(AP Photo/Jacquelyn Martin)

Even with more staff since the HIV outbreak, Indiana’s Scott County Health Department employees worked evenings, weekends and holidays to deal with the pandemic, including outbreaks at a food packing company and a label manufacturer. Indiana spends $37 a person on public health.

“When you get home, the phone never stops, the emails and texts never stop,” said Hall, the preparedness coordinator.

All the while, she and her colleagues worry about keeping HIV under control and preventing drug overdoses from rising. Other health problems don’t just disappear because there is a pandemic.

“We’ve been used to being able to ‘MacGyver’ everything on a normal day, and this is not a normal day,” said Amanda Mehl, the public health administrator for Boone County, Illinois, citing a TV show.

Pezzino, whose department in Kansas serves Topeka and Shawnee County, said he had been trying to hire an epidemiologist, who would study, track and analyze data on health issues, since he came to the department 14 years ago. Finally, less than three years ago, they hired one. She just left, and he thinks it will be nearly impossible to find another.

While epidemiologists are nearly universal in departments serving large populations, hardly any departments serving smaller populations have one. Only 28% of local health departments have an epidemiologist or statistician.

Strapped departments are now forced to spend money on contact tracers, masks and gloves to keep their workers safe and to do basic outreach.

Melanie Hutton, administrator for the Cooper County Public Health Center in rural Missouri, pointed out the local ambulance department got $18,000, and the fire and police departments got masks to fight COVID-19.

“For us, not a nickel, not a face mask,” she said. “We got [5] gallons of homemade hand sanitizer made by the prisoners.”

Public health workers are leaving in droves. At least 34 state and local public health leaders have announced their resignations, retired or been fired in 17 states since April, a KHN-AP review found. Others face threats and armed demonstrators.

Ohio’s Gottschalk said the backlash has been overwhelming.

“Being yelled at by residents for almost two hours straight last week on regulations I cannot control left me feeling completely burned out,” she said in mid-June.

Jennifer Gottschalk underwent a test for COVID-19 in a Toledo, Ohio, hospital on March 24. As the environmental health supervisor for the Toledo-Lucas County Health Department, she fielded calls about COVID-19 cases from a hospital bed while fighting the disease herself. She then worked throughout her home isolation, stopping only when her coughing was too severe to talk.(Jennifer Gottschalk via AP)

Gottschalk walks down a hallway of the department’s offices in Toledo, Ohio, on June 24. When the coronavirus pandemic struck earlier in the year, the county’s department was so short-staffed that her duties included overseeing campground and pool inspections, rodent control and sewage programs, while also supervising outbreak preparedness for a community of more than 425,000 people.(AP Photo/Paul Sancya)

Many are putting their health at risk. In Prince George’s County, Maryland, public health worker Chantee Mack died after, family and co-workers believe, she and several colleagues contracted the disease in the office.

A Difficult Road Ahead

Pence, in an op-ed in The Wall Street Journal on June 16, said the public health system was “far stronger” than it was when the coronavirus hit.

It’s true that the federal government this year has allocated billions for public health in response to the pandemic, according to the Association of State and Territorial Health Officials. That includes more than $13 billion to state and local health departments, for activities including contact tracing, infection control and technology upgrades.

A KHN-AP review found that some state and local governments are also pledging more money for public health. Alabama’s budget for next year, for example, includes $35 million more for public health than it did this year.

But overall, spending is about to be slashed again as the boom-bust cycle continues.

Roland Mack holds a poster with pictures and messages made by family members in memory of his sister, Chantee Mack, in District Heights, Maryland, on June 19. The Prince George’s County, Maryland, public health worker died of COVID-19 after, family and co-workers believe, she and several colleagues contracted the disease in their office.(AP Photo/Federica Narancio)

In most states, the new budget year begins July 1, and furloughs, layoffs and pay freezes have already begun in some places. Tax revenues evaporated during lockdowns, all but ensuring there will be more. At least 14 states have already cut health department budgets or positions or were actively considering such cuts in June, according to a KHN-AP review.

Since the pandemic began, Michigan temporarily cut most of its state health workers’ hours by one-fifth. Pennsylvania required more than 65 of its 1,200 public health workers to go on temporary leave, and others lost their jobs. Knox County, Tennessee, furloughed 26 out of 260 workers for eight weeks.

Frieden, formerly of the CDC, said it’s “stunning” that the U.S. is furloughing public health workers amid a pandemic. The country should demand the resources for public health, he said, just the way it does for the military.

“This is about protecting Americans,” Frieden said.

Cincinnati temporarily furloughed approximately 170 health department employees.

Robert Brown, chair of Cincinnati’s Primary Care Board, questions why police officers and firefighters didn’t face similar furloughs at the time or why residents were willing to pay hundreds of millions in taxes over decades for the Bengals’ football stadium.

“How about investing in something that’s going to save some lives?” he asked.

In 2018, Boston spent five times as much on its police department as its public health department. The city recently pledged to transfer $3 million from its approximately $60 million police overtime budget to its public health commission.

Looking ahead, more cuts are coming. Possible budget shortfalls in Brazos County, Texas, may force the health department to limit its mosquito-surveillance program and eliminate up to one-fifth of its staff and one-quarter of immunization clinics.

Months into the pandemic response, health departments are still trying to ramp up to fight COVID-19. Cases are surging in states including Texas, Arizona and Florida.

Meanwhile, childhood vaccinations began plunging in the second half of March, according to a CDC study analyzing supply orders. Officials worry whether they will be able to get kids back up to date in the coming months. In Detroit, the childhood vaccination rate dipped below 40%, as clinics shuttered and people stayed home, creating the potential for a different outbreak.

Cutting or eliminating non-COVID activities is dangerous, said E. Oscar Alleyne, chief of programs and services at the National Association of County and City Health Officials. Cuts to programs such as diabetes control and senior nutrition make already vulnerable communities even more vulnerable, which makes them more likely to suffer serious complications from COVID. Everything is connected, he said.

It could be a year before there’s a widely available vaccine. Meanwhile, other illnesses, including mental health problems, are smoldering.

The people who spend their lives working in public health say the temporary coronavirus funds won’t fix the eroded foundation entrusted with protecting the nation’s health as thousands continue to die.

Contributing to this report were: Associated Press writers Mike Stobbe in New York; Mike Householder in Toledo, Ohio; Lindsay Whitehurst in Salt Lake City, Utah; Brian Witte in Annapolis, Maryland; Jim Anderson in Denver; Sam Metz in Carson City, Nevada; Summer Ballentine in Jefferson City, Missouri; Alan Suderman in Richmond, Virginia; Sean Murphy in Oklahoma City, Oklahoma; Mike Catalini in Trenton, New Jersey; David Eggert in Lansing, Michigan; Andrew DeMillo in Little Rock, Arkansas; Jeff Amy in Atlanta; Melinda Deslatte in Baton Rouge, Louisiana; Morgan Lee in Santa Fe, New Mexico; Mark Scolforo in Harrisburg, Pennsylvania; and AP economics writer Christopher Rugaber, in Washington, D.C.

Related Topics

Cost and Quality Public Health States

How We Reported ‘Underfunded And Under Threat’

To assess the state of the public health system in the United States, KHN and The Associated Press analyzed data on government spending and staffing at national, state and local levels.

What reporters found was a mix of survey and budget data, each measuring a slightly different concept of “public health.”

Some datasets track only state public health systems, not agencies that operate at a county, city or regional level. Other data, including some from the U.S. Census Bureau, covers spending on all non-hospital health care. Public health efforts are mixed in with the costs of providing local medical transportation, running community clinics and offering mental health services.

The lack of comprehensive data specifically about public health makes assessing community programs, agencies and staffing levels difficult, experts say. Public health information is scattered and can’t be easily compared, unlike data about hospitals and medical treatment, according to Betty Bekemeier, a public health systems researcher and professor at the University of Washington. She is seeking to fix this as the leader of a multistate effort to standardize local health department spending data.

“We will not be able to improve our systems if we don’t have a better idea of how it works,” she said.

KHN and AP calculated 2016-18 average annual state spending directly on public health initiatives using the State Health Expenditure Dataset. To create the dataset, a team of researchers encoded data from the Census Bureau’s “Annual Survey of State Government Finances,” isolating public health costs to get the clearest sense of what governments spend only on public health efforts.

The data includes spending by all state agencies and their transfers to local governments. To account for inflation for this and all spending data, KHN and the AP adjusted amounts to 2019 dollars using a price deflator from the Bureau of Economic Analysis targeted toward government expenses.

A decade of data on state public health agencies’ expenditures and full-time equivalent staffing came from the Association of State and Territorial Health Officials. The data was reported directly by the state public health agencies through a national survey.

When creating national percentage change estimates, reporters excluded a handful of states missing comparable spending or staffing data.

The analysis included census finance data from state and local governments to compare spending on non-hospital health with other priorities such as policing and highway construction and maintenance.

At the local level, the National Association of County and City Health Officials’ “National Profile Study” surveys local health departments every three years and weights answers to account for nonresponse.

Beyond that, some states collect local health department spending and staffing data. Reporters used detailed data on local health departments in Florida, Minnesota, Missouri, North Carolina, Ohio and Washington — along with census population estimates — to examine per capita trends over time.

Finally, AP statehouse reporters posed an identical set of questions to states to get a sense of recent and upcoming budget and staffing changes to state public health departments. The AP gathered responses from 43 states.

Related Topics

Public Health States

Six Takeaways Of The KHN-AP Investigation Into The Erosion Of Public Health

Local and state public health departments across the country work to ensure that people in their communities have healthy water to drink, their restaurants don’t serve contaminated food and outbreaks of infectious diseases don’t spread. Those departments now find themselves at the forefront of fighting the coronavirus pandemic.

But years of budget and staffing cuts have left them unprepared to face the worst health crisis in a century.

KHN and The Associated Press sought to understand the scale of the cuts and how the decades-long starvation of public health departments by federal, state and local governments has affected the system meant to protect the nation’s health.

Here are six key takeaways from the KHN-AP investigation:

  • Since 2010, spending for state public health departments has dropped by 16% per capita, and for local health departments by 18%. Local public health spending varies widely by county or town, even within the same state.
  • At least 38,000 state and local public health jobs have disappeared since the 2008 recession, leaving a skeletal workforce in what was once viewed as one of the world’s top public health systems.
  • Nearly two-thirds of Americans live in counties that spend more than twice as much on policing as they spend on non-hospital health care, which includes public health.
  • More than three-quarters of Americans live in states that spend less than $100 per person annually on public health. Spending ranges from $32 in Louisiana to $263 in Delaware.
  • Some public health workers earn so little that they qualify for government assistance. During the pandemic, many have found themselves disrespected, ignored or even vilified. At least 31 state and local public health leaders have announced their resignations, retired or been fired in 15 states since April.
  • States, cities and counties whose tax revenues have declined during the current recession have begun laying off and furloughing public health staffers. At least 15 states have cut health department budgets or positions, or were actively considering such cuts in June, even as coronavirus cases surged in several states.

Related Topics

Public Health States

As Cases Spike, California Pauses Multimillion-Dollar Testing Expansion

In April, Gov. Gavin Newsom launched a multimillion-dollar state initiative to bring COVID-19 testing to the people and places with the least access: rural towns and disadvantaged inner-city neighborhoods.

California is now halting its expansion, citing costs, even as the state is getting walloped by record-setting spikes in new infections and double-digit increases in hospitalizations.

The state will no longer fund new testing sites despite pleas from counties for additional assistance — and it has closed some locations and moved them elsewhere. It also has threatened to pull testing out of underused sites, according to nearly two dozen interviews with county public health officials.

While it’s early, some winners and losers have emerged: El Dorado County, east of Sacramento, lost its testing site in the town of Shingle Springs in June because it couldn’t fill enough appointment slots, while Fresno County gained a site that had been pulled from elsewhere, said its health officer, Dr. Rais Vohra.

Yet San Mateo County has asked state officials three times for a second state-funded testing venue to address testing gaps in Black and farmworker neighborhoods, but has been “told no, repeatedly,” said Justin Mates, deputy county manager. So the county transformed its sole state site into a roving testing unit.

“Equity is certainly a concern for us,” Mates said. “We really need help with testing access if we’re going to reach our Latino residents and places like East Palo Alto,” a diverse city whose population is mainly Latino, African American and Asian/Pacific Islander.

California has committed up to $132 million in contracts with two private COVID-19 testing companies, Verily Life Sciences and OptumServe, to offer free coronavirus tests at more than 100 sites that the Newsom administration has identified as “testing deserts.” The expansion has dramatically increased the state’s overall testing numbers, which swelled from 16,000 tests per day in April to 105,000 on Monday.

Testing is also available at county-funded locations, private pharmacies, hospitals and community clinics.

State Health and Human Services Secretary Mark Ghaly confirmed that the state is pulling sites out of counties that aren’t generating high enough numbers and cutting off funding for new locations.

“With every asset and resource — especially when it’s scarce — you want it to go to places where it’s most needed,” Ghaly said. “It wouldn’t be prudent or wise to maintain spending in a place where resources aren’t being used.”

Newsom himself has voiced concern about the price tag, given “unprecedented” budget shortfalls. “There is a big cost associated with testing,” he said in late June.

A Newsom administration official confirmed the state wants to see counties fill at least 80% of testing slots at each location. And if testing drops below 50% for a few days or longer, counties are warned the sites could be transferred elsewhere.

Counties argue there’s a public health benefit to keeping underperforming locations open — simply to ensure that testing is available to rural and disenfranchised communities. Across the state, they are fighting to save state-funded sites even as they are being overwhelmed by rising coronavirus cases linked largely to social gatherings.

“It’s how we are able to quickly identify where the virus is and if there are hot spots,” said Dr. Olivia Kasirye, health officer for Sacramento County, where holiday celebrations and booze-fueled gatherings among family and friends are sending infection rates soaring.

Contra Costa County saw its testing numbers drop in June and was at risk of losing a state-funded site until it proved it could keep appointments near 80% of capacity, said its health officer, Dr. Chris Farnitano.

Riverside County was warned June 16 that a state-funded site north of Temecula would be “moved to another county” if it didn’t get its testing above 50%, according to an email from the state’s testing taskforce. The state told Mendocino County it could lose its state-funded site, the only free testing available within a two-hour drive for some rural residents, if it didn’t push numbers up.

Alameda County grew so frustrated with state requirements that it undertook a testing expansion of its own.

“We realized we couldn’t depend on the state, especially to reach our vulnerable communities,” said Dr. Jocelyn Freeman Garrick, an emergency room doctor at Highland Hospital in Oakland, who is leading the county’s testing task force.

El Dorado County, which lost its site, so far has maintained a relatively low count of COVID-19 cases. It can’t afford to replace the site but will “make do,” said county spokesperson Carla Hass.

Ghaly said the state is working with counties in danger of losing sites to give them a chance to fill testing slots. State officials declined to say how many counties have lost sites, but as new infections have soared, testing numbers are starting to pick back up. The list of counties at risk of losing a site has dwindled from around a dozen in early June to a few last week.

Public health experts say focusing so intently on testing numbers, and not on adequately testing in Black and Latino neighborhoods, risks abandoning communities that already face immense barriers to health care like racism and poverty.

“If you ignore these communities, then we’ll keep seeing the kinds of surges that we’re seeing now,” said Dr. Tony Iton, formerly the top health official for Alameda County and now a senior vice president of the California Endowment, which is working with counties to expand testing in underserved neighborhoods.

Entrenched socioeconomic barriers also make it difficult to get, and keep, testing numbers up. For instance, people who want to be tested at state sites often need Internet access and an email address. Most are drive-thru, requiring access to a vehicle.

Many low-income people can’t meet those requirements, and undocumented immigrants fear that providing personal information to obtain a test could expose them to immigration officials, said Dr. Marty Fenstersheib, a former health officer of Santa Clara County who is leading its testing program.

“We can have all the tests we want, but if people are afraid to come and get tested, it’s not going to be of any benefit,” he said.

State contracts funding the testing sites were extended this month but are set to expire Aug. 31, and administration officials have not told counties whether the state will continue funding them after that, said Mimi Hall, president of the County Health Executives Association of California and director of public health for Santa Cruz County.

Counties can’t afford to keep the sites running, said Hall, who is on the state’s testing task force.

“It’s hard to plan when we don’t know how long we’ll be able to keep them,” Hall said.

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

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NIH Spearheads Study To Test At-Home Screening For HPV And Cervical Cancer

With a tiny brush, briefly swab the vagina to collect cells. Then slide the swab into a screening kit and drop it into the mail.

Proponents believe a simple test like this, which can be done at home, may help the U.S. move closer to eradicating cervical cancer. The National Cancer Institute plans to launch a multisite study next year involving roughly 5,000 women to assess whether self-sampling at home is comparable to screening in the office by a clinician.

Nearly 14,000 Americans this year will be diagnosed with the highly preventable cancer, and more than 4,000 will die. Women who are uninsured or can’t get regular medical care are more likely to miss out on lifesaving screening, said Vikrant Sahasrabuddhe, a program director in the NCI’s Division of Cancer Prevention. If women could collect the vaginal and cervical cells to be tested for human papillomavirus (HPV) — the virus that causes virtually all cervical cancers — they could get screened from home, just as home-based stool samples can be used to detect colon cancer, he said.

“What we have seen is this persistent group of women who continue to get cervical cancer every year,” said Sahasrabuddhe, who oversees studies involving HPV-related cancers. “And that number is really not going down.”

Federal officials hope the research will fast-track a test approved by the Food and Drug Administration that could be part of screening guidelines if self-sampling is proved effective, Sahasrabuddhe said. Rather than wait for self-sampling studies to be done by the individual companies that make the HPV tests for clinicians, federal officials will team up with the companies, academic institutions and others in a public-private partnership, he explained. NCI officials, who expect to spend about $6 million in federal funds, will oversee the study’s data and analysis.

“If every company goes and does their own trial, they may take years to achieve it,” Sahasrabuddhe said. “We want to accelerate that process.”

HPV self-sampling, already promoted in countries such as Australia and the Netherlands, is one of several approaches that U.S. cervical cancer researchers are pursuing. Another key strategy involves vaccinating adolescents against HPV, which is transmitted through sexual activity. As of 2018, nearly 54% of girls had been fully vaccinated by age 17, as had almost 49% of boys, according to the most recent federal data. The countries that have had better success in reducing cervical cancer — one analysis predicts that Australia is on track to eliminate the disease — have emphasized HPV vaccination for adolescents.

Federal officials still advise vaccinated women to get regularly screened, as the vaccine doesn’t guard against all the strains that cause cervical cancer. But persuading some women to come into the office for the physical exam is sometimes a tough sell.

For some, access or cost may be an issue. Most insurance plans cover screening and there are also some public programs, but uninsured women who are unaware of them may have to pay for an office visit and test. Besides, women can’t always break away from work or find child care, or they may have had “negative emotions or experiences in the past with pelvic exams,” said Rachel Winer, a professor of epidemiology at the University of Washington School of Public Health who studies HPV self-sampling.

Reversing The Trend

Roughly 4 out of 5 women get regularly screened for cervical cancer, but the rates peaked around 2000 and have been on a slight decline since, according to federal data. That figure, which is based on patient self-reporting, may be optimistic. Another analysis, which looked at the medical records of 27,418 Minnesota women ages 30 to 65, found that nearly 65% were up to date as of 2016, according to the findings, published last year in the Journal of Women’s Health.

“Sadly, I think our data is probably more reflective of what’s happening with screening rates in our country,” said Dr. Kathy MacLaughlin, a study author and researcher at Mayo Clinic in Rochester, Minnesota.

One hurdle to getting screened may be the complexity of the guidelines, MacLaughlin said. Rather than an easy-to-remember annual exam, screenings occur at intervals of longer than a year. A woman’s age helps determine when the HPV test or a Pap smear, which collects cells from the cervix to look for precancerous changes, is recommended by the U.S. Preventive Services Task Force.

“It’s just that challenge of, how do any of us remember to do something every three years or every five years?” MacLaughlin said. “That’s hard.”

At-Home Logistics

While the NCI hasn’t yet settled on the precise self-sampling approach it will use, the technique generally requires the woman to insert a tiny brush into her vagina and rotate it several times to collect the cells. Then she slides the brush into a specimen container that has a preservative solution and returns the kit for HPV analysis.

According to a review of studies published in 2018 in the medical journal BMJ, the accuracy of identifying HPV was similar when the samples were collected by women at home as when collected by clinicians. A urine-based HPV test, which may prove easier for women to perform, also is being studied, said Jennifer Smith, a professor of epidemiology at the University of North Carolina’s Gillings School of Global Public Health.

Before companies can pursue applications for an FDA-approved home test, self-sampling by women has to be shown comparable to detect HPV, though perhaps it may not be quite as accurate as when a clinician is involved, Sahasrabuddhe said. NCI officials are still finalizing study details. But the plan is to invite four companies that already manufacture HPV tests for clinicians to participate, Sahasrabuddhe said. The companies will pick up the tab for the cost of the tests as well as future fees related to pursuing license applications through the FDA, he said. Sahasrabuddhe expects the study results to be available by 2024, if not sooner.

Any woman who tests positive for HPV will be referred for procedures, including possibly a biopsy, to look for abnormal cells or cervical cancer, Sahasrabuddhe said.

If an FDA-approved home test is developed, it’s crucial that uninsured women and others who don’t have easy access to medical care be able to get those procedures, Smith said.

“You just don’t send random kits out to people’s homes,” Smith said, “and not ensure that they have someone to talk to about the results and are going to be able to be integrated into a follow-up system.”

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Essential Worker Shoulders $1,840 Pandemic Debt Due To COVID Cost Loophole

Carmen Quintero works an early shift as a supervisor at a 3M distribution warehouse that ships N95 masks to a nation under siege from the coronavirus. On March 23, she had developed a severe cough, and her voice, usually quick and enthusiastic, was barely a whisper.

A human resources staff member told Quintero she needed to go home.

“They told me I couldn’t come back until I was tested,” said Quintero, who was also told that she would need to document that she didn’t have the virus.

Her primary care doctor directed her to the nearest emergency room for testing because the practice had no coronavirus tests.

The Corona Regional Medical Center is just around the corner from her house in Corona, California, and there a nurse tested her breathing and gave her a chest X-ray. But the hospital didn’t have any tests either, and the nurse told her to go to Riverside County’s public health department. There, a public health worker gave her an 800 number to call to schedule a test. The earliest the county could test her was April 7, more than two weeks later.

At the hospital, Quintero got a doctor’s note saying she should stay home from work for a week, and she was told to behave as if she had COVID-19, isolating herself from vulnerable household members. That was difficult — Quintero lives with her grandmother and her girlfriend’s parents — but she managed. No one else in her home got sick, and by the time April 7 came, she felt better and decided not to get the coronavirus test.

Then the bill came.

The Patient: Carmen Quintero, 35, a supervisor at a 3M distribution warehouse who lives in Corona, California. She has an Anthem Blue Cross health insurance plan through her job with a $3,500 annual deductible.

Total Bill: Corona Regional Medical Center billed Quintero $1,010, and Corona Regional Emergency Medical Associates billed an additional $830 for physician services. She also paid $50 at Walgreens to fill a prescription for an inhaler.

Service Provider: Corona Regional Medical Center, a for-profit hospital owned by Universal Health Services, a company based in King of Prussia, Pennsylvania, which is one of the largest health care management companies in the nation. The hospital contracts with Corona Regional Emergency Medical Associates, part of Emergent Medical Associates.

Medical Service: Quintero was evaluated in the emergency room for symptoms consistent with COVID-19: a wracking cough and difficulty breathing. She had a chest X-ray and a breathing treatment and was prescribed an inhaler.

What Gives: On that day in late March when her body shook from coughing, Quintero’s immediate worry was infecting her family, especially her girlfriend’s parents, both over 65, and her 84-year-old grandmother.

“If something was to happen to them, I don’t know if I would have been able to live with it,” said Quintero.

Quintero wanted to isolate in a hotel, but she could hardly afford to for the week that she stayed home. She had only three paid sick days and was forced to take vacation time until her symptoms subsided and she was allowed back at work. At the time, few places provided publicly funded hotel rooms for sick people to isolate, and Quintero was not offered any help.

For her medical care, Quintero knew she had a high-deductible plan yet felt she had no choice but to follow her doctor’s advice and go to the nearest emergency room to get tested. She assumed she would get the test and not have to pay. Congress had passed the CARES Act just the week before, with its headlines saying coronavirus testing would be free.

That legislation turned out to be riddled with loopholes, especially for people like Quintero who needed and wanted a coronavirus test but couldn’t get one early in the pandemic.

“I just didn’t think it was fair because I went in there to get tested,” she said.

Carmen Quintero (right) still tries to keep a safe distance from her grandmother, Teresa Carapia, and two other family members over 65. Quintero says she worried about them as she tried to self-isolate with COVID-like symptoms.(Heidi de Marco/KHN)

Some insurance companies are voluntarily reducing copayments for COVID-related emergency room visits. Quintero said her insurer, Anthem Blue Cross, would not reduce her bill. Anthem would not discuss the case until Quintero signed its own privacy waiver; it would not accept a signed standard waiver KHN uses. The hospital would not discuss the bill with a reporter unless Quintero could also be on the phone, something that has yet to be arranged around Quintero’s workday, which begins at 4 a.m. and ends at 3:30 p.m.

Three states have gone further than Congress to waive cost sharing for testing and diagnosis of pneumonia and influenza, given these illnesses are often mistaken for COVID-19. California is not one of them, and because Quintero’s employer is self-insured — the company pays for health services directly from its own funds — it is exempt from state directives anyway. The U.S. Department of Labor regulates all self-funded insurance plans. In 2019, nearly 2 in 3 covered workers were in these types of plans.

Resolution: As lockdown restrictions ease and coronavirus cases rise around the country, public health officials say quickly isolating sick people before the virus spreads through families is essential.

But isolation efforts have gotten little attention in the U.S. Nearly all local health departments, including Riverside County, where Quintero lives, now have these programs, according to the National Association of County and City Health Officials. Many were designed to shelter people experiencing homelessness but can be used to isolate others.

Raymond Niaura, interim chairman of the Department of Epidemiology at New York University, said these programs are used inconsistently and have been poorly promoted to the public.

“No one has done this before and a lot of what’s happening is that people are making it up as they go along,” said Niaura. “We’ve just never been in a circumstance like this.”

Quintero still worries about bringing the virus home to her family and fears being in the same room with her grandmother. Quintero returns from work every day now, puts her clothes in a separate hamper and diligently washes her hands before she interacts with anyone.

The bills have been another constant worry. Quintero called the hospital and her insurance company and complained that she should not have to pay since she was seeking a test on her doctor’s orders. Neither budged, and the bills labeled “payment reminders” soon became “final notices.” She reluctantly agreed to pay $100 a month toward her balance — $50 to the hospital and $50 to the doctors.

“None of them wanted to work with me,” Quintero said. “I just have to give the first payment on each bill so they wouldn’t send me to collections.”

The Takeaway: If you suspect you have COVID-19 and need to isolate to protect vulnerable members of your household, call your local public health department. Most counties have isolation and quarantine programs, but these resources are not well known. You may be placed in a hotel, recreational vehicle or other type of housing while you wait out the infection period. You do not need to have a positive COVID test to qualify for these programs and can use these programs while you await your test result. But this is an area in which public health officials repeatedly offer clear guidance — 14 days of isolation — which most people find impossible to follow.

At this point in the pandemic, tests are more widely available and federal law is very clearly on your side: You should not be charged any cost sharing for a coronavirus test.

Be wary, though, if your doctor directs you to the emergency room for a COVID test, because any additional care you get there could come at a high price. Ask if there are any other testing sites available.

If you do find yourself with a big bill related to suspected COVID, push beyond a telephone call with your insurance company and file a formal appeal. If you feel comfortable, ask your employer’s human resources staff to argue on your behalf. Then, call the help line for your state insurance commissioner and file a separate appeal. Press insurers — and big companies that offer self-insured plans — to follow the spirit of the law, even if the letter of the law seems to let them off the hook.

Bill of the Month is a crowdsourced investigation by Kaiser Health News and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!

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Hospital Executive Charged In $1.4B Rural Hospital Billing Scheme

A Miami entrepreneur who led a rural hospital empire was charged in an indictment unsealed Monday in what federal prosecutors called a $1.4 billion fraudulent lab-billing scheme.

In the indictment, prosecutors said Jorge A. Perez, 60, and nine others exploited federal regulations that allow some rural hospitals to charge substantially higher rates for laboratory testing than other providers. The indictment, filed in U.S. District Court in Jacksonville, Florida, alleges Perez and the other defendants sought out struggling rural hospitals and then contracted with outside labs, in far-off cities and states, to process blood and urine tests for people who never set foot in the hospitals. Insurers were billed using the higher rates allowed for the rural hospitals.

Perez and the other defendants took in $400 million since 2015, according to the indictment. Many of the hospitals run or managed by Perez’s Empower companies have since failed as they ran out of money when insurers refused to pay for the suspect billing. Half of the nation’s rural hospital bankruptcies in 2019 were affiliated with his empire.

“This was allegedly a massive, multi-state scheme to use small, rural hospitals as a hub for millions of dollars in fraudulent billings of private insurers,” said Assistant Attorney General Brian Benczkowski of the Justice Department’s Criminal Division in a statement.

Attempts to reach Perez for comment Monday evening were unsuccessful. But last year when Perez spoke to KHN, he said he was losing sleep over the possibility he could go to jail after propping up struggling rural hospitals.

“I wanted to see if I could save these rural hospitals in America,” Perez said. “I’m that kind of person.”

Pam Green, a former night charge nurse at the now-shuttered Horton Community Hospital in Horton, Kansas (population under 1,700), said she hopes Perez and his colleagues receive long prison sentences.

“He just devastated so many people, not just in Kansas, but in Oklahoma and all the other places where he had hospitals,” said Green, 58, of nearby Muscotah, Kansas. “I went months and months without pay, without health insurance. He robbed the community.”

Green recalled that money was so tight under Perez’s management of her former hospital that the electricity was shut off at least twice and staffers had to bring in their own supplies. She said she is owed about $12,000 in back pay, as well as money for uncovered dental expenses and a workplace injury that would have been covered had employees’ insurance or workers’ compensation premiums been paid.

A KHN investigation published in August 2019 detailed the rise and fall of Perez’s rural hospitals. At the height of his operation, Perez and his Miami-based management company, EmpowerHMS, helped oversee a rural empire encompassing 18 hospitals across eight states. Perez owned or co-owned 11 of those hospitals and was CEO of the companies that provided their management and billing services.

Perez styled himself a savior of rural hospitals, swooping into small towns with promises to save their struggling facilities using his “secret sauce” of financial ventures. Multiple employees told KHN they had no idea what happened to the money their hospitals earned after Perez and his associates took control, since the facilities seemed perpetually starved for cash.

Over the past two years, amid mounting legal challenges and concerns about the lab-billing operation, insurers cut off funding and his empire crumbled. Overall, 12 of the hospitals have entered bankruptcy and eight have closed. The staggering collapse left hundreds of employees without jobs and small towns across the Midwest and South without lifesaving medical care.

The four rural hospitals named in the indictment are Campbellton-Graceville Hospital in Graceville, Florida; Regional General Hospital of Williston, Florida; Chestatee Regional Hospital in Dahlonega, Georgia; and Putnam County Memorial Hospital in Unionville, Missouri.

The indictment marks the third major case federal prosecutors have filed alleging billing fraud at Perez-affiliated hospitals. In October, David Byrns pleaded guilty to a federal charge of conspiracy to commit health care fraud involving a Missouri hospital he managed with Perez. A Missouri Auditor General report previously found that the 15-bed hospital, Putnam County Memorial in Unionville, had received about $90 million in questionable insurance payments in less than a year.

In July 2019, Kyle Marcotte, owner of a Jacksonville Beach, Florida, addiction treatment center pleaded guilty for his part in a $57 million lab-billing scheme involving two Perez-affiliated hospitals, Campbellton-Graceville and Regional General Hospital. Marcotte admitted cooperating with unnamed hospital managers to provide urine samples from his patients for lab testing that was billed through the rural hospitals and, in exchange, getting a cut of the proceeds.

Perez, on his own and through Empower-affiliated companies, in 2016 and 2017 purchased South Florida properties that totaled more than $3.7 million, including three condos on Key Largo, according to property records. He told KHN last year that the Florida properties were bought with earnings from unrelated software companies but declined to give details. He and his brother Ricardo Perez, if convicted, must forfeit over $46 million, according to the indictment, as well as two Key Largo condos and other properties.

Another defendant, Aaron Durall, if convicted, could lose $184.4 million and a six-bedroom, 6,500-square-foot home in the affluent Parkland district north of Fort Lauderdale, Florida.

Perez-affiliated hospitals also face ongoing lawsuits in Missouri and other states filed by dozens of insurers asking for hundreds of millions in restitution for allegedly fraudulent billings. In those court documents, Perez repeatedly has denied wrongdoing. He told KHN last year that his lab-billing setup was “done according to Medicare and state guidelines.”

For former employees of EmpowerHMS and members of the affected communities, the indictment represents vindication. As the company foundered, hundreds of employees worked without pay in vain efforts to keep their hospitals afloat. They would discover later that, along with the missing paychecks, their insurance premiums had not been paid and their medical policies had been discontinued. In the June 2019 interview, Perez acknowledged that, as finances withered, he stopped paying employee payroll taxes.

“It’s nice to think he might be held accountable,” said Melva Price Lilley, a former X-ray technician at Washington County Hospital in Plymouth, North Carolina, which has reopened with new owners under a new name. “At least there’s a chance that he might have to suffer some consequences. That gives me some hope.”

Lilley, 56, said she and other employees could not retrieve their retirement savings from the bankrupt hospital until about three weeks ago. She has been trying to pay off about $68,000 in medical bills from a back surgery she needed for a workplace injury that wasn’t covered by workers’ compensation insurance premiums that went unpaid for hospital employees. She remains unable to work full time.

I-70 Community Hospital, an Empower facility in Sweet Springs, Missouri, has remained closed since February 2019. Tara Brewer, head of the Sweet Springs Chamber of Commerce and the local health department, said she was almost shocked to hear that Perez had gotten indicted after months of wondering if anything would happen.

While she hopes these charges bring closure to her community, she said, the charges do little to fix the closed hospital doors for a county that has had one of the highest per capita rates of coronavirus cases in Missouri.

“What he did to us will linger on for a long time,” Brewer said.

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‘More Than Physical Health’: Gym Helps 91-Year-Old Battle Isolation

MONROVIA, Calif. — Most mornings, like clockwork, you could find Art Ballard pumping iron.

At least five days a week, he drove to Foothill Gym, where he beat on the punching bag, rode a stationary bike and worked his abs. After he joined the gym five years ago, he dropped 20 pounds, improved his balance and made friends.

At 91, he’s still spry and doesn’t take any medication other than an occasional Tylenol for aches and pains.

“Doctors love me,” he said.

But when California enacted a statewide stay-at-home order in mid-March, his near-daily physical exercise and social interactions abruptly ended.

Ballard’s health started to deteriorate: His back hurt, his legs cramped and he started becoming short of breath. As happens too often with older people, he also started to feel isolated and depressed.

“I was deeply concerned for myself because I didn’t have an exercise routine at home,” he said.

Art Ballard is proud that he doesn’t have to rely on several medications at his age. He takes only Tylenol as needed for aches and pains.(Heidi de Marco/KHN)

Art Ballard worked out at Foothill Gym a few weeks before it was officially open to the public. “I’m feeling so good,” he says. “I snapped back.”(Heidi de Marco/KHN)

The University of Southern California’s Dornsife Center for Economic and Social Research conducted an analysis in late March, as the coronavirus established a foothold in the U.S., that found that older adults over 60 who lived alone were more likely to report feeling anxious or depressed than those living with companions.

The combination of the pandemic and nationwide lockdown orders put this already vulnerable population at greater risk, said Julie Zissimopoulos, co-director of the aging and cognition program at USC’s Leonard D. Schaeffer Center for Health Policy & Economics. Social distancing measures have weakened the support systems that older people who live alone depend on for basic activities, such as help with grocery shopping and transportation to doctor appointments.

“There’s a huge, disproportionate impact on older adults with this virus and the health outcomes,” said Lisa Marsh Ryerson, president of AARP Foundation. “During this shutdown, we’ve had growing public health and community acknowledgement of how serious it can be to sever the ties with our network.”

Ballard, a retired jeweler, lives alone in a one-bedroom condo in Monrovia, a city of about 36,000 people about 20 miles northeast of downtown Los Angeles. He lost his wife of more than 50 years, Dorothy, to Alzheimer’s disease in 2015. Since then, he has embraced his solitude and reveled in his newfound bachelorhood. He enjoys cooking and trying out recipes, listening to 1950s music and watching YouTube videos about World War II.

Ballard holds a photograph of himself and his wife, Dorothy. She died from complications of Alzheimer’s disease almost five years ago. (Heidi de Marco/KHN)

He has a girlfriend he met online — a retired greyhound trainer who lives in Arkansas. They haven’t yet met in person.

Ballard felt he could handle the isolation of the lockdown order. He didn’t have visitors during quarantine, but his son, Dan Ballard, checked on him by phone weekly.

In the beginning, Ballard tried to keep busy. He did his shopping early in the morning and took strolls around his neighborhood. But after a couple of months of not visiting the gym, Ballard began feeling sad and frustrated, and his health started to slide. He relied more on his walker and sometimes struggled to breathe.

“My girlfriend was concerned with how I was thinking,” said Ballard, who speaks to her on the phone several times a day.

For Ballard, a self-proclaimed gym addict, Foothill Gym was a second home. Just as in the 1980s sitcom “Cheers,” it’s a place where everybody knows his name. Not going to the “club,” as he calls it, was taking a toll on his mental and physical health, so he decided to visit Brian Whelan, the owner of the small, family-run gym, in late May.

“He comes in, out of breath, with a walker,” Whelan recalled. “He couldn’t hold his head up straight and it took him five minutes to catch his breath.”

During the lockdown, Ballard started having difficulty keeping his balance. His solution was to walk around his neighborhood with a walker. (Heidi de Marco/KHN)

Art Ballard takes a break between sets to chat with Foothill Gym owner Brian Whelan on June 13. For Ballard, the benefits of the gym are twofold. “It’s the health factor and the social aspect,” he says. “Everybody there is so positive. It makes my day worthwhile.”(Heidi de Marco/KHN)

Art Ballard performs seated cable pulls during his total body workout at the gym. “I try to get my heart rate up to 140,” Ballard says.(Heidi de Marco/KHN)

Whelan felt sad and angry. “Everyone here was almost in tears because this vibrant man was gone,” he said. So Whelan broke the rules. He invited Ballard to visit the gym even before it officially reopened to the public.

“The gym business is more than physical health,” said Whelan. “It’s mental health.”

Ballard resumed his beloved routine the last week of May, with the gym mostly to himself.

“Every day for the past two months, I’ve been sad,” Ballard said on the first day back. “Today, I woke up and I was happy.”

Day after day, Ballard improved. “Now he comes in without a walker, head up straight, and the spark in his eyes is getting brighter,” Whelan said.

Ballard says it took him a while to get his hands on a mask. He wears it when he goes grocery shopping and to doctor appointments. (Heidi de Marco/KHN)

Art Ballard lives alone in a one-bedroom apartment. He’s self-sufficient and says he wants to live independently as long as possible. More than one-quarter of adults 65 and older live by themselves, according to 2018 U.S. Census Bureau statistics.(Heidi de Marco/KHN)

Art Ballard combs his freshly cut hair before heading to the gym. He has always had a crew cut, and the quarantine forced him, for the first time, to grow it out.(Heidi de Marco/KHN)

The gym reopened June 15. Despite the threat of COVID-19, Ballard is back to working out six days a week. Masks are required to enter the gym but can be removed when exercising.

Ballard isn’t worried. “I’m 100% comfortable,” he said. “I’ll wear a mask if they ask me to.”

Son Dan said he’s worried about his dad being around people, but realizes the benefits.

“It’s a scary balance. If he stops going to the gym and can’t see anybody, I know he’s going to deteriorate,” he said. “At the end of the day, it’s a quality-of-life decision that’s his to make.”

Ballard believes not being able to socialize was a bigger threat to his health than the risk of contracting the coronavirus.

“I found out how important my routine and exercise is,” said Ballard. “It’s given me back my life. And it’s only going to get better.”

Ballard always ends his gym session punching the heavy bag at least 60 times in a row, he says. “The most important thing to do is to shake those bones up, especially when you’re old,” he says. (Heidi de Marco/KHN)

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Workers Filed More Than 4,100 Complaints About Protective Gear. Some Still Died.

COVID-19 cases were climbing at Michigan’s McLaren Flint hospital. So Roger Liddell, 64, who procured supplies for the hospital, asked for an N95 respirator for his own protection, since his work brought him into the same room as COVID-positive patients.

But the hospital denied his request, said Kelly Indish, president of the American Federation of State, County and Municipal Employees Local 875.

On March 30, Liddell posted on Facebook that he had worked the previous week in both the critical care unit and the ICU and had contracted the virus. “Pray for me God is still in control,” he wrote. He died April 10.

Roger Liddell(Courtesy of Bill Sohmer)

The hospital’s problems with personal protective equipment (PPE) were well documented. In mid-March, the state office of the Occupational Safety and Health Administration (OSHA) received five complaints, which described employees receiving “zero PPE.” The cases were closed April 21, after the hospital presented paperwork saying problems had been resolved. There was no onsite inspection, and the hospital’s written response was deemed sufficient to close the complaints, a local OSHA spokesperson confirmed.

The grief and fear gripping workers and their families reflect a far larger pattern. Since March, more than 4,100 COVID-related complaints regarding health care facilities have poured into the nation’s network of federal and state OSHA offices, which are tasked with protecting workers from harm on the job.

A KHN investigation found that at least 35 health care workers died after OSHA received safety complaints about their workplaces. Yet by June 21, the agency had quietly closed almost all of those complaints, and none of them led to a citation or a fine.

The complaint logs, which have been made public, show thousands of desperate pleas from workers seeking better protective gear for their hospitals, medical offices and nursing homes.

The quick closure of complaints underscores the Trump administration’s hands-off approach to oversight, said former OSHA official Deborah Berkowitz. Instead of cracking down, the agency simply sent letters reminding employers to follow Centers for Disease Control and Prevention guidelines, said Berkowitz, now a director at the National Employment Law Project.

“This is a travesty,” she said.

A third of the health care-related COVID-19 complaints, about 1,300, remain open and about 275 fatality investigations are ongoing.

During a June 9 legislative hearing, Labor Secretary Eugene Scalia said OSHA had issued one coronavirus-related citation for violating federal standards. A Georgia nursing home was fined $3,900 for failing to report worker hospitalizations on time, OSHA’s records show.

“We have a number of cases we are investigating,” Scalia said at the Senate Finance Committee hearing. “If we find violations, we will certainly not hesitate to bring a case.”

Texts between Barbara Birchenough and her daughter, (in blue) Kristin Carbone.(Courtesy of Kristin Carbone)

A March 16 complaint regarding Clara Maass Medical Center in Belleville, New Jersey, illustrates the life-or-death stakes for workers on the front lines. The complaint says workers were “not allowed to wear” masks in the hallway outside COVID-19 patients’ rooms even though studies have since shown the highly contagious virus can spread throughout a health care facility. It also said workers “were not allowed adequate access” to PPE.

Nine days later, veteran Clara Maass registered nurse Barbara Birchenough texted her daughter: “The ICU nurses were making gowns out of garbage bags. … Dad is going to pick up large garbage bags for me just in case.”

Kristin Carbone, the eldest of four, said her mother was not working in a COVID area but was upset that patients with suspicious symptoms were under her care.

In a text later that day, Birchenough admitted: “I have a cough and a headache … we were exposed to six patients who we are now testing for COVID 19. They all of a sudden got coughs and fevers.”

“Please pray for all health care workers,” the text went on. “We are running out of supplies.”

By April 15, Birchenough, 65, had died of the virus. “They were not protecting their employees in my opinion,” Carbone said. “It’s beyond sad, but then I go to a different place where I’m infuriated.”

OSHA records show six investigations into a fatality or cluster of worker hospitalizations at the hospital. A Labor Department spokesperson said the initial complaints about Clara Maass remain open and did not explain why they continue to appear on a “closed” case list.

Nestor Bautista, 62, who worked closely with Birchenough, died of COVID-19 the same day as she did, according to Nestor’s sister, Cecilia Bautista. She said her brother, a nursing aide at Clara Maass for 24 years, was a quiet and devoted employee: “He was just work, work, work,” she said.

Barbara Birchenough(Courtesy of Kristin Carbone)

Nestor Bautista(Courtesy of Cecilia Bautista)

Responding to allegations in the OSHA complaint, Clara Maass Medical Center spokesperson Stacie Newton said the virus has “presented unprecedented challenges.”

“Although the source of the exposure has not been determined, several staff members” contracted the virus and “a few” have died, Newton said in an email. “Our staff has been in regular contact with OSHA, providing notifications and cooperating fully with all inquiries.”

Other complaints have been filed with OSHA offices across the U.S.

Twenty-one closed complaints alleged that workers faced threats of retaliation for actions such as speaking up about the lack of PPE. At a Delaware hospital, workers said they were not allowed to wear N95 masks, which protected them better than surgical masks, “for fear of termination or retaliation.” At an Atlanta hospital, workers said they were not provided proper PPE and were also threatened to be fired if they “raise[d] concerns about PPE when working with patients with Covid-19.”

Of the 4,100-plus complaints that flooded OSHA offices, over two-thirds are now marked as “closed” in an OSHA database. Among them was a complaint that staffers handling dead bodies in a small room off the lobby of a Manhattan nursing home weren’t given appropriate protective gear.

More than 100 of those cases were resolved within 10 days. One of those complaints said home health nurses in the Bronx were sent to treat COVID-19 patients without full protective gear. At a Massachusetts nursing home that housed COVID patients, staff members were asked to wash and reuse masks and disposable gloves, another complaint said. A complaint about an Ohio nursing home said workers were not required to wear protective equipment when caring for COVID patients. That complaint was closed three days after OSHA received it.

It remains unclear how OSHA resolved hundreds of the complaints. A Department of Labor spokesperson said in an email that some are closed based on an exchange of information between the employer and OSHA, and advised reporters to file Freedom of Information Act requests for details on others.

“The Department is committed to protecting America’s workers during the pandemic,” the Labor Department said in a statement. “OSHA has standards in place to protect employees, and employers who fail to take appropriate steps to protect their employees may be violating them.”

The agency advised its inspectors on May 19 to place reports of fatalities and imminent danger as a top priority, with a special focus on health care settings. Since late March, OSHA has opened more than 250 investigations into fatalities at health care facilities, government records show. Most of those cases are ongoing.

According to the mid-March complaints against McLaren Flint, workers did not receive needed N95 masks and “are not allowed to bring them from home.” They also said patients with COVID-19 were kept throughout the hospital.

Patrick Cain and his wife, Kate(Courtesy of Kelly Indish)

Filing complaints, though, did little for Liddell, or for his colleague, Patrick Cain, 52. After the complaints were filed, Cain, a registered nurse, was treating people still awaiting the results of COVID-19 diagnostic tests — potentially positive patients ― without an N95 respirator. He was also working outside a room where potential COVID-19 patients were undergoing treatments that research supported by the University of Nebraska has since shown can spread the virus widely in the air.

At the time, there was a debate over whether supply chain breakdowns of PPE and weakened CDC guidelines on protective gear were putting workers at risk.

Cain felt vulnerable working outside of rooms where COVID patients were undergoing infection-spreading treatments, he wrote in a text to Indish on March 26.

Texts between union president Kelly Indish and Patrick Cain (right)(Courtesy of Kelly Indish)

“McLaren screwed us,” he wrote.

He fell ill in mid-March and died April 4.

McLaren has since revised its face-covering policy to provide N95s or controlled air-purifying respirators (CAPRs) to workers on the COVID floor, union members said.

A spokesperson for the McLaren Health Care system said the OSHA complaints are “unsubstantiated” and that its protocols have consistently followed government guidelines. “We have always provided appropriate PPE and staff training that adheres to the evolving federal, state, and local PPE guidelines,” Brian Brown said in an email.

Separate from the closed complaints, OSHA investigations into Liddell and Cain’s deaths are ongoing, according to a spokesperson for the state’s Department of Labor and Economic Opportunity.

Nurses at Kaiser Permanente Fresno Medical Center also said the complaints they aired before a nurse’s death have not been resolved. (KHN is not affiliated with Kaiser Permanente.)

On March 18, nurses filed an initial complaint. They told OSHA they were given surgical masks, instead of N95s. Less than a week later, other complaints said staffers were forced to reuse those surgical masks and evaluate patients for COVID without wearing an N95 respirator.

Several nurses who cared for one patient who wasn’t initially suspected of having COVID-19 in mid-March wore no protective gear, according to Amy Arlund, a Kaiser Fresno nurse and board member of the National Nurses Organizing Committee board of directors. Sandra Oldfield, a 53-year-old RN, was among them.

Arlund said Oldfield had filed an internal complaint with management about inadequate PPE around that time. Arlund said the patient’s illness was difficult to pin down, so dozens of workers were exposed to him and 10 came down with COVID-19, including Oldfield.

Sandra Oldfield(Courtesy of Lori Rodriguez)

Lori Rodriguez, Oldfield’s sister, said Sandra was upset that the patient she cared for who ended up testing positive for COVID-19 hadn’t been screened earlier.

“I don’t want to see anyone else lose their life like my sister did,” she said. “It’s just not right.”

Wade Nogy, senior vice president and area manager of Kaiser Permanente Fresno, confirmed that Oldfield had exposure to a patient before COVID-19 was suspected. He said Kaiser Permanente “has years of experience managing highly infectious diseases, and we are safely treating patients who have been infected with this virus.”

Kaiser Permanente spokesperson Marc Brown said KP “responded to these complaints with information, documents and interviews that demonstrated we are in compliance with OSHA regulations to protect our employees.” He said the health system provides nurses and other staff “with the appropriate protective equipment.”

California OSHA officials said the initial complaints were accurate and the hospital was not in compliance with a state law requiring workers treating COVID patients to have respirators. However, the officials said the requirement had been waived due to global shortages.

Kaiser Fresno is now in compliance, Cal/OSHA said in a statement, but the agency has ongoing investigations at the facility.

Arlund said tension around protective gear remains high at the hospital. On each shift, she said, nurses must justify their need for a respirator, face shield or hair cap. She expressed surprise that the OSHA complaints were considered “closed.”

“I’m very concerned to hear they are closing cases when I know they haven’t reached out to front-line nurses,” Arlund said. “We do not consider any of them closed.”

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KHN’s ‘What The Health?’: High Court’s Surprising Abortion Decision


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The Supreme Court surprised both sides in the polarized abortion battle Monday by ruling, 5-4, that a Louisiana law requiring doctors who perform the procedure to have admitting privileges at a nearby hospital is an unconstitutional infringement of a woman’s right to an abortion.

As expected, the court’s four liberals in the case, June Medical Services v. Russo, said that the law did not provide any protections for women and merely made it harder for them to obtain an abortion and that it was nearly identical to a Texas law struck down in 2016. The four conservatives said the Louisiana law should be upheld, although that would have left the state with only a single abortion provider. The swing vote was Chief Justice John Roberts, who, in a concurring opinion, said he disagreed with the ruling in the Texas case but it is now precedent and thus should not be overturned.

This week’s panelists are Julie Rovner of Kaiser Health News, Alice Miranda Ollstein of Politico and Jennifer Haberkorn of the Los Angeles Times.

The panelists broke down the decision along several lines, including:

  • Why a court with five justices who have all voted to back abortion restrictions did not uphold the first major abortion law to come before it since Anthony Kennedy retired and was replaced by Brett Kavanaugh.
  • How the ruling could have gone much further than merely upholding the Louisiana law. The court had been asked to use the case to overturn Roe v. Wade in its entirety and to bar abortion providers from filing suit on behalf of their patients. The justices did neither.
  • Why Justice Roberts’ vote in this case does not suggest he will vote with abortion-rights supporters in other cases, but might offer a clue on how he will vote in the upcoming case challenging the constitutionality of the Affordable Care Act.
  • How this case could play at the polls in November.

“What the Health?” is taking a break on Thursday but will return July 9.


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Supreme Court, Rejecting Restrictive La. Law, Refuses To Roll Back Abortion Rights

In a decision certain to roil the fall elections, a Supreme Court with a majority of anti-abortion justices Monday refused to use its first opportunity to roll back abortion rights. In a 5-4 ruling, the justices said a Louisiana law requiring doctors who perform abortions to have admitting privileges at a nearby hospital is an unconstitutional burden on a woman’s right.

The decision in June Medical Services v. Russo effectively upholds a case from just four years ago. In 2016, in Whole Woman’s Health v. Hellerstedt, a 5-3 majority struck down portions of a controversial Texas law, including not only the admitting privileges requirement, but also a requirement for abortion clinics to meet the same standards as surgical centers that perform more advanced procedures.

The deciding vote was cast by Chief Justice John Roberts, who voted in the past case to uphold the Texas law. In a concurring opinion, he said his vote here was based on the court’s unwritten rules about precedent.

“The legal doctrine of stare decisis requires us, absent special circumstances, to treat like cases alike,” Roberts wrote. “The Louisiana law imposes a burden on access to abortion just as severe as that imposed by the Texas law, for the same reasons. Therefore Louisiana’s law cannot stand under our precedents.”

Had the law been upheld, it would likely have resulted in the closure of two of the three remaining abortion clinics in the state, the plaintiffs argued before the court in March. Justices had numerous questions about how doctors at each of the clinics tried and failed to obtain the required privileges. That was not because the doctors were not qualified, but because most hospitals do not extend privileges to doctors who do not admit patients, and outpatient abortions rarely result in hospital admissions.

The decision is likely to touch off a major backlash by conservatives who had hoped to see progress rolling back abortion rights since Anthony Kennedy — who often sided with the court’s liberals to uphold abortion rights — retired and was replaced by Brett Kavanaugh.

As usual, abortion is likely to be a galvanizing issue in the fall presidential and congressional campaigns.

Supporters of abortion rights worried that if the Louisiana law were upheld, the case would open the door to other states that want to restrict abortion without outright banning it. According to the Guttmacher Institute, which tracks reproductive health legislation, 15 states either already have admitting privileges laws on the books, or would have been likely to enact them because they have anti-abortion governors and legislative majorities.

Still, abortion rights at the high court are far from secured. As of June 1, 11 states have passed laws that would ban abortion in the first trimester of pregnancy, according to Guttmacher. Tennessee joined that group just days ago. Several of those laws are in the pipeline heading for the high court.

The court also declined to rule on a technicality that could have had far-reaching implications. Louisiana had asked the court to rule that abortion providers lacked standing to sue on behalf of women seeking abortions. Doctors and clinics have been filing suits on behalf of their patients since at least the 1980s and the Supreme Court has always allowed it. And those doctors, of course, are in some ways more directly affected by the law because the penalties for violation accrue to them, not their patients.

The court, however, did not accept that argument either.

Wrote Justice Stephen Breyer in the majority opinion, “We have long permitted abortion providers to invoke the rights of their actual or potential patients in challenges to abortion-related regulations.”

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California Prisons Are COVID Hotbeds Despite Billions Spent On Inmate Health

From Corcoran and Avenal state prisons in the arid Central Valley to historical San Quentin on the San Francisco Bay, California prisons have emerged as raging COVID-19 hot spots, even as the state annually spends more on inmate health care than other big states spend on their entire prison systems.

The new state budget taking effect July 1 authorizes $13.1 billion for California’s 34 prisons, housing 114,000 inmates, more than three times what any other state spends. That sum includes $3.6 billion for medical and dental services and mental health care — roughly what Texas spends to run its entire 140,000-inmate prison system.

And, yet, despite the extraordinary dedication of resources, California prison officials are struggling to contain the COVID outbreaks, let alone prevent them. On March 25, there was just one confirmed COVID-19 case among California’s inmates. Three months later, more than 4,600 inmates have contracted the disease, an infection rate of about 40 per 1,000 inmates and rising — more than seven times higher than the infection rate for the state’s population as a whole. Twenty-one inmates have died. More than 730 staffers have tested positive, and two have died.

Prison systems in several other states are seeing worse outbreaks. In Ohio, at least 84 inmates have died. In Michigan prisons, 68 inmates have died. In Texas, at least 79. But given what it spends on prison health care, and its history, California might have seen the scourge coming.

Prisoner rights attorneys in California for years have waged high-profile court challenges alleging inadequate health care delivery behind bars. As a result of their efforts, federal judges in San Francisco and Sacramento oversee the state’s prison health care system. A special office, known as the California Correctional Health Care Services, has a staff of 57 to monitor the delivery of care.

“Every year, there is a major outbreak,” said San Francisco attorney Michael Bien, who for 30 years has wrangled with the state over conditions for inmates diagnosed with varying levels of mental illness. Hepatitis, HIV and other communicable diseases are common in prisons. “Prisons are like nursing homes,” Bien said. “They’re very dangerous for infectious diseases.”

In 2011, the U.S. Supreme Court concluded that California’s prisons were so crowded and the physical and mental health care so deficient that conditions amounted to cruel and unusual punishment. In response, California cut its prison population and now houses 114,000 inmates, down from a peak of 173,000 in 2006. Many health experts believe the prison system is still too crowded to keep the novel coronavirus from spreading.

The California Institution for Men in Chino, in the suburbs east of Los Angeles, was the first California lockup struck. It reports more than 890 cases involving inmates and 16 deaths. In an effort to contain the virus at the Chino prison, the California Department of Corrections and Rehabilitation (CDCR) on May 30 transferred 121 inmates considered especially vulnerable to infection 444 miles north to California’s oldest prison, San Quentin, just north of San Francisco.

Assembly member Marc Levine, a Democrat whose Marin County district includes San Quentin, said some Chino prisoners initially were housed on the upper tier of a San Quentin cellblock, called the Badger Unit. That allowed their droplets to descend on inmates below.

“Everything was preventable. Everything,” Levine said.

In a statement, CDCR spokesperson Dana Simas said inmates from Chino who had tested positive upon arrival at San Quentin “were not exposed to the general population” of the prison.

However the virus arrived, more than 830 San Quentin inmates since have tested positive. Chino inmates also were transferred to Corcoran State Prison, south of Fresno. Now, 155 Corcoran prisoners have the virus. In Lassen County, officials are blaming the transfer of prisoners from San Quentin to the California Correctional Center in Susanville for an outbreak that has infected 211 inmates in the past two weeks.

Corrections officials say they now routinely distribute cloth masks to inmates and workers throughout the prison system, providing hand sanitizer in common areas, and have increased attention to disinfecting surfaces. Prisons are screening and taking the temperatures of staffers who enter the prisons.

“We have taken unprecedented steps to address the COVID-19 pandemic in all state prisons, including the cessation of visiting, volunteers, and group programs; developing comprehensive prevention and treatment protocols,” Simas said in a statement.

California’s prisons were built to contain felons, not the coronavirus. Each of the state’s 34 prisons house 2,000 to 5,000 inmates. Many live in dorms, sleeping in double bunks and sharing showers and dining halls. Others live two to a 60- to 80-square-foot cell.

Earlier this year, to create more space, the state sped the release of 3,500 inmates who had less than six months to serve on their sentences. Starting July 1, the state once more will start speeding the release of prisoners who have six months or less left on their sentences, with caveats: They cannot have been convicted of violent or serious felonies, domestic violence or sex crimes.

They also must have plans for housing. That’s important for officials grappling with California’s other epidemic: homelessness.

It’s not clear whether COVID-related releases from state prisons have amplified the state’s homeless crisis. But El Dorado County District Attorney Vern Pierson, vice president of the California District Attorneys Association, predicts it’s a matter of time.

“We’re going to exacerbate an already bad situation,” Pierson said. “The numbers that will become homeless will be high. The supervision will be less and less. The likelihood of reoffending will likely go up.”

In Sacramento, Mayor Darrell Steinberg, co-chair of Newsom’s homelessness task force, said that since the start of the pandemic the capital city has moved 800 people from the streets into hotels, a hopeful sign.

But that gain has been more than offset because fewer people are in county jails. To limit the spread of the coronavirus in county lockups, jailers statewide have reduced the number of total inmates from 72,000 to 51,000, the California Board of State and Community Corrections reports.

In part because of those releases, homeless encampments along the Sacramento River have “grown and grown in a very significant way,” Steinberg said. Similar spikes in homelessness are occurring across the state.

Releasing people, “if they do not present a real risk,” is not the problem, Steinberg said. “The problem is releasing them without any connection with housing and the support necessary for them to be successful.”

CDCR’s response to the pandemic will come under scrutiny in a July 1 oversight hearing to be convened by state Sen. Nancy Skinner, a Berkeley Democrat who chairs the Senate Committee on Public Safety.

“What are the biggest congregate facilities in the state? Prisons,” Skinner said. “They are exactly the type of facility no one wants to be in a pandemic.”

California’s efforts to stem the outbreaks matter beyond the prison gates, several experts noted. Prison workers go home at the end of their shifts. Inmates too sick to be cared for in prison infirmaries are sent to community hospitals. Ultimately, prison health and public health are inextricably intertwined.

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Public Health

In Arizona Race, McSally Makes Health Care Pledge At Odds With Track Record

Trailing Democratic challenger Mark Kelly in one of the country’s most hotly contested Senate races, Arizona Sen. Martha McSally is seeking to tie herself to an issue with across-the-aisle appeal: insurance protections for people with preexisting health conditions.

“Of course I will always protect those with preexisting conditions. Always,” the Republican said in a TV ad released June 22.

The ad comes in response to criticisms by Kelly, who has highlighted McSally’s votes to undo the Affordable Care Act. That, he argued, would leave Americans with medical conditions vulnerable to higher-priced insurance.

The Arizona Senate race has attracted national attention and is considered a toss-up, though Kelly is leading in many polls. McSally’s attempt to present herself as a supporter of protecting people with preexisting conditions — a major component of the 2010 health law — is part of a larger pattern in which vulnerable Republican incumbents stake out positions advocating for this protection while also maintaining the GOP’s strong stance against the ACA.

McSally, who was appointed by the governor to take over John McCain’s Senate seat in 2019, used similar messaging in her failed 2018 bid for the state’s other Senate position. And President Donald Trump echoed the declaration at a June 23 rally in Phoenix, saying McSally — along with the rest of the Republican Party — “will always protect people with preexisting conditions.”

With that in mind, we decided to take a closer look. We contacted McSally’s campaign, which cited her support of a different piece of legislation, the Protect Act. But independent experts told us that legislation doesn’t satisfy the standard she sets out.

Past and Present

Only one national law makes sure people with preexisting medical conditions don’t face discrimination or higher prices from insurers. It’s the Affordable Care Act.

Both as a member of the House of Representatives and as a senator, McSally has supported efforts to undo the health law — voting in 2015 to repeal it and in 2017 to replace it with the Republican-backed American Health Care Act, which would have permitted insurers to charge higher premiums for people with complicated medical histories.

“Anyone who voted for that bill was voting to take away the ACA’s preexisting condition protections,” said Jonathan Oberlander, a health policy professor at the University of North Carolina-Chapel Hill. “Sen. McSally is trying to erase history for electoral purposes.”

Especially as COVID-19 cases climb, health care — and, in particular, the ACA — has emerged as a flashpoint in the Arizona election, said Dr. Daniel Derksen, a professor of public health, medicine and nursing at the University of Arizona.

“Martha McSally has in her actions, in her votes, been pretty consistent about cutting back benefits and trying to repeal the ACA without any clear plan in mind that would protect people who gained insurance through the ACA,” Derksen added. “Her words on preexisting condition protections don’t align with any votes I’ve seen.”

McSally’s campaign argued that the ACA is just one strategy, and a flawed one at that. Dylan Lefler, her campaign manager, instead pointed to her support of the Republican-backed Protect Act as evidence to back up her promise. Specifically, it ostensibly bans insurance plans from “impos[ing] any preexisting condition exclusion with respect to … coverage,” per the bill text.

The problem, though, is that simply banning that exclusion isn’t enough, because the law also has to make sure the health insurance plans that cover preexisting conditions remain affordable. The bill, sponsored by Sen. Thom Tillis (R-N.C.), does nothing to provide subsidies or cost-sharing mechanisms — meaning people both with and without preexisting conditions wouldn’t necessarily be able to afford those plans. Without that framework, the act remains a “meaningless promise,” argued Linda Blumberg, a fellow at the Urban Institute, a social policy think tank.

And it has other holes: for instance, permitting insurers to charge women more than men.

“No six-page bill is ever the way of achieving something,” said Thomas Miller, a scholar at the American Enterprise Institute. “This is a check-the-box effort to try to say, ‘We’re [moving] in that direction.’”

It’s not just legislation. There’s also Texas v. Azar, a pending case in which a group of Republican attorneys general are arguing the Supreme Court should strike the entire health law, including its preexisting condition protections. The Trump administration has sided with the Republican states.

McSally has consistently declined to comment on the lawsuit, saying she doesn’t want to weigh in on “a judicial proceeding.” In reporting this fact check, we asked where she stood on the case. The campaign didn’t specifically answer but pointed to her general disapproval of the ACA. Meanwhile, Senate Democrats have called on the administration to reverse its stance.

That context makes McSally’s silence especially relevant, said Sabrina Corlette, a research professor at Georgetown University.

“When given the opportunity, she has declined to oppose this lawsuit, which would essentially eliminate the protections that exist,” Corlette said.

So — big picture? McSally’s record in Washington hasn’t been one of preserving or building on preexisting condition protections.

Our Ruling

In her new TV ad, McSally claims she will “always protect those with preexisting conditions.”

But nothing in her voting record, which tracks closely with the Republican repeal-and-replace philosophy, supports this claim. And she has continually declined opportunities to oppose a pending legal threat to the ACA, including its provisions related to preexisting conditions, by a group of GOP governors and supported by the Trump administration.

Meanwhile, the legislation her campaign cited to justify her stance falls short in terms of meaningfully protecting Americans with preexisting medical conditions.

McSally has not in the past or present taken actions that back up her statement. We rate it False.

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Conflicting COVID Messages Create Cloud Of Confusion Around Public Health And Prevention

Regina Fargis didn’t know what to do.

Fargis runs Summit Hills — a health and retirement community in Spartanburg, South Carolina, that offers skilled nursing, activities and communal meals for its residents, most of whom are over 60, the highest-risk category for coronavirus complications. In South Carolina, more than a hundred new cases were emerging daily. So she took precautions: no visitors, hand sanitizer everywhere and regular reminders for residents about the importance of social distancing.

For a time, it worked. Many similar facilities were hit hard by the virus, but Summit Hills remained COVID-free. Summit Hills’ first cases didn’t emerge until mid-June. Three residents and four employees have now tested positive and are being quarantined. For months, though, Fargis was able to protect her residents.

Still, even under the best circumstances, she couldn’t prevent one thing. By mid-May, two residents had become convinced that the COVID-19 death count — which has surpassed 125,000 people in the U.S. — was a talking point manufactured by Democrats. Some people may be dying, they said, but it wasn’t actually that severe. They didn’t think her precautions were necessary.

“I don’t know how to respond, to tell you the truth,” Fargis said. “If someone has that kind of mindset, what kind of conversation do you have” to convince them of the pandemic’s severity and the need for strict precautions?

Since the start of the pandemic, the public has been barraged by conflicting messages in part because the country is dealing with a new and still poorly understood virus and in part because politicians and scientists deliver conflicting advice. But rumors, misinformation and outright falsehoods — some intentionally propagated — have also flourished in that cauldron of confusion.

As the nation reopens for business and retreats from protective stay-at-home orders, those widely circulating lies could prove deadly.

NewsGuard, a startup by two former journalists that vets the internet for misinformation, has identified 217 websites in Europe and the United States that publish “materially false” information about COVID-19. The volume is so great that NewsGuard, which was launched to check political fabrications, has pivoted to full-time COVID-19 fact-checking.

The misinformation includes the “Plandemic” video, Facebook posts claiming 5G cell networks cause the virus and articles suggesting it can be cured with garlic or using a combination of hot water with baking soda and lemon.

Health scares always spawn scurrilous stories. But with COVID-19, “there’s lots of opportunity for misinformation,” said Dhavan Shah, a professor of mass communication at the University of Wisconsin-Madison.

That is particularly true in the United States, where the coronavirus has somehow morphed into a right-versus-left political issue — and Americans increasingly reject information that doesn’t match their leanings.

Research shows people who support the Trump administration and rely on right-leaning news organizations are more likely to believe the virus has been exaggerated. In general, Republicans are more likely, according to recent polling, than Democrats to think that COVID-19 was never a threat and that the worst is over. That possibly contributed to the push for early reopening in some states that had not met the requirements recommended by the Centers for Disease Control and Prevention for doing so. In many of them, daily case counts are now spiking. And Republicans are less likely than Democrats to don protective masks, which are believed to reduce the spread of the virus. (President Donald Trump famously has refused to wear a mask in public.)

Groups like anti-vaxxers, conspiracy theorists and immigration opponents have also used the virus to push their own misinformation, per a report from Data & Society, a research institute in New York.

“It’s become a political football now,” said Steven Brill, a co-CEO of NewsGuard. “That tends to get the misinformation and disinformation amplified. People on one side or the other tend to want to amplify what endorses or strengthens their position.”

Misinformation Grows In A Vacuum

Federal health officials from agencies such as the CDC and the Food and Drug Administration usually are tasked with providing the public with understandable, scientifically supported guidance. But the advice from experts like Dr. Anthony Fauci, who heads the National Institute of Allergy and Infectious Diseases, has consistently been undermined by Trump, who instead touts unproven treatments and frequently challenges the severity of the virus.

In fact, political figures like Trump have held outsize influence in shaping public understanding. “The news feed abhors a vacuum,” said Jeff Hancock, a professor of communication at Stanford University who has studied the implications of COVID misinformation. “Since the expertise of the CDC and others have been called into question … it exacerbates the problem.”

Experts’ initial confusion about how to respond to a new virus has also allowed for suspicion. When the coronavirus arrived in the United States, the prevailing thought was that asymptomatic patients couldn’t spread it and that people needn’t wear face coverings. Subsequent studies reversed those judgments.

All that helps explain why falsehoods took hold. Researchers from the University of Oxford’s Reuters Institute for the Study of Journalism reviewed 225 pieces of online misinformation about COVID-19. Misinformation spread by political figures and celebrities made up only 20% of the sample but accounted for 69% of engagement.

Independent groups, including NewsGuard and Hancock’s Stanford Social Media Lab, have launched projects meant to combat misinformation — teaching older people through peer-to-peer tutoring to navigate digital content or launching websites that point people toward more credible data and analysis. But these efforts, usually difficult, are almost impossible now in the age of social distancing.

The “volume and velocity” of social media spread means claims spread farther, faster, Shah said.

At Summit Hills, the politicization of COVID-19 has “without a doubt” made it harder for Fargis, its executive director, to convince her residents — many of whom would typically look to the federal government for credible information — of the pandemic’s severity.

Some cons deliberately target seniors, offering more than misinformation: Bad actors pretended to have access to their victims’ stimulus checks, asking for bank account and Social Security information. Others sell fake protective equipment.

At Hebrew SeniorLife, a hospital and living center in Massachusetts, which operates rehab centers and senior-living facilities around the Boston area, misinformation and online scams — such as fake fundraisers on Facebook for first responders — are serious concerns, said Rachel Lerner, the organization’s general counsel.

Older Americans experience a “perfect storm,” Hancock said. “They’re more susceptible to the virus. They are targets of misinformation and online scams at a much higher rate than regular folks are.”

When South Carolina began opening up, Fargis decided to see if the numbers of new COVID-19 cases declined significantly before lifting precautions. Now, with the virus in her facility, she has no intention of letting up social distancing rules and other prevention strategies.

And since May, at least one of her residents has since come around to understanding the pandemic’s severity. But another, she said, still emails her arguing that the virus has been overblown or that social distancing does not work and suggesting that unproven medicines — like hydroxychloroquine or beta-glucans — can treat or prevent the illness.

“We’d all be far better off if we kept those nonsensical remarks out of the news,” she said. “The more misinformation we have, the more likely we are going to have lives at stake.”

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