Tagged California

Black Churches Fill a Unique Role in Combating Vaccine Fears

In the hospital with covid-19 in December, Lavina Wafer tired of the tubes in her nose and wondered impatiently why she couldn’t be discharged. A phone call with her pastor helped her understand that the tube was piping in lifesaving oxygen, which had to be slowly tapered to protect her.

Now that Wafer, 70, is well and back home in Richmond, California, she’s looking to her pastor for advice about the covid vaccines. Though she doubts they’re as wonderful as the government claims, she plans to get vaccinated anyway — because of his example.

“He said he’s not going to push us to take it. It’s our choice,” Wafer said, referring to a recent online sermon that praised the vaccines as God-given science with the power to save. “But he wanted us to know he’s going to take it as soon as he can.”

Helping people accept the covid vaccines is a public health goal, but it’s also a spiritual one, said Henry Washington, the 53-year-old pastor of The Garden of Peace Ministries, which Wafer attends.

Lavina Wafer was hospitalized with covid in December. Now that she’s well, she’s looking to her pastor for guidance on the covid vaccine shot. (Lavina Wafer)

Clergy must ensure that people “understand they have an active part in their own salvation, and the salvation of others,” said Washington. “I have tried to suggest that taking the vaccine, social distancing and protecting themselves in their household is something that God requires us to do as good stewards.”

Many Black Americans look to their religious leaders for guidance on a wide range of issues — not just spiritual ones. Their credibility is especially crucial on matters of health, as the medical establishment works to overcome a legacy of experimentation and bias that makes some Black people distrustful of public health messages.

Now that the vaccines are being distributed, public health advocates say churches are key to reaching Black citizens, especially older generations more vulnerable to severe covid disease. They have been hospitalized for covid and died at a disproportionate rate throughout the pandemic, and initial data on who is getting covid shots shows that Black people lag far behind other racial groups.

Black churches have also suffered during the pandemic. African American pastors were most likely to say they had had to delete positions or cut staff pay or benefits to survive, and 60% said their congregations hadn’t gathered in person the previous month, as opposed to 9% of white pastors, according to a survey published in October by Lifeway Research, which specializes in data on Christian groups.

Washington’s 75-member church is in Richmond, which has the highest number of covid deaths in Contra Costa County, outside of deaths in long-term care facilities. The very diverse city, across the bay from San Francisco, also has one of the lowest rates of vaccination.

Offerings to Washington’s church plunged 50% in 2020 due to job loss among congregants, but he’s weathered the pandemic with a small-business loan and a second job as a general contractor remodeling bathrooms and kitchens.

To combat misinformation, he’s been meeting virtually with about 30 other Black pastors once a month in calls organized by the One Accord Project, a nonprofit that organizes Black churches in the San Francisco Bay Area around nonpartisan issues like voter registration and low-income housing. Throughout the pandemic, the calls have focused on connecting pastors with public health officials and epidemiologists to make sure they have the most up-to-date information to pass on to their members, said founder Sabrina Saunders.

Sabrina Saunders is the founder of One Accord Project, a nonprofit that brings together Black churches in the Bay Area on nonpartisan campaigns like voter registration and low-income housing. Throughout the pandemic, she’s hosted monthly conference calls with up to 30 pastors to connect them with public health officials and epidemiologists. (Sabrina Saunders)

The African American church is an anchor for the community, Saunders said. “People get a lot of emotional support, people get resources, and their pastor isn’t just looked upon as a spiritual leader, but something more.”

And guidance is needed.

The share of Black people who say they have been vaccinated or want to be vaccinated as soon as possible is 35%, while 43% say they want to “wait and see” the shots’ effects on others, according to a KFF survey. Eight percent say they’ll get the shot only if required, while 14% say they definitely won’t be vaccinated. Among whites, the first two figures are 53% and 26%, respectively; for Hispanics, 42% and 37%. (KHN is an editorially independent program of KFF.)

Among the “wait and see” group, 35% say they would seek information about the shots from a religious leader, compared with 28% of Hispanics and 14% of white people.

Grassroots outreach to Black churches happens in every public health emergency, but the pandemic has hastened the pace of collaboration with public health officials, said Dr. Leon McDougle, assistant dean for diversity and cultural affairs at the Ohio State University College of Medicine. The last time he saw such a broad coalition across Black churches, medical associations, schools and political groups was during the HIV/AIDS epidemic in the 1980s.

“This is at an entirely different level, though, because we’ve had almost half a million die in a year,” McDougle said of the covid pandemic.

Historically, no other institution in African American communities has rivaled the church in terms of its reach and the trust it enjoys, said Dr. Paris Butler, a plastic and reconstructive surgeon at the University of Pennsylvania Health System. Last month, he and a colleague spoke to leaders from 21 churches in Philadelphia to answer basic questions about how the vaccine was produced and tested.

“Being an African American myself, and growing up in a Baptist church, I understand the value of that trusted voice,” Butler said. “If we don’t reach out to them, we’re making a mistake.”

Dr. Paris Butler was featured in Penn Medicine’s vaccination campaign. This poster appeared throughout Pennsylvania Hospital, where he practices, sharing his reasons for being vaccinated. (Penn Medicine)
Dr. Judith Green McKenzie, chief of the division of occupational medicine at the University of Pennsylvania’s Perelman School of Medicine, helps an employee fill out a consent form. She hopes that older people who get a covid vaccine can go on to influence younger relatives when their turn comes. (Daniel Burke / Penn Medicine) (Daniel Burke / Penn Medicine)

Leaders with massive social media followings, like Bishop T.D. Jakes, are also weighing in, publishing video conversations with experts including Dr. Anthony Fauci to inform followers about the vaccines.

Church attendance is waning among young Black adults, as it is for other races. But elders can set examples for younger people undecided about the vaccine, said Dr. Judith Green McKenzie, chief of the division of occupational medicine at the University of Pennsylvania’s Perelman School of Medicine.

“When they see their grandma go, they may say, ‘I’m going,’” she said. “Grandma got this two months ago and she’s fine.”

Pastor Eddie Anderson leads the McCarty Memorial Christian Church in Los Angeles. He’s asking members who have already gotten the vaccine to write down their experiences and prepare to share them with the rest of the congregation.(Rudy Espinoza)

Encouraging vaccine trust is delicate work. The Black community has reason to be skeptical of the health system, said Eddie Anderson, the 31-year-old leader of McCarty Memorial Christian Church in Los Angeles. In one-on-one conversations, congregants tell him they fear being guinea pigs. The low vaccine supply also makes Anderson hesitate to recommend, from the pulpit, that members get the shot as soon as they’re able. He fears frustration with difficult online sign-ups would further sap motivation.

“I want to do that when it’s readily available,” he said. “I want to preach it, and then within a weekend a family can actually go get the vaccine.”

Despite the doubts and fears, Anderson said the majority of his 125-member congregation, about half of whom are senior citizens, want the vaccine, in order to be with loved ones again. One older member is desperately seeking a vaccine appointment so he can help his daughter, who is going through cancer treatments. But the online sign-up process is confusing and nearly impossible for his followers, Anderson said.

For now, he’s focused on asking several vaccinated members to write down everything about their experience and share it on social media. He also plans to record them talking about their shots — and to show that many people of different races were in the same vaccine line — and will broadcast the videos during church announcements.

While he can’t tell people what to do, Anderson hopes he can remove any potential spiritual barriers to the vaccine.

“My biggest fear is for someone to say, ‘I didn’t get vaccinated’ or ‘I didn’t get a test’ because it’s against [their] faith, or because ‘I don’t see that in the Bible,’” he said. “Any of those arguments, I want to get those off the table.”

‘Into the Covid ICU’: A New Doctor Bears Witness to the Isolation, Inequities of Pandemic


Can’t see the audio player? Click here to listen on SoundCloud.


This week marks a grim milestone: Half a million Americans have died of covid-19. KHN reporter Jenny Gold, in collaboration with Reveal from the Center for Investigative Reporting and PRX, spent eight months following one first-year medical resident working on the front lines of the pandemic.

Dr. Paloma Marin-Nevarez graduated from the Stanford University medical school in June, right before the virus began its second major surge. She’s one of more than 30,000 new doctors who started residencies in 2020. Just weeks after graduating, Marin-Nevarez began training as an ER doctor at Community Regional Medical Center in Fresno, one of the areas in California hardest hit by the pandemic.

Listeners follow Marin-Nevarez as she faces the loneliness and isolation of being a new doctor, working 80 hours a week in the era of masks and physical distancing. She also witnesses the inequality of the pandemic, with Latino, Black and Native American people dying of covid-19 at much higher rates than white people. Marin-Nevarez finds herself surrounded by death and having to counsel families about the loss of loved ones. We view the pandemic through the eyes of a rookie doctor, finding her footing on the front lines of the virus.

Learning to Live Again: A Lazarus Tale From the Covid Front Lines

The twinkle in his eyes, the delight in his smile, the joyous way he moved his disease-withered frame. They all proclaimed a single, resounding message: Grateful to be alive!

“As my care team and my family tell me, ‘You were born again. You have to learn to live again,’” said Vicente Perez Castro. “I went through a very difficult time.”

Hell and back is more like it.

Perez, a 57-year-old cook from Long Beach, California, could barely breathe when he was admitted on June 5 to Los Angeles County’s Harbor-UCLA Medical Center. He tested positive for covid-19 and spent three months in the intensive care unit, almost all of it hooked up to a ventilator with a tube down his throat. A different tube conducted nutrients into his stomach.

At a certain point, the doctors told his family that he wasn’t going to make it and that they should consider disconnecting the lifesaving equipment. But his 26-year-old daughter, Janeth Honorato Perez, one of three children, said no.

And so, on a bright February morning half a year later, here he was — an outpatient, slowly making his way on a walker around the perimeter of a high-ceilinged room at Rancho Los Amigos National Rehabilitation Center in Downey, one of L.A. County’s four public hospitals and the only one whose main mission is patient rehab.

Perez walks around the room at Rancho Los Amigos National Rehabilitation Center while a physical therapist intern times him.(Heidi de Marco / KHN)

Perez, who is 5-foot-5, had lost 72 pounds since falling ill. His legs were unsteady, his breathing labored, as he plodded forward. But he kept moving for five or six minutes, “a huge improvement” from late last year, when he could walk only for 60 seconds, said Bradley Tirador, one of his physical therapists.

Rancho Los Amigos has an interdisciplinary team of physicians, therapists and speech pathologists who provide medical and mental health care, as well as physical, occupational and recreational therapy. It serves a population that has been disproportionately affected by the pandemic: 70% of its patients are Latino, as are 90% of its covid patients. Nearly everyone is either uninsured or on Medi-Cal, the government-run insurance program for people with low incomes.

Rancho is one of a growing number of medical centers across the country with a program specifically designed for patients suffering the symptoms that come in the wake of covid. Mount Sinai Health System’s Center for Post-Covid Care in New York City, which opened last May, was one of the first. Yale University, the University of Pennsylvania, UC Davis Health and, more recently, Cedars-Sinai Medical Center in Los Angeles are among the health systems with similar offerings.

Rancho Los Amigos National Rehabilitation Center in Downey is one of L.A. County’s four public hospitals and the only one dedicated to rehabilitation. The hospital serves mostly Latino, low-income patients.(Heidi de Marco / KHN)

Rancho Los Amigos treats only patients recovering from severe illness and long stays in intensive care. Many of the other post-covid centers also tend to those who had milder cases of covid, were not hospitalized and later experienced a multitude of diffuse, hard-to-diagnose but disabling symptoms — sometimes described as “long covid.”

The most common symptoms include fatigue, muscle aches, shortness of breath, insomnia, memory problems, anxiety and heart palpitations. Many health care providers say these symptoms are just as common, perhaps more so, among patients who had only moderate covid.

A survey conducted by members of the Body Politic Covid-19 Support Group showed that, among patients who’d experienced mild to moderate covid, 91% still had some of those symptoms an average of 40 days after their initial recovery.

Other studies estimate that about 10% of covid patients will develop some of these prolonged symptoms. With more than 28 million confirmed cases in the U.S. and counting, this post-covid syndrome is a rapidly escalating concern.

“What we can say is that 2 [million] to 3 million Americans at a minimum are going to require long-term rehabilitation as a result of what has happened to this day, and we are just at the beginning of that,” said David Putrino, director of rehabilitation innovation at Mount Sinai Health.

Perez was a cook at a hotel restaurant before he fell ill, so his occupational therapy involves meal preparation.(Heidi de Marco / KHN)

Health care professionals seem guardedly optimistic that most of these patients will fully recover. They note that many of the symptoms are common in those who’ve had certain other viral illnesses, including mononucleosis and cytomegalovirus disease, and that they tend to resolve over time.

“People will recover and will be able to get back to living their regular lives,” said Dr. Catherine Le, co-director of the covid recovery program at Cedars-Sinai. But for the next year or two, she said, “I think we will see people who don’t feel able to go back to the jobs they were doing before.”

Rancho Los Amigos is discussing plans to begin accepting patients who had mild illness and developed post-covid syndrome later, said Lilli Thompson, chief of its rehab therapy division. For now, its main effort is to accommodate all the severe cases being transferred directly from its three public sister hospitals, she said.

The most severely ill patients can have serious neurological, cardiopulmonary and musculoskeletal damage. Most — like Perez — have lost a significant amount of muscle mass. They typically have “post-ICU syndrome,” an assortment of physical, mental and emotional symptoms that can overlap with the symptoms of long covid, making it difficult to tease out how much of their condition is a direct impact of the coronavirus and how much is the more general impact of months in intensive care.

Speech pathologist Katherine Chan checks Vicente Perez Castro’s throat. He had a tracheotomy while in the hospital for covid. (Heidi de Marco / KHN)
Perez uses a breathing trainer during his therapy. (Heidi de Marco / KHN)

The large, rectangular rehab room where Perez met with his therapists earlier this month is half-gym, half-sitcom set. Part of the space is occupied by weights, video-linked machines that help strengthen hand control and high-tech treadmills, including one that reduces the pull of gravity, enabling patients who are unsteady on their feet to walk without falling. “We tell patients, ‘It’s like walking on the moon,’” Thompson said.

At the other end of the room sits a large-screen TV and a low couch, which helps people practice standing and sitting without undue stress. In a bedroom area, patients relearn to make and unmake their beds. A few feet away, a small office space helps them work on computer and telephone skills they may have lost.

Perez takes a break during his therapy. He could barely breathe when he was admitted to Los Angeles County’s Harbor-UCLA Medical Center in early June of last year.(Heidi de Marco / KHN)

Because Perez was a cook at a hotel restaurant before he fell ill, his occupational therapy involves meal preparation. He stood at the sink, rinsing lettuce, carrots and cucumbers for a salad, then took them over to a table, where he sat down and chopped them with a sharp knife. His knife hand trembled perilously, so occupational therapist Brenda Covarrubias wrapped a weighted band around his wrist to steady him.

“He is working on getting back the skills and endurance he needs for his work, and just for routine daily activities like walking the dogs and walking up steps,” Covarrubias said.

Perez’s hands trembled as he tried to cut vegetables, so a weighted band was wrapped around his wrist to help keep him steady.(Heidi de Marco / KHN)

Perez, who immigrated to the U.S. from Guadalajara, Mexico, nearly two decades ago, was upbeat and optimistic, even though his voice was faint and his body still a shell of its former self.

When his speech therapist, Katherine Chan, removed his face mask for some breathing exercises, he pointed to the mustache he’d sprouted recently, cheerfully exclaiming he had trimmed it himself. And, he said, “I can change my clothes now.”

Weeks earlier, Perez had mentioned how much he loved dancing before he got sick. So they made it part of his physical therapy.

“Vicente, are you ready to bailar?” Kevin Mui, a student physical therapist, asked him, as another staff member put on a tune by the Colombian cumbia band La Sonora Dinamita.

Slowly, shakily, Perez rose. He anchored himself in an upright position, then began shuffling his feet from front to back and side to side, hips swaying to the rhythm, his face aglow with the sheer joy of being alive.

Perez dances to cumbia music as part of his physical therapy.(Heidi de Marco / KHN)

New California Law Makes It Easier to Get Care for Mental Health and Substance Abuse

Karen Bailey’s 20-year-old daughter has struggled with depression and anxiety for years. Since 2017, she’s been in three intensive group therapy programs and, each time, the family’s insurer cut her coverage short, says Bailey.

“At a certain point, they would send us a form letter saying: We have determined that she is all better, it’s no longer necessary, so we are not covering it anymore,” says Bailey, 59, who lives in Los Angeles. “And believe me, she was not all better. In one case, she was worse.”

In making coverage decisions about mental health and addiction treatment, insurers frequently use “their own kind of black box criteria, not knowable to enrollees and not consistent with standards of care,” says Julie Snyder, director of government affairs at the Steinberg Institute, a Sacramento-based mental health policy and advocacy group.

A California law that took effect Jan. 1, SB-855, should make it much harder for state-regulated commercial health plans to do so. It requires them to use nationally recognized clinical standards established by nonprofit associations of clinical specialists to determine which mental health and addiction treatments they’ll cover — and for how long.

This means, for example, that insurers will find it more difficult to limit a client to only a week of residential addiction treatment when 30 days is the clinical standard, or to treat only the most immediate physical symptoms of anorexia and not the underlying psychological drivers, says Snyder.

“It’s a very strong law, and it has the potential to really be a game changer,” says Karen Fessel, executive director and founder of the Mental Health and Autism Insurance Project, which supported the legislation.

There could hardly be a better time to beef up mental health coverage, as we approach the anniversary of a pandemic that’s been tied to an increase in depression, anxiety, substance use and suicidal thoughts.

Crucially, the new law, which updates and replaces California’s previous mental health parity statute, dramatically expands the number of conditions insurers must cover.

The state law in force until this year required coverage for only nine “severe” mental illnesses, including schizophrenia, bipolar disorder and major depressive disorder, and for “serious emotional disturbances” in children. SB-855 mandates coverage for conditions ranging from mild to severe.

Federal law already required broader coverage, but in vague terms that health plans have frequently circumvented with their restrictive definitions of what’s medically necessary, patient advocates say.

By expanding the range of conditions health plans are obliged to cover and holding them to stiffer standards on the type and amount of care they must pay for, the new law closes “loopholes you could drive a Mack truck through,” says state Sen. Scott Wiener (D-San Francisco), who authored the legislation.

For years, many health plans declined to cover mental health treatment until a patient was in crisis, Wiener says. The new law “makes sure people will be able to get care early while they still have a home, a family, a job.”

Another key aspect of the law is that it requires health plans to cover out-of-network providers at in-network costs if an enrollee is unable to find timely treatment a reasonable distance — generally, 15 miles or 30 minutes — from their home.

“That is something we run into all the time,” Bailey says. The family has spent $100,000 over the years on out-of-network mental health providers for their two kids, she says.

Opponents of the new law, including the California Association of Health Plans and the California Chamber of Commerce, have argued it will significantly increase health care costs, subject insurers to continuous litigation and — through its stringent definition of medical necessity — impede the ability of providers to decide what’s best for their patients.

Proponents say the medical necessity guidelines spelled out by the specialists’ associations allow providers wide discretion to decide the best treatment for each patient. An analysis conducted for state legislators by the California Health Benefits Review Program estimated that in the first year of the law’s implementation, premiums and enrollee cost sharing would rise a mere 0.002%.

The new law won’t help everybody: It applies only to state-regulated commercial health plans covering some 13 million Californians — about one-third of the state’s population. It excludes Medi-Cal, which insures another third of state residents, as well as federally regulated commercial plans, which cover nearly 6 million.

Because only a minuscule share of patients fight their health plans over denials of care, mental health advocates hope that diligent enforcement by the Department of Managed Health Care, which regulates plans covering the vast majority of commercially insured Californians, will discourage insurers from denying necessary care in the first place.

Rachel Arrezola, a spokesperson for the agency, which opposed provisions of the legislation last year, said it fully intends to ensure compliance and has begun to do so.

But if your health plan still denies you the care you believe you need, fight it, patient advocates and health care attorneys say.

“You need to be vigilant, and you need to advocate for yourself and you need to appeal denials, and you need to do it in writing,” says Cari Schwartz, a Los Angeles lawyer who represents patients.

If you appeal a decision over the phone, take detailed notes, write down the time and day of the conversation and get the name of the person you spoke with, Schwartz says. Build a file of all communications and other information related to your case, she says.

And be persistent. “I think insurance companies bank on individuals giving up the fight,” Schwartz says.

If you need help, contact the Health Consumer Alliance (1-888-804-3536 or www.healthconsumer.org), which offers free advice and legal services.

If your mental health provider requested a certain type of treatment in 2020 that was denied by your health plan, ask the provider to resubmit it this year, because the changed legal landscape might work in your favor, says the Steinberg Institute’s Snyder.

With most commercial health plans, you have 180 days from the date you receive a denial to file an appeal. You must first appeal to your insurer. If it fails to respond after 30 days, or upholds its decision, you can take it to the agency that regulates your policy.

In most cases, that will be the Department of Managed Health Care (www.dmhc.ca.gov or 1-888-466-2219), which has a help center and allows you to file a complaint online. If your regulator is the California Department of Insurance, you can call its helpline at 1-800-927-4357 for advice, and file a complaint on its website (www.insurance.ca.gov).

Most Californians enrolled in commercial health plans are entitled to a review by independent medical experts if they are denied care because the insurer deems it unnecessary, or it’s experimental — or the insurer won’t reimburse them for emergency care.

The reviews, which can be requested through state regulators, are well worth the effort: About 60% of Independent Medical Reviews filed through the Department of Managed Health Care result in the patient getting the treatment that was initially denied, Arrezola says.

Be sure to open an archive on the managed care department’s website (https://wpso.dmhc.ca.gov/imr/), in which you can search past decisions for cases similar to yours. They can help you frame your arguments.

Ultimately, the utility of the new law depends on the will of regulators to enforce it and of consumers to avail themselves of it.

“With any luck, it means people won’t have to take out a $50,000 mortgage on their house to pay for their children’s opioid treatment,” says Snyder. “Unfortunately, that is all too common.”

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

‘It’s a Minefield’: Biden Health Pick Must Tread Carefully on Abortion and Family Planning

As President Joe Biden works to overhaul U.S. health care policy, few challenges loom larger for his health secretary than restoring access to family planning while parrying legal challenges to abortion proliferating across the country.

Physicians, clinics and women’s health advocates are looking to Xavier Becerra, Biden’s nominee to run the Department of Health and Human Services, to help swiftly unwind Trump-era funding cuts and rules that decimated the nation’s network of reproductive health providers over the past four years.

But Becerra, who as California’s attorney general fought the Trump administration’s family planning restrictions, faces increasingly conservative federal courts that have backed efforts to restrict reproductive health services, including a Supreme Court dominated by Republican appointees.

The new administration must also contend with an energized anti-abortion movement looking to leverage political power in red state legislatures to finally achieve its decades-long quest to ban abortion outright.

Any Biden administration moves to preserve abortion and other family planning services could set up new legal battles between the federal government and states.

“It’s a minefield,” said Mary Ziegler, a law professor at Florida State University who has written extensively about the history of the nation’s abortion debate. 

“Expectations on both sides are extremely high,” she said. “And the Supreme Court may force the issue to the top of the agenda if it does something aggressive to restrict abortion.”

The outlines of the brewing showdown came further into focus Tuesday as Becerra faced opposition from a number of Republicans on the Senate health committee on the first of two days of confirmation hearings.

“For many of us, your record has been … very extreme,” Sen. Mike Braun (R-Ind.) told Becerra at the hearing, accusing him of being “against pro-life.” More than three dozen groups opposed to abortion rights have urged the Senate to reject Becerra, who has been a longtime advocate of abortion rights and federal support for contraceptives.

By contrast, Becerra has drawn strong support from abortion rights groups, which have applauded his efforts challenging Trump restrictions on family planning services. “He will be a great partner,” said Alexis McGill Johnson, president of the Planned Parenthood Federation of America.

Becerra, whose wife, Dr. Carolina Reyes, is an obstetrician, is scheduled to appear before the Senate Finance Committee on Wednesday, after which his nomination is expected to move to the floor or the Senate for consideration by the whole body.

Successive presidential administrations since the 1980s have restricted or expanded federal support for family planning, depending on which party controlled the White House.

But tensions between the two sides intensified under President Donald Trump, making the task before Biden and Becerra that much more delicate.

Trump, who relied heavily on political backing from religious conservatives, moved more aggressively than his GOP predecessors to curtail access to abortion and clamp down on federal funding for clinics that provide reproductive care.

Organizations such as Planned Parenthood that long received federal money through the half-century-old Title X program were forced out of it when the Trump administration effectively barred recipients of federal aid from providing abortions or counseling women about the procedure.

That, in turn, led to widespread cutbacks at clinics across the country and huge drops in the number of people able to get family planning services, according to health care providers.

“We’re seeing so many fewer clients,” said Brenda Thomas, chief executive of Arizona Family Health Partnership, which coordinates the state’s Title X program. Thomas said the number of patients in Arizona’s program dropped 24% in 2019 after the Trump administration issued the new rules and declined an additional 40% in 2020, as the covid-19 pandemic further hampered services.

In Missouri, a provider operating three family planning clinics left the program, leading to a 14% decrease in patients getting services through Title X, according to the Missouri Family Health Council.

And in California, the Title X restrictions led to a 40% reduction in patients in 2019, said Lisa Matsubara, general counsel at Planned Parenthood Affiliates of California.

Like many other family planning advocates, Matsubara said Biden needs to do more than just reverse the cuts. “We don’t want to just, like, go back to what it was before the Trump administration,” she said. “We’re really looking and hoping that the administration really takes the necessary steps to expand access.”

Biden has pledged to rewrite the family planning regulations so clinics providing reproductive health services can return to the program.

Within days of taking office, Biden issued an executive order to reverse other family planning restrictions imposed by the last administration, including rescinding the so-called global gag rule that prevented international aid groups that receive U.S. funding from counseling pregnant patients about abortion.

Rolling back some federal policies, like the restrictions on international aid, are relatively simple. Biden and Becerra likely also could quickly reverse Trump-era restrictions on mifepristone, a pill used to induce abortion early in a pregnancy.

But rewriting rules on funding for family planning or reissuing other complex regulations could be considerably more fraught, experts say.

“Both sides have really learned how to maximize use of courts,” said Alina Salganicoff, who directs women’s health policy at KFF, a health policy nonprofit. (KHN is an editorially independent program of KFF.) 

“If anyone understands the legal challenges, it’s Becerra,” Salganicoff said. “But these are thorny issues. There are questions about how the Biden administration can move forward and how fast. And there’s no question they are going to be sued.”

After taking office, Biden said his administration would review the Title X restrictions, which are also under review by the Supreme Court.

As California attorney general, Becerra sued to stop the Trump administration rules. The case was rejected by lower federal courts, though a separate lawsuit in Maryland challenging the rules was successful, setting up the case for the Supreme Court.

Last month, the court issued its first abortion-related decision since Trump appointee Amy Coney Barrett replaced Ruth Bader Ginsburg, upholding a Trump-era rule that blocked mail delivery of mifepristone. 

Many legal experts see more substantial court fights on the horizon as conservative-leaning states pass increasingly restrictive abortion laws.

Just last week, South Carolina Gov. Henry McMaster, a Republican, signed a bill barring abortions as soon as a fetal heartbeat can be detected with ultrasound, or about five or six weeks after a pregnancy begins.

The South Carolina law was temporarily blocked by a federal judge after Planned Parenthood filed a lawsuit. 

The Supreme Court has never upheld a law as restrictive as South Carolina’s. But the high court is the most conservative it has been in decades, raising the prospect that justices may reconsider the landmark 1973 Roe v. Wade decision, which recognized the right to an abortion.

That could force Biden — and potentially Becerra — to step much more directly into efforts in Congress to safeguard abortion rights, said Ziegler, the Florida law professor.

“There will be huge pressure on the Biden administration to do big, bold things,” she said. 

Lessons From California Prison Where Covid ‘Spread Like Wildfire’

When news of the pandemic first reached the men incarcerated at Avenal State Prison in central California, inmate Ed Welker said the prevailing mood was panic. “We were like, ‘Yeah, it’s going to come in here and it’s going to spread like wildfire and we’re all going to get it,’” he said. “And that’s exactly what happened.”

Almost a year later, 94% of Avenal’s incarcerated men have contracted covid-19 and eight have died. With more than 3,600 confirmed cases among prisoners and staff members, the facility tops the list of the country’s largest covid clusters in prisons compiled by The New York Times and the UCLA Covid-19 Behind Bars Data Project.

Calling the prison system’s response to the pandemic “nonchalant,” “incompetent” and at times “negligent,” Welker and his fellow inmates described a crowded and dangerous living situation. Inmates interviewed by Valley Public Radio said physical distancing was nearly impossible, and constant moves in and out of quarantine were confusing and disruptive. The postponement of visits and rehabilitative programs left the men with little opportunity to vent their frustrations.

“It’s chaos over here, man,” said John Walker, 50, an inmate interviewed via the prison system’s collect-calling service during the fall surge in cases. “That’s why the mental health program’s blowing up.”

Similar grievances have been voiced by prisoners across the country, who have contracted the virus at a rate more than three times that of the general population, according to an analysis by The Associated Press and the Marshall Project, a nonprofit newsroom dedicated to the U.S. criminal justice system. Lawsuits and criminal justice advocates detail a pandemic response in prisons and jails that has ranged from careless to egregious.

California’s prison authority denies many of these men’s claims and instead points to the long list of precautions the agency has adopted since the pandemic began. Dana Simas, press secretary at the California Department of Corrections and Rehabilitation, wrote in an email that state and Avenal officials “are continuously working with public health and health care experts to address this unprecedented pandemic and protect those who live and work in our state prisons.”

The virus continues to devastate prison populations and employees. Despite a dramatic drop in new infections since the holidays, more than 15,000 inmates nationwide have contracted the virus in the past three weeks, according to the Marshall Project. California’s facilities serve as a case study in which outbreaks recur while prison advocates argue that officials failed to enact a critical precaution: relieving overcrowding.

“There has not been the political will to do what’s necessary to keep people safe, which is to dramatically reduce prison and jail populations,” said Aaron Littman, a teaching fellow at UCLA School of Law and deputy director of the COVID-19 Behind Bars Data Project.

With more than 3,600 confirmed cases among inmates and staff members, Avenal State Prison has the country’s largest covid-19 clusters of any prison. (California Department of Corrections and Rehabilitation)
Protesters gather outside Avenal State Prison on June 6, 2020. At this prison in Central California, 94% of the incarcerated men have contracted covid-19 and eight have died. (Michelle Tran)

Early in the pandemic, corrections agencies across the country put in place measures to prevent outbreaks, mandating masks and physical distancing, setting aside housing units specifically for quarantined inmates, and establishing testing protocols for staffers and the incarcerated.

“The measures are important, the measures help … but those are not sufficient,” said Littman.

Horrific errors occurred. In late May, for instance, a transfer of a handful of inmates later discovered to have been covid-positive sparked an outbreak that killed 29 people and infected 2,600 others at San Quentin State Prison in Northern California.

Decision-makers disagree about what’s safe. At Avenal, as in all of California’s prisons, labor contracts permit guards to work different shifts in different buildings, despite the fact that many academic experts and the Centers for Disease Control and Prevention discourage the practice.

The public health director of Kings County, where Avenal is located, tried to order the prison to temporarily freeze staff assignments in May, but the state prison authority politely informed him the county has no jurisdiction over a state-run facility. “The response to us was, ‘Well, because of labor agreements, we can’t do that,’” said Kings County Supervisor Craig Pedersen. “It was one of the most frustrating interactions we had, I think, in this process.”

Workplace culture may also undermine well-intentioned precautions. In a review published in October, California’s Office of the Inspector General, the state prison watchdog, reported that staff members failed to properly wear masks at two-thirds of the prisons it inspected. The report concluded lax enforcement was to blame.

landscape of prison facility situated beside a lakeThe second-largest cluster of covid-19 cases in the nation is also in Kings County, California, at the California Substance Abuse Treatment Facility and State Prison in Corcoran, California. (California Department of Corrections and Rehabilitation)(California Department of Corrections and Rehabilitation)

Still, like Littman, many advocates and academics say preventive measures can accomplish little in such tightly packed environments. “Our review of the evidence indicates that relieving population pressures in jails, prisons, and detention centers greatly facilitates adherence to CDC guidelines, controlling COVID-19 outbreaks, and reducing health risks, particularly for medically vulnerable people,” members of the National Academies of Sciences, Engineering, and Medicine wrote in an October report. “Smaller populations make it easier for correctional officials to place individuals in single cells, have sufficient resources for testing, and safely quarantine individuals after exposure to an infected person.”

When the pandemic began, 1.5 million inmates were housed in roughly 1,900 state and federal prisons, many of which were not just crowded but overcrowded. California’s prisons were stuffed with an average of 30% more inmates than they were designed to house. Avenal’s occupancy was nearly 50% beyond capacity.

Since March, the state corrections department has granted early releases to 19,000 inmates due to medical and other circumstances, but a federal judge argued it hasn’t been enough. “I have cajoled, begged and pleaded with the governor and the secretary to release a very significantly higher number of inmates beyond their current release efforts,” U.S. District Judge Jon Tigar said during a January hearing for an ongoing court case regarding medical care within the state’s prisons. “With all appreciation for the efforts they have made, those requests have fallen on deaf ears.”

It’s not just the incarcerated who are contracting covid at alarming rates. Throughout the country, nearly 103,000 prison employees have tested positive for the virus and 184 have died, a sum that doesn’t begin to account for the infections transmitted beyond prison walls to families and communities.

“It’s a huge concern,” said Jeff Garner, executive director of the nonprofit Kings Community Action Organization in rural Kings County, where three state prisons provide jobs for more than 4,300 people. “The prisons are a huge employer in our county. Whether it’s employees or clients, it’s kind of like those six degrees of separation.”

Just 40 miles from Avenal, on the other side of this agricultural county in the San Joaquin Valley, is the California Substance Abuse Treatment Facility and State Prison, Corcoran, ranked by The New York Times as the country’s second-largest cluster of covid in prison. Kings County health officials have not responded to multiple requests for comment about how these two prison outbreaks have contributed to community transmission of the virus.

a dozen or so people hold bright colored signs to protest covid cases in prisonProtesters gather outside Avenal State Prison on June 6, 2020. At this prison in Central California, 94% of the incarcerated men have contracted covid-19 and eight have died.(Colby Lenz)

Could the arrival of the vaccines finally put a stop to covid in prisons? In December, nearly 500 academics and public health experts signed a letter to the CDC calling for prisoners and correctional employees to receive priority access. At least nine states included incarcerated people in the first tier of vaccination plans, while 15 included prison staffers, according to the Prison Policy Initiative, a research organization that studies mass incarceration.

California began offering vaccines to medically vulnerable inmates at a limited number of facilities in December. By mid-February, the state had vaccinated close to 35,800 inmates and 24,900 correctional staffers.

Ed Welker, 58, hasn’t been offered a vaccine yet, but he said he’s not interested. Despite the 63 million doses that have already been shot into American arms, he’s wary of long-term side effects — and he also feels that, at Avenal, the vaccine is obsolete. “For this particular population, I think it’s a waste of time and money, because everybody here for the most part has had” covid, he said.

Although Welker said many inmates share his views, they appear to be in a minority: In a recent court filing, state officials reported that more than two-thirds of incarcerated people who’ve been offered the vaccine have accepted it.

Still, Welker argues that getting vaccinated, like masking and physical distancing, is a moral imperative for correctional staffers, who could bring the virus back to the prison. “They signed up for this,” he said. “It’s their job to protect us.”

Kerry Klein is a reporter with Valley Public Radio.

This story is from a reporting partnership that includes Valley Public RadioNPR and KHN, an editorially independent program of KFF.

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

New Single-Payer Bill Intensifies Newsom’s Political Peril

SACRAMENTO — A group of Democratic state lawmakers introduced legislation Friday to create a single-payer health care system to cover all Californians, immediately defining the biggest health policy debate of the year and putting enormous political pressure on Gov. Gavin Newsom.

The Democratic governor faces the increasingly likely prospect of a Republican-driven recall election later this year. The single-payer bill adds to his political peril from the left if he doesn’t express support, and from the right if he does.

State Assembly member Ash Kalra, author of AB 1400, said the coronavirus pandemic has exposed a broken health care system that has left millions without reliable and affordable health coverage. His bill would address those gaps in the system, he said, effectively eliminating private health insurance by shifting responsibility for administering and financing health coverage to the state government.

The new system, called CalCare, would expand coverage to nearly 3 million uninsured Californians and provide rich benefits, including dental care, generous prescription drug coverage and long-term care, according to the bill language, which was obtained by California Healthline before the measure was introduced.

The move, however, faces monumental financial and legal barriers, and would likely require new taxes. While the measure does not assign a price tag to the overhaul, a separate single-payer bill that failed in 2017 would have cost an estimated $400 billion each year.

“People are dying and suffering. They’re going bankrupt and starting GoFundMe pages just in order to survive in the wealthiest state in the wealthiest nation on earth,” said Kalra, a liberal Democrat from San Jose. “We now have a Democratic White House, and forward-thinking Democrats like Xavier Becerra going to Washington who can be incredibly helpful.”

Nearly 20 other Assembly Democrats signed on to the legislation, which is among the first state-based single-payer proposals to be introduced under the Biden administration. Massachusetts lawmakers this year introduced similar legislation, and other states are considering it.

Sponsored by the California Nurses Association, a powerful union and political force in Sacramento, the single-payer bill is expected to ignite a fierce health care fight among liberal and moderate Democratic lawmakers, and draw intense opposition from deep-pocketed health industry groups, including insurers, doctors and hospitals.

“Eliminating private health coverage in California will always be unworkable for a number of reasons. It would cost $400 billion a year, which we can’t afford,” said Ned Wigglesworth, spokesperson for Californians Against the Costly Disruption of our Healthcare, which includes major private health insurers and the state doctor and hospital lobbying groups, which also opposed the 2017 single-payer bill.

“Shifting to an entirely government-based health system would be especially harmful and disruptive now, as California’s health care community is focused on meeting the acute health care needs of our state during a pandemic,” Wigglesworth added.

Assembly member Jim Wood (D-Santa Rosa), who as chair of the Assembly Health Committee controls which health policy legislation gets a hearing, cast doubt on the feasibility of single-payer late last year, saying the state should instead build on the Affordable Care Act. Supporters fear his potential opposition could block the bill.

California’s proposal, if approved, could test the Biden administration’s willingness to grant states freedom to enact sweeping health care reforms such as a single-payer system. Becerra, California’s attorney general, has expressed unwavering support for single-payer and would be positioned to weigh in on the plan should he be confirmed as President Joe Biden’s Health and Human Services secretary. Becerra’s Senate confirmation hearings start Tuesday.

“The president himself doesn’t necessarily have to support single-payer on a national level to allow states to move forward,” Kalra said.

The introduction of a single-payer proposal this year forces Newsom into a delicate position. The first-term governor, who said he supported the creation of a state-based single-payer health care system when he ran for governor in 2018, has since distanced himself, expressing doubt that California can embark on such a massive transformation on its own.

Newsom’s office did not respond to a request for comment.

Newsom, once seen as a rising Democratic Party star, faces a burgeoning recall effort driven by state and national Republicans. The embattled governor is under fire for a clumsy and confusing vaccine rollout; backlogs and fraud at the state’s unemployment agency; and violating his own public health rules when he dined maskless last year at the ritzy French Laundry restaurant. Democrats have also criticized the governor for his pandemic response, including his inability to reach a legislative deal to open schools to in-person instruction.

With the March 17 deadline looming for the recall to qualify for the ballot, Newsom will undoubtedly be asked to weigh in on the single-payer proposal.

“It’s not a factor in this calculation,” said Stephanie Roberson, lead lobbyist with the California Nurses Association, which campaigned for Newsom during his gubernatorial run. “Our concern is people are dying and losing their health care. We’re sorry if this parallels some untimely political event for the governor.”

Last year, Newsom convened a commission to study the possibility of a single-payer system and other ways to cover more Californians. But the pandemic stalled its progress and the commission hasn’t met since August.

The exorbitant cost of developing a new system is a major hurdle. In 2017, the last time California lawmakers floated a single-payer proposal, a state legislative analysis pegged the projected cost at $400 billion a year. Assembly Speaker Anthony Rendon shelved the proposal, calling it “woefully incomplete,” in part because it was unveiled without a financing mechanism.

Kalra, who has not identified a way to pay for the massive transformation and said he’s unsure whether it would require higher taxes, will undoubtedly face similar skepticism over how to fund it.

His bill calls for CalCare to cover comprehensive health services far beyond what’s required under the Affordable Care Act, including traditional medical services, dental care, prescription drug coverage, long-term care, and mental health and substance use treatment.

It would also end all out-of-pocket patient costs — including premiums, copays and deductibles — and ban health care providers participating in CalCare from operating in the private marketplace. CalCare’s governing board would determine health care prices and set rules for providers.

While single-payer would require a significant initial investment, Kalra argued, the state might be able to reroute federal dollars for Medicare, Medicaid and other programs into CalCare. The system would also eventually cost less, he said, because it would simplify health care financing, end for-profit care and cut out private middlemen.

“Look, we’re already paying more than $400 billion a year for our current system,” Kalra said. “We currently have the most expensive health care system in the world, and our outcomes certainly don’t get us what we pay for.”

The latest estimates, based on federal data, show health care spending in California is about $450 billion a year, according to Gerald Kominski, a professor of health policy and management at the UCLA Fielding School of Public Health.

But switching to single-payer isn’t as simple as transferring those expenses to a new system, he said. Somehow, the money that employers and employees contribute to private health insurance plans needs to be funneled into a unified system.

“The mechanism you use to do that is almost certainly some form of taxation,” Kominski said. “It’s literally impossible for a single-payer system to move forward without capturing those current expenditures. They’re too substantial.”

While the proposal would not ban all private health insurance, it would allow only for coverage that supplements CalCare. The aim is to enroll all Californians, eliminating the need for private health coverage, said Carmen Comsti, a regulatory policy specialist with the California Nurses Association who is also on the state’s single-payer commission.

But that could present enormous challenges. Nearly 6 million Californians are enrolled in private health coverage regulated by the federal government. Enrolling them in CalCare could require a change in federal regulatory law, and would likely require changes to the state constitution — which, in addition to passing tax increases, could force single-payer backers to obtain voter approval.

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

Companies Pan for Marketing Gold in Vaccines

For a decade, Jennifer Crow has taken care of her elderly parents, who have multiple sclerosis. After her father had a stroke in December, the family got serious in its conversations with a retirement community — and learned that one service it offered was covid-19 vaccination.

“They mentioned it like it was an amenity, like ‘We have a swimming pool and a vaccination program,’” said Crow, a librarian in southern Maryland. “It was definitely appealing to me.” Vaccines, she felt, would help ease her concerns about whether a congregate living situation would be safe for her parents, and for her to visit them; she has lupus, an autoimmune condition.

As the coronavirus death toll soars and demand for the covid vaccines dwarfs supply, an army of hospitals, clinics, pharmacies and long-term care facilities has been tasked with getting shots into arms. Some are also using that role to attract new business — the latest reminder that health care, even amid a global pandemic, is a commercial endeavor where some see opportunities to be seized.

“Most private sector companies distributing vaccines are motivated by the public health imperative. At some point, their DNA also kicks in,” said Roberta Clarke, associate professor emeritus of marketing at Boston University.

Among senior living facilities — which saw their largest drop in occupancy on record last year — some companies are marketing vaccinations to recruit residents. Sarah Ordover, owner of Assisted Living Locators Los Angeles, a referral agency, said many in her area are offering vaccines “as a sweetener” to prospective residents, sometimes if they agree to move in before a scheduled vaccination clinic.

Oakmont Senior Living, a high-end retirement community chain with 34 locations, primarily in California, has advertised “exclusive access” to the vaccines via social media and email. A call to action on social media reads: “Reserve your apartment home now to schedule your Vaccine Clinic appointment!”

Although the vaccine offer was a selling point for Crow, it wasn’t for her parents, who have not been concerned about contracting covid and didn’t want to forgo their independence, she said. Ultimately, they moved in with her sister, who could arrange home care services.

This marketing approach might sway others. Oakmont Senior Living, based in Irvine, reported 92 move-ins across its communities last month, a 13% increase from January 2020, noting the vaccine is “just one factor among many” in deciding to become a resident.

But some object to facilities using vaccines as a marketing tool. “I think it’s unethical,” said Dr. Michael Carome, director of health research at consumer advocacy group Public Citizen. While he believes that facilities should provide vaccines to residents, he fears attaching strings to a vaccine could coerce seniors, who are particularly vulnerable and desperate for vaccines, into signing a lease.

Tony Chicotel, staff attorney at California Advocates for Nursing Home Reform, worries that seniors and their families could make less informed decisions when incentivized to sign by a certain date. “You’re thinking, ‘I’ve got to get moved in in the next week or otherwise I don’t get this shot. I don’t have time to read everything in this 38-page contract,’” he said.

An Oakmont Senior Living advertisement touts access to covid vaccines to attract new residents.(Oakmont Management Group)

Oakmont Senior Living responded by email: “Potential residents and their families are always provided with the information they need to be confident in a decision to choose Oakmont.”

Some people say facilities are simply meeting their demand for covid vaccines. “Who is going to put an elderly person in a place without a vaccine? Congregate living has been a hotbed of the virus,” said retired philanthropy consultant Patti Patrizi. She and her son recently chose a retirement community in Los Angeles for her ex-husband for myriad reasons unrelated to the vaccines. However, they accelerated the move by two weeks to coincide with a vaccination clinic.

“It was definitely not a marketing tool to me,” said Patrizi. “It was my insistence that he needs it before he can live there.”

The concept of using vaccines to market a business isn’t new. The 2009 H1N1 pandemic ushered in drugstore flu shots, and pharmacies have since credited flu vaccines with boosting storefront sales and prescriptions. Many offer prospective vaccine recipients coupons, gift cards or rewards points.

A few pharmacies have continued these marketing activities while rolling out covid shots. On its covid vaccine information site, CVS Pharmacy encouraged visitors to sign up for its rewards program to earn credits for vaccinations. Supermarket and pharmacy chain Albertsons and its subsidiaries have a button on their covid vaccine information sites saying, “Transfer your prescription.”

But the pandemic isn’t business as usual, said Alison Taylor, a business ethics professor at New York University. “This is a public health emergency,” she said. Companies distributing covid vaccines should ask themselves “How can we get society to herd immunity faster?” rather than “How many customers can I sign up?” she said.

In an email response, CVS said it had removed the reference to its rewards program from its covid vaccination page. Patients will not earn rewards for receiving a covid shot at its pharmacies, the company said, and its focus remains on administering the vaccines.

Albertsons said via email that its covid vaccine information pages are intended to be a one-stop resource, and information about additional services is at the very bottom of these pages.

Boston University’s Clarke doesn’t see any harm in these marketing activities. “As long as the patient is free to say ‘no, thank you,’ and doesn’t think they’ll be penalized by not getting a vaccine, it’s not a problem,” she said.

At least one health care provider is offering complimentary services to people eligible for covid vaccines. Membership-based primary care provider One Medical — now inoculating people in several states, including California — offers a free 90-day membership to groups, such as people 75 and older, that a local health department has tasked the company with vaccinating, according to an email from a company spokesperson who noted that vaccine supply and eligibility requirements vary by county.

The company said it offers the membership — which entails online vaccine appointment booking, second dose reminders and on-demand telehealth visits for acute questions — because it believes it can and should do so, especially when many are struggling to access care.

While these may very well be the company’s motives, a free trial is also a marketing tactic, said Silicon Valley health technology investor Dr. Bob Kocher. Whether it’s Costco or One Medical, any company offering a free sample hopes recipients buy the product, he said.

Offering free trial memberships could pay off for providers like One Medical, he said; local health departments can refer many patients, and converting a portion of vaccine recipients into members could offer a cheaper way for providers to get new patients than finding them on their own.

“Normally, there’s no free stuff at a provider, and you have to be sick to try health care. This is a pretty unique circumstance,” said Kocher, who doesn’t see boosting public health and taking advantage of an uncommon marketing opportunity as mutually exclusive here. “Vaccination is a super valuable way to help people,” he said. “A free trial is also a great way to market your service.”

One Medical insisted the membership trial is not a marketing ploy, noting that the company is not collecting credit card information during registration or auto-enrolling trial participants into paid memberships. But patients will receive an email notifying them before their trial ends, with an invitation to sign up for membership, said the company.

Health equity advocates say more attention needs to be paid to the people who slip under the radar of marketers — yet are at the highest risk of getting and dying from covid, and the least likely to be vaccinated.

Kathryn Stebner, an elder-abuse attorney in San Francisco, noted that the high cost of many assisted living facilities is often prohibitive for the working class and people of color. “African Americans are dying [from covid] at a rate three times as much as white people,” she said. “Are they getting these vaccine offers?”

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

California Aims to Address the ‘Urgent’ Needs of Older Residents. But Will Its Plan Work?

Even as the pandemic derailed some of Gov. Gavin Newsom’s biggest health care proposals, such as lowering prescription drug costs, it crystallized another: the pressing need to address California’s rapidly aging population.

Already nine months into their work when Newsom issued the nation’s first statewide stay-at-home order last March, members of a state task force on aging watched as the coronavirus disproportionately sickened and killed older people, and left many isolated in nursing homes, assisted living facilities and their own homes.

“In many ways, it just accelerated and made more urgent that work,” said Kim McCoy Wade, director of California’s Department of Aging, who led the task force.

The group’s work culminated in the release last month of a 10-year “Master Plan for Aging,” a blueprint intended to guide state and local governments, the private sector and charitable organizations to improve housing, health care, caregiving, equity and affordability for California’s older residents.

The state’s existing system of programs and services can be confusing for seniors who must navigate a disconnected patchwork of public and private offerings. If they’re able to find a program that fits their needs, it’s often too costly for anyone other than low-income Medi-Cal recipients, whose participation is covered by public funding.

McCoy Wade hopes the state’s Master Plan website will serve as a destination for Californians looking for programs or support, much as the First 5 website is for caregivers of young children.

But right now, the site mostly lists scores of ideas, such as creating a variety of affordable housing options for Californians, improving public transit, expanding geriatric care, redesigning nursing homes to be smaller and more home-like, improving broadband access and expanding telehealth.

That broad, holistic approach to health care is needed to help the state’s aging population, said Dr. Sarita Mohanty, president and CEO of The SCAN Foundation, which advocates for older people. (Kaiser Health News, which publishes California Healthline, receives support for its coverage of aging and long-term care issues from The SCAN Foundation.)

The number of Californians age 60 and older is projected to grow to about 11 million by 2030, accounting for one-quarter of the state’s population. In 2019, that group made up roughly one-fifth of the state’s population, according to U.S. Census data.

“We can’t be reactive. We have to be extremely proactive,” said Mohanty, an internist. “It’s not just about health care; it’s about health and communities.”

But will the plan end up gathering dust on a shelf, as have so many other government reports? McCoy Wade pledged that won’t happen, pointing to an online dashboard that tracks the administration’s progress implementing the plan’s proposals through the state budget, the legislature and in communities.

There is already momentum. The administration has pledged to embark on more than 100 initiatives in the next two years, McCoy Wade said. In his proposed 2021-22 state budget, Newsom has asked for $250 million to buy and rehabilitate assisted living facilities for homeless seniors, and his administration is working with the federal government to determine how Californians can continue to use telehealth medicine after the pandemic.

McCoy Wade talked to California Healthline about why Newsom issued an executive order to create the plan, why it is so important for Californians and some ways to move it forward. The interview has been edited for length and clarity.

Q: Why does California need a Master Plan for Aging?

The executive order was really driven by the demographic change that we’re living longer, we’re having multiple stages of aging, and aging is diversifying.

Are you living in a single-family home that entire 30, 40, 50 years? Are you working perhaps longer, are you volunteering longer, are you living with three, four or five generations in one house? Are you living alone because your spouse, your friends and your peers may have died? That has been one of the “aha” moments but also one of the challenges: How do you plan for aging when it is so diverse?

Q: The Master Plan offers a blueprint for the next 10 years, but what are some proposals that can be tackled in the next few years?

In this pandemic, we learned a lot. It’s important that people can stay in the home they choose but also have services accessible to them. For middle-class people, Medicare doesn’t pay for the services people need, so you see the governor proposing a new Office of Medicare Innovation and Integration to help more Californians.

As we age, there are a couple of things that can be really helpful: taking care of housecleaning, taking care of shopping, taking care of cooking. We can retrofit houses to prevent falls. I think there’s a real recognition that we have to expand the ability for middle-class folks to afford and have access to services and supports.

Home and health go together at all ages. But as you age, in particular, and for the older adults who are not homeowners, keeping up with rent, keeping up with the house itself, really becomes a risk to health. How do we make sure there are affordable housing options?

You see the governor’s budget proposal for $250 million to purchase residential living facilities and dedicate them to older adults who either are at risk of homelessness or are homeless.

Q: What are some of the long-term goals?

The big issue for all of California is affordability. The governor has unveiled strategies around more housing, more housing, more housing and a range of housing in terms of families living together, caregivers living together, and affordable housing options. Older adults could either stay in the main house or move to a smaller unit. It just creates a whole lot of opportunities for those different ages and stages.

Getting health care costs and housing costs and care costs — the expense side of the ledger — down is incredibly helpful. But, the income has to somehow keep up to provide basic needs and basic quality of life. The SSI/SSP program is a top priority of our stakeholders, and there is a commitment to try to start walking that back up towards the federal poverty line and to begin to increase it in 2023. There’s a widespread recognition it is not keeping up with the cost of living, much less the federal poverty line.

Q: You say many older Californians have a hard time paying for the help and services they need as they age. Is it just too expensive?

“Expensive” feels like not a shocking enough word. In community forums, people cry about spending down their savings and their kids’ savings and they’re going bankrupt. It’s not hundreds of dollars. It’s in the five figures a month.

Q: How did the pandemic affect what you included in the plan?

We pivoted to check-in campaigns to call people and check in at home because we knew there were challenges around isolation or gaps in services. That check-in campaign was manual, list by list. So, one of the things we want to look at is how do we create more preregistration, more automated systems. All this calling and lists should not be a one-time thing, and, sadly, in California we need it for wildfires. Now we need it for vaccines. We may need it in an earthquake.

This pandemic had just a devastating impact on Black and Latino and South Pacific Islander communities. The catch line for the Master Plan became that equity is baked in; it’s not kind of the last paragraph. So, language access has become much more essential. Our department is doing a plan on diversifying our hiring and all the commission appointments. We just really need to do better.

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

Vaccines Go Mobile to Keep Seniors From Slipping Through the Cracks

ANTIOCH, Calif. — A mobile “strike team” is bringing vaccines to some of Northern California’s most vulnerable residents along with a message: This is how you avoid dying from covid-19.

So far, that message has been met with both nervous acceptance and outbursts of joy from a population that has been ravaged by the disease. One 68-year-old pastor, who lives in a racially diverse, low-income senior housing complex, rolled down his sleeve after his shot and said he wants to live to see 70 — just to spite the government.

The team of county nurses and nonprofit workers is targeting Contra Costa County residents who are eligible for covid vaccines but have been left out: residents of small assisted-living facilities that haven’t yet been visited by CVS or Walgreens, and occasionally people who live in low-income senior housing. The retail pharmacy giants have a federal government contract to administer vaccines in most long-term care facilities.

Launched a few weeks ago, the strike team moves through each vaccination clinic with practiced choreography. At a small group home in Antioch recently, a nurse filled syringes while another person readied vaccine cards and laid them on a table. An administrative assistant — hired specifically for these clinics — checked everyone’s paperwork and screened them for symptoms and allergies before their shots, logging them into the state’s database afterward. After the shots, a strike team member told each person when their 15 minutes of observation was up.

The mobile strike team in Contra Costa County pulls up to a senior apartment complex in Richmond, California. Its members tote a special cooler to keep vaccines cold, syringes, bandages and a roll of “just vaccinated” stickers. (Rachel Bluth/KHN)

In a little over an hour, 14 people had a shot in their arm, a card in their hand and their data in the system. Nurses wiped down the chairs and tables and packed up supplies.

As the state vaccination plan moves past long-term care facilities and on to the next group, deploying mobile units will help prevent eligible people in small facilities from being left behind, said Dr. Mike Wasserman, past president of the California Association of Long Term Care Medicine.

“The assisted living side has been our greatest tragedy,” Wasserman said. “It’s February. We’re vaccinating others already and we haven’t finished vaccinating those who need it most.”

California is in the midst of transferring primary control of vaccine distribution from local public health departments to Blue Shield of California. The agreement between the state and the insurance company includes incentives for vaccinating underserved and minority populations, and like Contra Costa, Los Angeles, Kern and other counties are creating mobile clinics to reach vulnerable residents.

But as efficiently as these clinics can run, it’s still slow going to vaccinate a few people at a time in a state that has lost more than 44,500 people to covid.

Small long-term care facilities, usually with no more than six beds, are the strike team’s main target. These “six-beds” are a major source of residential care for older Californians, as well as others who need care and supervision but don’t want to live in nursing homes. Of almost 310,000 long-term care beds in California, about one-third are in nursing homes, according to Nicole Howell, executive director for Ombudsman Services of Contra Costa, Solano and Alameda counties. Two-thirds are in some form of assisted living, mostly six-beds.

In the converted garage of a six-bed long-term care facility in Antioch, California, public health nurses ready doses of covid vaccine for staffers and residents. Once the vials are pulled from the freezer, the nurses have six hours to administer doses before they expire. Alarms on the nurses’ phones ring each hour, indicating it’s time to log the temperature of the cooler. (Rachel Bluth/KHN)

These homes are typically in residential areas, with little to distinguish them from other houses on a suburban block. They’re small businesses, often owned by families, that offer a “social” model of care, not a medical one. There is no doctor or director of nursing on staff.

Long-term care residents were in line to be vaccinated right after front-line health workers, starting in nursing homes. Theoretically, residents of small facilities like six-beds should get their shots from the same federal program vaccinating most nursing homes, which is administered through CVS and Walgreens.

But it’s difficult to coordinate with these homes because there are so many, Howell explained, and they often have fewer resources and minimal IT infrastructure. Because these aren’t large corporate chains or 500-bed facilities with everyone’s medical records on hand, it takes time and local knowledge to reach them all, she said.

Catherine Harris, 72, gets her first dose of covid vaccine in the community room of a low-income senior housing complex in Richmond, California. She got her shot from a mobile vaccine team that visits Contra Costa County’s vulnerable residents. (Rachel Bluth/KHN)

CVS and Walgreens said they have administered first and second doses to nearly all nursing home residents in the state and have started on assisted living communities. They said they do not have breakdowns of which kinds of assisted living facilities they have visited, but CVS Health spokesperson Joe Goode noted that the pharmacy has completed the first round of doses at nearly 80% of participating assisted living facilities, with hundreds more clinics scheduled.

The state has largely left it up to facilities to call the pharmacies to schedule clinics, though many did not know it was their responsibility until late January, according to Mike Dark, a lawyer with California Advocates for Nursing Home Reform. He had been fielding calls for weeks from families who were told that, if they wanted to get their loved ones in six-bed homes vaccinated, they needed to figure it out themselves, he said.

“Smaller assisted living facilities, the ones least equipped to deal with this virus, still house people with significant impairment and needs,” Dark said. “It’s been a scandal, really, how poorly this process has been going.”

Robert Ellison, 86, receives his vaccine card during a vaccine clinic at his low-income apartment building in Richmond, California. He and William Patterson, 83, spent their 15-minute post-vaccination observation period out on the patio. (Rachel Bluth/KHN)

The residents at Above All Care, a six-bed in Orange County, finally got their first shots on Feb. 4, according to owner Nicolas Oudinot. But that came after weeks of confusion and silence.

“From November to mid-January, I had no information,” Oudinot said. “I went from nothing to getting a call every day. They tried to schedule the same facility two or three times.”

In late December, when it became clear that many long-term care facilities wouldn’t get clinics scheduled for months, Contra Costa County decided the federal program needed to be supplemented with local resources, said Dr. Chris Farnitano, the county health officer.

“This is where we’re seeing the most dying happening,” Farnitano said. “These are the most vulnerable people. We’ve got to protect them sooner.”

The mobile vaccine strike team emerged from a collaboration among the county, local home health agencies, advocates for long-term care residents and nonprofit groups. It was created without additional public funding when Choice in Aging, a local nonprofit that provides community-based support to older residents, paid its own administrative workers to staff the clinics alongside county public health nurses.

The team of five or six people heads out several days a week, hauling rolling carts packed with syringes, bandages and a special vaccine cooler. The team might spend one day vaccinating 100 people in six-bed and other small facilities for older people or those with disabilities. The next, it might visit 50 seniors and their caregivers gathered from a few low-income apartments.

Christina Ponce, a public health nurse for Contra Costa County, fills syringes with the Pfizer-BioNTech vaccine. She can almost always squeeze six doses out of each vial. (Rachel Bluth/KHN)

The vaccines are treated like a precious resource. Nothing goes to waste and there’s a list of caregivers on standby if the team finds itself with extra shots. Nurses say they can almost always squeeze a sixth dose of what they call “liquid gold” out of the vials, intended to contain five.

When defrosted vials aren’t in the cooler, they’re carried gingerly, sandwiched between two egg cartons so they don’t tip or break. Often, the team’s biggest problem is running too far ahead of schedule.

Its efforts seem to be working: 810 people in 50 facilities had been vaccinated as of Tuesday.

Choice in Aging CEO Debbie Toth said she originally got into this line of work to give people a choice of where to spend their last years. But the pandemic has given her work new urgency: saving lives.

“These are people who would die” if they got covid, she said. “We have an opportunity to make sure they don’t. That’s our north star.”

California Healthline correspondent Angela Hart contributed to this report.

New Scan Finds Prostate Cancer Cells Hiding in the Body

New Scan Finds Prostate Cancer Cells Hiding in the Body

The test seems likely to improve the diagnosis and treatment of a disease that kills 33,000 American men each year.

Dr. Mark Samberg, a retired urologist in Sacramento, learned his cancer had spread beyond his prostate with a new scan that finds radioactively tagged cancer cells in the body. 
Dr. Mark Samberg, a retired urologist in Sacramento, learned his cancer had spread beyond his prostate with a new scan that finds radioactively tagged cancer cells in the body. Credit…Max Whittaker for The New York Times
Gina Kolata

  • Dec. 16, 2020, 2:08 p.m. ET

After doctors found cancer in Dr. Mark Samberg’s prostate last spring, the 70-year-old retired urologist prepared to have his prostate removed. He knew that the surgery would cure him, assuming the cancer was confined to the organ.

But his doctors had a nagging concern — the cancer cells seen on the biopsy were aggressive and may already have escaped from his prostate. If so, the operation would not cure him. The problem for Dr. Samberg, and for many men with aggressive prostate cancer, was this: If there are cancer cells outside the prostate, how can they be found?

Now the Food and Drug Administration has approved a test that can locate prostate cancer cells wherever they are. Exuberant cancer specialists said the test would alter treatment for patients nationwide.

“It’s the most exciting thing in prostate cancer in my lifetime,” said Dr. Kirsten Greene, chair of the urology department at the University of Virginia School of Medicine.

The test relies on a radioactive tag attached to a molecule that homes in on prostate cancer cells that have spread to other locations in the body and may seed new tumors. Once tagged, the clusters of cells appear as bright spots on PET scans.

At the moment, the F.D.A.’s approval applies only to testing at the University of California, San Francisco, and the University of California, Los Angeles, which conducted clinical trials. But several companies hope to market similar tests soon.

“It’s absolutely fabulous,” said Dr. Oliver Sartor, professor of medicine at Tulane University School of Medicine. When he learned that the test had been approved, he said, he danced in his office “and had a toast of imaginary champagne.”

Now specialists are hoping to use the technique to kill cancer cells, not just find them. The idea is to attach a radioactive drug to the molecule that seeks out prostate cancer cells. The molecule will deliver the drug directly to those cells and, it is hoped, the radiation will destroy the cancer. Experiments already have begun at U.C.S.F. and U.C.L.A.

The road to the new test has been long. Nearly 30 years ago, researchers discovered that prostate cancer cells carry a unique protein on their surfaces called prostate specific membrane antigen, or P.S.M.A. More recently, researchers found small molecules that could home in on P.S.M.A.

Scientists theorized that radioactive tracers attached to those molecules could make prostate cancer cells visible on PET scans. In 2010, researchers at the University of Heidelberg in Germany published the first images of prostate cancer cells located in this way.

Over the past four years, studies involving about 1,000 patients by Dr. Jeremie Calais, a nuclear medicine physician at U.C.L.A., and Dr. Thomas Hope, a nuclear medicine physician at U.C.S.F., showed that the scan accurately detected prostate cancer cells anywhere in the body before treatment and even after treatment, when cancer may recur.

The research led to changes in treatment for most patients, including decisions to recommend targeted radiation, guided by the scans, rather than chemotherapy or androgen-blocking therapy, treatments that impact the entire body.

Dr. Hope described two situations in which the PET scans can transform treatment decisions.

Most men learn they have prostate cancer when a simple blood test finds high levels of prostate specific antigen, or P.S.A. The next step is a biopsy of the prostate and removal of cancer cells for examination to see how aggressive they appear.

Men often have MRI scans to see if the capsule surrounding the prostate has been breached — a sign the cancer has gotten out. And doctors consider how high P.S.A. levels are. The higher they are, the more cancer in the body and the more likely it has spread.

The second scenario occurs after a man has had his prostate removed or destroyed by radiation. If the patient’s P.S.A. levels start to rise months or years later, the cancer that doctors thought they had cured had already seeded itself elsewhere in the man’s body.

In both situations, “we know they have disease, but we don’t know where it is,” Dr. Hope said. The new scan seems able to show doctors where to look. The researchers are now conducting studies to see if these treatment revisions ultimately prolong patients’ lives.

Dr. Samberg, who lives in Sacramento, was one of the participants in the U.C.S.F. trial. Before his scheduled prostatectomy, the scan turned up cancerous cells in his bones and lymph nodes. “That was shocking,” he said.

Without the new test, the doctors would have removed Dr. Samberg’s prostate, and they would have realized he still had cancer when his P.S.A. levels began to rise. In such a case, doctors usually irradiate the area where the prostate used to be — the prostate bed, which is the site of remaining cancers a bit more than half the time.

For Dr. Samberg, that procedure, like the prostatectomy, would not have helped. “Standard therapy for me would fail,” he said. Instead, the discovery that his cancer was in his bones and lymph nodes pointed to targeted radiation therapy, hormonal therapy and, most recently, immunotherapy.

“I am in complete remission,” Dr. Samberg said. “I hope it makes a difference long term.”

Sweetgreen Makes Healthful Fast Food — But Can You Afford It?

Photo

Employees work the line at Sweetgreen, a chain restaurant that uses fresh ingredients from local farms to make fast food healthier, in Berkeley, Calif.

Employees work the line at Sweetgreen, a chain restaurant that uses fresh ingredients from local farms to make fast food healthier, in Berkeley, Calif.Credit Jason Henry for The New York Times

Healthful, fast and affordable food is the holy grail of the public health and nutrition community. A popular restaurant chain shows just how much of a challenge that is.

It began when three Georgetown University students were frustrated that they could not find a healthy fast-food restaurant near their campus. With money raised from family and friends, they started their own, renting a small storefront on M Street in Georgetown. The result was Sweetgreen, a restaurant that offered organic salads, wraps and frozen yogurt. Pretty soon, the daily line of lunchtime customers stretched out the door and around the corner.

Ten years later, the line is still there, but Sweetgreen has grown into a nationwide salad chain, with more than 40 locations. Sweetgreen is part of a small but growing breed of farm-to-table fast-food chains – like Chopt Creative Salad Company on the East Coast and Tender Greens in California – that are giving fast-food restaurants a plant-based makeover. Their mission: to fix fast food, which has long been fattening and heavily processed.

Photo

At Sweetgreen, fresh vegetables, cheeses and other ingredients are shipped directly to each restaurant from nearby farms and then chopped or cooked on site.

At Sweetgreen, fresh vegetables, cheeses and other ingredients are shipped directly to each restaurant from nearby farms and then chopped or cooked on site.Credit Jason Henry for The New York Times

Sweetgreen’s owners say their goal is to offer customers foods made with nutritious, sustainable and locally grown ingredients. The company has decentralized its food sourcing and production. Fresh vegetables, cheeses and other ingredients are shipped directly to each restaurant from nearby farms and then chopped or cooked on site. They don’t sell soda or use refined sugar.
Sweetgreen expects to open another 20 stores in major cities around the country this year, and eventually to expand to places where experts say healthy, delicious fast food is needed most — low-income neighborhoods.

But while the chain has proven there is a big appetite for more healthful fast food, the goal of taking this concept to poor areas may be a distant reality. The company and other chains like it operate almost exclusively in affluent communities, far from the low-income food deserts where obesity is rampant and farmers’ markets and healthy food stores are scarce. And with salads that typically cost between $9 and $14, some question whether a healthful fast-food chain like Sweetgreen can ever be affordable for average Americans.

Maegan George, a Columbia University student who lives near a Sweetgreen, calculated that for the price of one Sweetgreen salad, she could buy the same ingredients in bulk at a local market and make several similar salads at home.

“I’m a first-generation student and I’m on full financial aid,” she said. “Sweetgreen is delicious and I enjoy it. But there’s no way I could afford to eat there on a regular basis.”

Jackie Hajdenberg, another Columbia student, wrote about the restaurant for the campus newspaper, The Spectator, earlier this year, lamenting that on a per calorie basis, a salad at Sweetgreen was three times the price of a Big Mac at McDonald’s.

“Sweetgreen has not only made it easier for people to make healthy decisions – it has also illustrated the unequal socioeconomic landscape of the world in which we live,” she wrote.

Photo

Salad options at Sweetgreen change often, depending on what is available at local farms.

Salad options at Sweetgreen change often, depending on what is available at local farms.Credit Jason Henry for The New York Times

Sweetgreen says it prices its food so that it can compensate its suppliers and employees fairly, and that it expects nutritious fast food to become more affordable as the healthy food movement grows. Nicolas Jammet, a co-founder of Sweetgreen, said the company wants to serve lower-income customers, and has long-term plans to expand to low-income communities.

To get there, he said, the company will have to overcome hurdles involving its supply chain, the minimum wage and greater nutrition awareness and education among the public. For the past six years the company has been running a nutrition education program in schools that teaches children about healthier eating and locally grown food.

“It’s a long-term goal for us to be part of this larger systematic change that needs to happen,” he said. “But there are so many parts of this problem that need to be addressed.”

Mr. Jammet notes that the company was among the first to show that fast-food chains don’t need profits from soda and sugary drinks to succeed. He believes chains like Sweetgreen have caused a ripple effect throughout the fast-food industry.

In January, for example, Chick-fil-A unveiled a new kale, broccolini and nut “superfood” salad, responding to customer demands for “new tastes and healthier ways to eat in our restaurants.” McDonald’s is experimenting with kale salads, and Wendy’s is testing a spinach, chicken and quinoa salad.

“Companies like McDonald’s have more power to change the way that people eat than we do,” Mr. Jammet said. “We don’t see these companies as the enemy. We just have to force change on them.”

Public health experts say that such changes cannot come soon enough. A University of Toronto study recently showed that people have a higher risk of developing diabetes if they live in “food swamps” – an area with three or more fast-food restaurants and no healthy dining options.

Another study published in JAMA in June found that the percentage of Americans eating an unhealthy diet — high in sugar, refined grains, soft drinks and processed foods and low in fruits and vegetables — was on the decline, but the improvements in diet were much smaller for lower-income Americans.

Photo

Customers wait in line at Sweetgreen in Berkeley, Calif.

Customers wait in line at Sweetgreen in Berkeley, Calif.Credit Jason Henry for The New York Times

Overall about twice as many people from poor households have poor diets compared to those at higher income levels.
Why is traditional fast food so cheap? One reason is the underlying infrastructure of the industry. Many of the ingredients, like the soy that’s turned into oil for deep fryers, or the the corn that’s fed to animals and used to make high-fructose corn syrup, begin with crops that are heavily subsidized by the government. To make their food economical, many traditional fast-food chains mass-produce their food in large factories, often stripping it of fiber and other nutrients that decrease its shelf life, while adding salt, sugar and other flavorings and preservatives.

Then they freeze and ship the processed components, like burger patties, bread, pickles and sauce, to their restaurants. There they are reheated and assembled, often with minimal effort, ensuring that a Big Mac in Seattle looks and tastes the same as a Big Mac in Charlotte, N.C.

By comparison, every Sweetgreen location has a chalkboard that lists the farms where its organic arugula, peaches, yogurt or blueberries are produced. As a result, the menus vary by location and by season. In Boston, Sweetgreen stores use New England Hubbard squash. In Los Angeles, the menu features a different variety of squash grown locally in California.

Those differences mean fresher, more nutritious ingredients, but ultimately costlier food for customers — one of the obstacles that Sweetgreen and other chains like it will have to overcome if they hope to make their food more accessible to all income brackets.
Marion Nestle, a professor of nutrition, food studies and public health at New York University and the author of “Food Politics,’’ says restaurants like Sweetgreen offer an encouraging, but imperfect, model for making fast food more healthful.

“What’s not to like?” she asks. “The cost, maybe, but for people who can afford it the quality is worth it. Next step: Moving the concept into low-income areas.”

Related: