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Contratar a un “ejército” diverso para rastrear COVID-19 durante la reapertura

Como rastreadora de contactos, a Teresa Ayala-Castillo a veces le preguntan si los tés de hierbas y el Vicks VapoRub pueden tratar a COVID-19.

Estas terapias no son exactamente una guía oficial de salud, pero Ayala-Castillo no se sorprende. Escucha y luego sugiere otras ideas, como descansar y beber mucho líquido.

“No quiero decirles que son cuentos, porque estos remedios son cosas con las que estoy 100% familiarizada ya que mi mamá los usó conmigo”, dijo Ayala-Castillo, una ecuatoriana-estadounidense bilingüe, de primera generación, que trabaja para la ciudad de Long Beach, California.

Los departamentos de salud de los Estados Unidos trabajan a un ritmo frenético para dotar de personal a sus “ejércitos” de rastreadores de contactos para controlar la propagación del coronavirus que causa COVID-19.

Los expertos estiman que los departamentos de salud locales y estatales tendrán que agregar entre 100.000 y 300.000 personas para que la economía vuelva a funcionar.

Mientras organizan estos grupos, muchos estados y localidades quieren contratar a personas de minorías raciales y étnicas más afectadas por el virus. Entienden la necesidad de contar con rastreadores capacitados y culturalmente competentes que puedan convertir a contactos desconfiados o renuentes en participantes entusiastas en la campaña para erradicar el virus.

Las actividades de rastreo del virus varían según el estado. La mayoría han creado planes para añadir rastreadores de contactos mediante la contratación o el voluntariado, pero los más ricos —incluidos California, Connecticut, Massachusetts, Nueva Jersey, Nueva York y Washington— llevan ventaja, aseguró Marcus Plescia, director médico de la Asociación de Funcionarios de Salud Estatales y Territoriales.

Delaware, cuya meta es comenzar las contrataciones en un mes, dará prioridad a personas de comunidades vulnerables y que sean bilingües. Y Minnesota contrata personal con cuotas de diversidad que coinciden con la demografía de los casos de COVID-19 del estado.

“No hay una fórmula mágica que asegure el éxito de esa llamada y establezca una conversación productiva”, señaló Chris Elvrum, del Departamento de Salud de Minnesota. “Tenemos que entender que existen diferentes maneras de abordar el tema para las diferentes comunidades”.

El rastreo de la enfermedad funciona así: luego que alguien da positivo para COVID-19, un investigador del departamento de salud local llama al paciente para hacerle preguntas específicas sobre su salud, sus movimientos y con quién interactuó durante un cierto período de tiempo.

Luego, un rastreador llama a las personas identificadas por el paciente para hacerles saber que estuvieron potencialmente expuestos al virus. A estos contactos se les pide permanecer en casa por 14 días. Si viven con otras personas, la recomendación puede extenderse a esos individuos.

Si se siguen las órdenes de permanecer en casa, resulta relativamente fácil averiguar quién puede haber estado expuesto a la enfermedad, dicen funcionarios de salud.

Las personas infectadas por lo general sólo han estado con familiares o amigos cercanos y a menudo advierten a los contactos que esperen una llamada del departamento de salud, explicó Emily Holman, quien maneja el área enfermedades contagiosas de Long Beach.

Pero en algunos casos se puede requerir la presencia de trabajadores de campo, indicó la doctora Kara Odom Walker, secretaria del Departamento de Salud y Servicios Sociales de Delaware.

“Hay algunas comunidades que no van a responder a una llamada telefónica, a un mensaje de texto o a una carta”, dijo Walker. “Eso podría deberse a una falta de cultura de la salud, al miedo, o al estatus migratorio”.

Hasta ahora, la mayoría sigue las instrucciones, aseguran los funcionarios. Holman estima que menos del 1% de los contactados en Long Beach se negaron a participar.

Pero surgen problemas, especialmente entre quienes no pueden trabajar desde casa o son el único sustento de sus hijos, apuntó Elvrum.

Las personas notificadas sobre su contacto con alguien con COVID pueden pensar que la llamada es parte de un fraude, o preocuparse de que la información sea compartida con las autoridades de inmigración o que les cueste su trabajo.

Los departamentos de salud no tienen que entregar la información recopilada con fines médicos a las autoridades federales de inmigración, pero se necesita un rastreador de contactos sensible, empático y conocedor de la cultura para explicar esto.

“Necesitas a alguien que sea un agente cultural para decir, no sólo que estas medidas son para protegerte, sino para decir que confíes en mí y que todo irá bien”, comentó Walker. “Yo voy a asegurarme personalmente de que tienes lo que necesitas para una cuarentena segura”.

Teresa Ayala-Castillo, quien ha trabajado para la ciudad de Long Beach durante 20 años, fue supervisora de facturación antes de ser reasignada para localizar a los pacientes con COVID-19 en marzo. Ella dice que su experiencia como ecuatoriana estadounidense de primera generación ayuda a las personas a sentirse a gusto con ella por teléfono. (Cortesía de Teresa Ayala-Castillo)

Minnesota pondrá a 1,400 empleados a trabajar en la localización de contactos para julio, informó Elvrum. Los contratos estipulan que buscan a personas de grupos raciales y étnicos proporcionales a su número en el estado o al porcentaje de casos positivos de COVID-19 en esos grupos. Lo que sea más alto.

Se contrata a personas que hablen hmong, somalí y español, según Kou Thao, quien dirige el Centro para la Equidad en la Salud del Departamento de Salud de Minnesota.

Un 23% de los casos positivos del estado se registran entre personas de raza negra, que constituye sólo el 7% de la población total del estado. Los hispanos constituyen el 19% de los casos y el 6% de la población. Sin embargo, alrededor del 22% de los casos son desconocidos.

Virginia, que cuenta con 200 rastreadores de contactos y espera contratar un total de 1,300 empleados para apoyar el esfuerzo, busca personas que hablen de mandarín, criollo haitiano, español y bengalí, según Mona Bector, comisionada del Departamento de Salud del estado.

Virginia ha recibido más de 6,000 curriculums para estos puestos, dijo Bector.

Long Beach se enorgullece de una fuerza laboral diversa que refleja la población de la ciudad. Los funcionarios sacaron a sus rastreadores de contactos e intérpretes, incluyendo a Ayala-Castillo, de los miembros del personal municipal que hablan samoano, jemer, tagalo, español, vietnamita, mandarín y otros idiomas para crear una plantilla de 60 personas. Su objetivo es tener 200 personas entrenadas y listas para ser desplegadas cuando sea necesario.

Tener trabajadores que puedan hablar con los contactos en el idioma que prefieran es un paso importante, expresó Crystal Watson, del Centro de Seguridad Sanitaria de Johns Hopkins. Ser capaz de extraer información mientras se es sensible a las preocupaciones y desconfianzas de los pacientes es primordial, añadió.

El sargento Jairo Paulino, de 38 años, miembro de la Guardia Nacional de Delaware, es uno de los militares bilingües que se ofrecen a ayudar con las llamadas a los contactos de COVID-19. Cuando empezó el trabajo a mediados de mayo, notó que había un “gran atraso” en la lista de nombres porque el estado no tenía suficientes hispanohablantes para contactarlos a todos con rapidez.

Paulino nació en la República Dominicana y llegó a Nueva York de niño. Creció traduciendo para su padre y asistiendo a la iglesia; ambas referencias ayudan a construir la confianza en la comunidad latina, dijo.

El escaso acceso a Internet también plantea un desafío. En Tulare, un condado rural en el centro de California, los trabajadores de la salud piden a los pacientes que utilicen un portal en línea para ayudar a agilizar la recopilación de datos de sus contactos. Sin embargo, entre el 5% y el 10% de las personas no pueden conectarse a Internet, explicó Tiffany Swarthout, del departamento de salud del condado. En esos casos, los trabajadores de la salud hablarán con el paciente por teléfono.

Las preocupaciones laborales representan otra área de dificultad para los rastreadores de contactos. Algunas personas son reacias a quedarse en casa porque no tienen ingresos, especialmente si la pandemia ha dejado a miembros de la familia sin trabajo, señaló Jody Menick, una enfermera que supervisa la localización de contactos en el condado de Montgomery, Maryland, en las afueras de Washington, D.C.

Algunos empleadores solicitan pruebas de que los pacientes y sus contactos pueden regresar con seguridad después de la cuarentena, y algunas jurisdicciones proporcionan cartas oficiales que especifican el período de cuarentena del trabajador.

Pero los trabajadores indocumentados, que cuentan con menos protecciones que los empleados con estatus legal, han sido presionados para que se presenten a trabajar, contó Menick, poniéndoles en una situación muy difícil.

“¿Voy a conseguir dinero para comprar comida para mi familia, o me voy a quedar en casa?”

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California Noticias En Español Public Health States

Hiring A Diverse Army To Track COVID-19 Amid Reopening

As a contact tracer, Teresa Ayala-Castillo is sometimes asked whether herbal teas and Vicks VapoRub can treat COVID-19. These therapies aren’t exactly official health guidance, but Ayala-Castillo isn’t fazed. She listens and then suggests other ideas — like getting rest and drinking plenty of fluids.

“I don’t want to call them old wives’ tales, but these remedies are things that I’m 100% familiar with because my mom used them on me,” said Ayala-Castillo, a bilingual first-generation Ecuadorian American who works for the city of Long Beach, California.

Health departments across the U.S. are working at a furious pace to staff their armies of contact tracers to control the spread of the coronavirus that causes COVID-19. Experts estimate local and state health departments will have to add 100,000 to 300,000 people to get the economy back on track.

As they build these forces, many states and localities are trying hard to hire from the racial and ethnic minority communities hit hardest by the virus. They’re anticipating a need for skilled, culturally competent tracers who can convert suspicious or hesitant contacts into enthusiastic, willing participants in the drive to stamp out the virus.

Virus-tracking activities vary by state. Most states have created plans to add contact tracers through hiring or volunteering, but wealthier ones — including California, Connecticut, Massachusetts, New Jersey, New York and Washington — are further along than others, said Marcus Plescia, chief medical officer of the Association of State and Territorial Health Officials.

Delaware, which aims to begin hiring in a month, plans to prioritize hires from vulnerable communities with bilingual language skills. Minnesota is hammering out staffing contracts with diversity quotas that match the demographics of the state’s COVID-19 cases.

“One size does not fit all for making that first call and being successful in having them pick up the phone and have a good conversation,” said Chris Elvrum, a deputy incident manager at the Minnesota Department of Health. “We need to recognize that we have to approach it in different ways for different cultural communities in the state.”

Tracking the disease works like this: After someone tests positive for COVID-19, a case investigator from the local health department calls the patient to ask detailed questions about her health, movements and whom she interacted with over a certain time frame. A contact tracer then calls everyone the patient named to let them know they were potentially exposed to the virus. These contacts are instructed to stay home and self-quarantine for 14 days after the exposure. If they live with other people, the recommendation may extend to those individuals.

Under stay-at-home orders, it’s often relatively easy to figure out who may have been exposed to the disease, health officials say. Infected people usually have been around only family or close friends and will often warn contacts to expect a call from the health department, said Emily Holman, communicable disease controller for Long Beach.

But shoe-leather fieldworkers may be required in some instances, said Dr. Kara Odom Walker, secretary of the Delaware Department of Health and Social Services. “There are some communities that aren’t going to respond to a phone call, a text message or a letter,” said Walker. “That could be due to health literacy issues, which could be due to fear, or documentation status.”

So far, most people are following instructions, say officials. Holman estimates that fewer than 1% of those contacted in Long Beach refused to participate.

Teresa Ayala-Castillo, who has worked for the city of Long Beach for 20 years, was a billing supervisor before being reassigned to contact tracing for COVID-19 patients in March. She says her background as a first-generation Ecuadorian American helps people feel at ease with her on the phone. (Courtesy of Teresa Ayala-Castillo)

But some defiance is likely, especially among those who cannot work from home or are the only provider for their children, Elvrum said. People being notified about contacts with a COVID-positive patient might think the call is a scam, or worry the information will be shared with immigration authorities or cost them their job. Health departments do not have to turn information collected for medical purposes over to federal immigration enforcement, but it takes a sensitive, empathetic and knowledgeable contact tracer to explain this.

“You need someone to be a cultural broker to say, not only are these policies in place to protect you, but I’m telling you to trust me that this will be OK,” Walker said. “I’m going to make sure you have what you need to safely quarantine.”

Minnesota plans to dedicate 1,400 staffers to contact tracing by July, Elvrum said. Contracts with two companies involved in the hiring stipulate that they bring on people of racial and ethnic groups proportional to their numbers in the state or the percentage of positive COVID-19 cases in those groups — whichever is higher.

They’re seeking hires who speak Hmong, Somali and Spanish, said Kou Thao, director of the Center for Health Equity in the Minnesota Department of Health.

About 23% of the state’s positive cases are among black people, who make up only 7% of the state population. Hispanics make up 19% of cases — and 6% of the population. However, about 22% of the cases are unknown.

Virginia, which has 200 contact tracers and hopes to hire a total of 1,300 staff to support the effort, is looking for speakers of Mandarin, Haitian Creole, Spanish and Bengali, said Mona Bector, deputy commissioner for administration at the Virginia Department of Health.

The state has received more than 6,000 résumés for these positions, Bector said.

Long Beach prides itself on a diverse workforce that reflects the city’s population. Officials pulled their contact tracers and interpreters, including Ayala-Castillo, from municipal staff members who speak Samoan, Khmer, Tagalog, Spanish, Vietnamese, Mandarin and other languages to create a staff of 60. Their goal is to have 200 people trained and ready to deploy as needed.

Having workers who can speak to contacts in the language they prefer is a step forward, said Crystal Watson, a senior scholar from the Johns Hopkins Center for Health Security. Being able to extract information while being sensitive to patients’ concerns and mistrust is paramount, she added.

Sgt. Jairo Paulino, a 38-year-old member of the Delaware National Guard, is one of several bilingual guardsmen volunteering to help call COVID-19 contacts. When he started the job in mid-May, he noticed there was a “major backlog” of names because the state didn’t have enough Spanish speakers to reach out to everyone quickly.

Paulino was born in the Dominican Republic and moved to New York as a boy. He grew up translating for his father and attending church — both elements that help build trust in the Latino community, he said.

Poor access to the internet also poses a challenge. In Tulare, a rural county in central California, health workers ask patients to use an online portal to help streamline data collection of their contacts. However, 5% to 10% of people cannot get online, said Tiffany Swarthout, an administrative specialist at the county health department. In those cases, health workers will speak to the patient on the phone.

Employment concerns represent another tricky area for contact tracers. Some people they reach out to may hesitate to stay home because they are strapped for cash, especially if the pandemic has left members of the family without work, said Jody Menick, a nurse who supervises contact tracing in Montgomery County, Maryland, just outside Washington, D.C.

Some employers are requesting proof that patients and contacts were safe to return after quarantine, and some areas provide official letters that specify the worker’s quarantine period.

But undocumented workers — who have fewer protections than employees with legal status — have been pressured to show up to work in her area, Menick said, leaving them with a difficult decision.

“Am I going to have money to buy food for my family, or am I going to stay home?”

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California Public Health States

California AG Seeks More Power To Battle Merger-Hungry Health Care Chains

California’s health care industry has a consolidation problem.

Independent physician practices, outpatient clinics and hospitals are merging or getting gobbled up by private equity firms or large health care systems. A single company can dominate an entire community, and in some cases, vast swaths of the state.

Such dominance can inflate prices, and consumers end up facing higher insurance premiums, more expensive outpatient services and bigger out-of-pocket costs to see specialists.

Now that COVID-19 has slammed the health care industry, especially the small practices that are barely seeing patients, the trend is likely to accelerate.

“I don’t see anything that’s going to stop this wave of consolidations amongst docs,” said Glenn Melnick, a health care economist at the University of Southern California.

“If this thing goes on a long time,” he said of the coronavirus, “then it becomes a tsunami.”

California Attorney General Xavier Becerra has made battling health care consolidation a signature issue since he took office in 2017. With the additional pressure that COVID-19 is putting on vulnerable practices and facilities, Becerra is now pressing the state legislature to expand his authority to slow health care mergers.

“We find that in these times of crisis, economic and health crisis, that the smaller health care players and stakeholders are oftentimes most at risk of being swallowed up by the big fish,” Becerra told California Healthline.

His success would fundamentally change how the health care industry merges and grows in California.

When a health care system, private equity firm or hedge fund plans to merge with or acquire another practice or facility — whether that means buying a small practice or joining a multistate hospital chain — Becerra wants to know about it. He wants written notice, and the ability to deny any sale that doesn’t deliver better access, cost or quality health care to Californians.

Becerra already can regulate mergers among nonprofit health care facilities. Under SB-977, a collaboration between Becerra’s office and the legislature, he would get the ability to regulate the for-profit sector as well.

“Certainly it would put California where it’s accustomed to being,” Becerra said. “At the head of the pack.”

The bill has support from organized labor and consumer advocacy groups. Gov. Gavin Newsom has come out against health care consolidation in the past but hasn’t taken an official stance on the bill.

Yet Becerra isn’t convinced passage will be smooth.

“The biggest concern I have is the legislation will be killed by the industry,” he said. “We’ll end up seeing over-consolidation because decent practices that got on the edge could not swim with sharks.”

Indeed, health care industry players are already lining up against the bill. Alex Hawthorne, a lobbyist for the California Hospital Association, said that hospitals are stretched thin because of the pandemic, and that now isn’t the time for Becerra to be meddling in routine agreements between practices.

“It bestows absolute and arbitrary discretion on the office of the attorney general,” Hawthorne said at a budget hearing in May.

In 2010, about 25% of California physicians worked in a practice owned by a hospital. By 2016, more than 40% of doctors worked in hospital-owned practices, according to research published in the journal Health Affairs in 2018.

There’s evidence that consolidation can hurt consumers. A separate 2018 study found that the cost of medical procedures in highly consolidated Northern California was 20% to 30% higher than in Southern California.

Since 2018, California’s attorney general has had the authority to regulate mergers among nonprofit health care systems, which Becerra exercised the same year when considering a merger between two health care giants: Dignity Health and Catholic Health Initiatives. He said he would approve the deal only if the systems agreed to certain requirements, such as starting a homelessness program.

Later that year, Becerra joined a suit against Sutter Health for using its market power to drive up health care costs in Northern California.

The lawsuit alleged that Sutter, which has 24 hospitals and 34 surgery centers, had spent years buying up practices and facilities, giving insurers little choice but to include them in their networks and agree to higher rates for services.

In October 2019, Becerra secured a $575 million settlement against Sutter, which has yet to be finalized or paid out, that requires Sutter to change how it charges insurance companies and give patients more information about prices.

Sutter Health opposes SB-977, which was introduced in February by state Sen. Bill Monning (D-Carmel). The measure is intended to address some of the challenges Becerra encountered with the Sutter case, Becerra said.

“The best way to prevent problems from occurring in a merger is just to prevent the merger altogether,” said Jaime King, associate dean at UC Hastings College of the Law in San Francisco. “It’s really hard to unwind a merger after you’ve already done it.”

Under the measure, the attorney general must be notified before a system, hedge fund or private equity firm attempts to enter into a merger, acquisition or another kind of affiliation change with another practice or facility. The bill defines a health care system as one with two or more hospitals in multiple counties, or three or more hospitals within one county.

That would trigger a public review process allowing supporters and opponents to make their cases to a review board. The board would assess the transaction, using criteria to determine whether it would improve access, quality and price.

The bill also would make it illegal for systems to act anti-competitively and give the attorney general the power to bring a civil suit against monopolistic systems.

The Senate Health Committee approved the bill, which is expected to be heard in another committee this week.

“Maybe it does mean consolidation should occur, but only because we’ve done the oversight to make sure it’s because of quality and access,” Becerra said. “Not because a big fish wants to make bigger profit.”

The measure includes waivers for rural practices and a fast-track review process for transactions under $500,000.

The California Chamber of Commerce opposes the bill, as does the California Medical Association, which represents doctors. While the California Medical Association is concerned about the survival of small physician practices, it believes the bill is too broad and should focus more tightly on hospital consolidation, said spokesperson Anthony York.

“This approach will only further force smaller providers out of business,” especially as the health systems respond to the COVID-19 emergency, the group’s legislative advocate, Amy Durbin, wrote in a letter of opposition.

For many independent practices struggling for survival, the debate over Becerra’s powers is academic.

Dr. Sarah Azad, who owns a women’s health practice in Mountain View, California, said at least three independent practices in her area have started the process to merge or sell since March because of dramatically lower patient volume.

Her practice is fine for now, despite the fact that her patient volume was only about 30% of normal in March and 60% of normal in April. Azad received a loan from the federal Paycheck Protection Program for small businesses so she could pay her five doctors in May.

“If you catch me on a bad month, I feel like we’re one disaster away from bankruptcy,” Azad said.

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

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California Health Industry

Por qué los recortes en salud perjudican siempre a los californianos más vulnerables

Shirley Madden, de 83 años, depende de un cuidador y de sus dos hijas para seguir viviendo en casa, y no en una residencia.

Sus hijas, Carrie, de 55 años, y Kristy Madden, de 60, usan sillas de ruedas y necesitan un segundo cuidador que las ayude en su vida diaria.

Pero ese apoyo crítico para el cuidado, además de otros beneficios de atención médica para millones de californianos, podrían reducirse para ayudar a cubrir el enorme déficit presupuestario provocado por el coronavirus.

El gobernador de California, Gavin Newsom, ha propuesto recortes presupuestarios drásticos a los programas de salud pública, incluyendo Medi-Cal, el programa de Medicaid de California para personas de bajos ingresos, cuando se espera un aumento de inscripciones debido a la pérdida récord de empleos por culpa de la pandemia.

Los expertos temen que estos recortes puedan poner en peligro los miles de millones de dólares en fondos federales de emergencia para la salud asignados a California.

“Entiendo que hay una pandemia y que la situación es mala y que todo el mundo sufre”, dijo Carrie Madden de Chatsworth, California. Carrie y su hermana padecen distrofia muscular y su madre ha sobrevivido a un ataque al corazón mientras lucha contra la demencia.

Los temores de Madden se ven agravados por la crisis de COVID-19, que ha afectado con más fuerza a los mayores y a quienes tienen enfermedades crónicas. No quiere que su madre, su hermana o ella misma terminen en una residencia o en cualquier centro de cuidados a largo plazo, que son los lugares con más brotes.

“Este es el enfoque equivocado”, señaló. “Hará que las personas discapacitadas terminen en residencias para mayores”.

En todo el país, los estados consideran recortes a Medicaid para equilibrar sus presupuestos. En parte porque la salud suele ser la mayor parte del gasto estatal, después de la educación.

También proyectan que más gente se inscribirá en el programa de salud pública, a medida que el número de estadounidenses desempleados alcance niveles astronómicos. Más de 20 millones de estadounidenses solicitaron el subsidio de desempleo en abril, elevando la tasa de personas sin trabajo al 14,7%, la peor desde la Gran Depresión de la década de 1930.

Nueva York aprobó recortes a Medicaid que entrarán en vigor cuando termine la emergencia federal, mientras que Georgia ha dado instrucciones a todas sus agencias para reducir el gasto en un 14%.

En California, donde casi 2,9 millones de personas han solicitado el desempleo en los últimos dos meses, Newsom describió los recortes propuestos como “prudentes” y “estratégicos”, un giro enorme a los grandes planes que dio a conocer a principios de este año para ampliar la atención médica a algunos de los residentes más necesitados.

Para hacer frente a un déficit estimado de $54 mil millones en el presupuesto estatal 2020-21, Newsom propone un recorte de $205 millones —una reducción del 7% en las horas de los cuidadores— al programa de Servicios de Apoyo en el Hogar del que dependen los Maddens.

El programa, financiado principalmente por Medi-Cal, paga a los cuidadores para dar de comer a las personas que necesitan ayuda para vivir de forma independiente, lavar su ropa, bañarlos, administrarles tratamientos médicos y mantener su hogar limpio.

La lista de los otros recortes es larga: reducirá o eliminará programas que permiten a los mayores de bajos ingresos y a los discapacitados vivir en su propio hogar, como la atención médica diurna y el apoyo de los trabajadores sociales.

Propone facilitar al estado el cobro del pago póstumo de los fallecidos, mayores de 55 años, y afiliados a Medi-Cal, por una amplia gama de gastos médicos a través del controvertido “Programa de Recuperación de Bienes“. Sugiere que se reinstauren requisitos de ingresos más estrictos para que algunas personas mayores y las que tengan discapacidades puedan tener derecho a Medi-Cal gratuito.

Y ha pedido a los legisladores que eliminen $54,7 millones en beneficios “opcionales” de Medi-Cal, como la atención de podología para adultos, gafas, terapia del habla y exámenes de audición; beneficios que los mismos legisladores restauraron recientemente después de recortarlos durante la última recesión.

“No son beneficios opcionales para una persona que ha sufrido un derrame cerebral o necesita dientes para comer”, explicó Tricia Berke Vinson, una abogada de la Sociedad de Ayuda Legal del condado de San Mateo.

“Entiendo que estamos en una crisis presupuestaria”, añadió. “Pero no creo que se pueda equilibrar a costa de adultos mayores y enfermos”.

Médicos, dentistas y otros proveedores de atención de salud que tratan a pacientes de Medi-Cal también podrían perder $1,200 millones en pagos suplementarios que se derivan de la Propuesta 56, un impuesto sobre el tabaco que los votantes aprobaron en 2016.

La propuesta del gobernador demócrata incluye un “detonante” automático para eliminar los recortes si el estado obtiene más dólares federales para la crisis de la COVID, trasladando la responsabilidad al Congreso para negociar otro paquete de estímulo.

No se sabe si los legisladores aceptarán los enormes recortes a Medi-Cal que el gobernador ha propuesto. Por ejemplo, el plan del Senado estatal preserva la financiación de Medi-Cal y supone que el Congreso aprobará otro proyecto de ley de estímulo.

Ambas cámaras de la legislatura deben llegar a un acuerdo y presentar su versión del presupuesto al gobernador antes del 15 de junio.

“Salvar estos programas es salvar vidas y ahorrar dinero”, indicó el legisador Jim Wood (demócrata de Santa Rosa), presidente del Comité de Salud de la Asamblea. “Corten estos programas y los costos aumentarán y se perderán vidas”.

Tanto los expertos como algunos legisladores temen que el enfoque de Newsom pueda poner en peligro los miles de millones de dólares, en fondos federales de emergencia para la salud, que ya están asignados a California.

Los estados que abandonan a los inscritos en Medicaid, o reducen sus beneficios, corren el riesgo de perder los pagos federales de salud adicionales autorizados por el Congreso esta primavera, expresó Edwin Park, experto en Medicaid y profesor de la Escuela McCourt de Política Pública de la Universidad de Georgetown.

“El gobierno federal ha dicho que no se puede reducir la elegibilidad ni cancelar o recortar los beneficios”, dijo Park, y señaló que los legisladores de Nueva York retrasaron los recortes de Medicaid del estado hasta después de que terminara la emergencia federal, para asegurarse de que recibirán la ayuda federal ahora.

Los Centros de Servicios de Medicare y Medicaid no respondieron a las solicitudes de comentarios. La guía publicada en su sitio web sugiere que los estados deben mantener intactos los programas de Medicaid.

Se espera que California reciba $5.1 mil millones en fondos federales adicionales para Medi-Cal hasta el 30 de junio de 2021, según el presupuesto que Newsom hizo público a mediados de mayo.

La administración Newsom no cree que los recortes presupuestarios de Medi-Cal le cuesten al estado el dinero federal adicional ya aprobado por el Congreso.

“Nunca hay una garantía hasta que hablemos con el gobierno federal. Así que hasta entonces, es difícil decir qué se va a hacer a nivel federal”, dijo Yang Lee, analista del Departamento de Finanzas del estado.

La administración Newsom calcula que unos dos millones de californianos se inscribirán en Medi-Cal para julio como resultado de la pandemia, lo que eleva la inscripción en el programa a 14.5 millones, más de un tercio de todos los californianos.

La administración estima $3,100 millones en gastos adicionales para cubrir a los nuevos inscritos. La Legislative Analyst’s Office cree que esa cifra representa un exceso de $750 millones, en parte porque los nuevos inscritos serán principalmente personas más jóvenes y saludables que no necesitan tanta atención como los mayores de bajos ingresos y las personas con discapacidades.

Para muchos de los inscritos, las propuestas de Newsom recortarían múltiples beneficios.

Cynde Soto, de 63 años, dijo que se sintió como si “alguien me hubiera dado un puñetazo en el estómago” cuando supo que el plan del gobernador recortaría el presupuesto de los Servicios de Apoyo en el Hogar. Esta residente de Long Beach, que es tetrapléjica,  teme que los recortes del estado la obliguen a ir a una residencia de mayores. Además, teme perder la atención dental y de visión de Medi-Cal si se aprueban los otros recortes de Newsom.

“Es una pesadilla. No sé qué voy a hacer”, comentó Soto. “¿Por qué siempre somos los primeros a los que golpean?”.

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‘Why Do We Always Get Hit First?’ Proposed Budget Cuts Target Vulnerable Californians

Shirley Madden, 83, relies on a caregiver and her two grown daughters to remain living at home — and not in a nursing home.

Her daughters, 55-year-old Carrie and 60-year-old Kristy Madden, both use wheelchairs and need a second caregiver to help them navigate their own daily lives.

But that critical caregiving support, along with other health care benefits for millions of Californians, could be scaled back to help plug a massive budget deficit triggered by the coronavirus.

California Gov. Gavin Newsom has proposed sweeping budget cuts to safety-net health care programs ― including Medi-Cal, California’s Medicaid program for low-income people ― just as enrollment is projected to spike because of record job losses related to the pandemic.

Health care experts also fear the cuts could jeopardize billions of dollars in emergency federal health funding allotted to California.

“I understand there’s a pandemic and it’s really bad and everybody is hurting,” said Carrie Madden of Chatsworth, California. Carrie and her sister have muscular dystrophy and their mother is a heart attack survivor who struggles with dementia.

Madden’s fears are compounded by the COVID-19 crisis, which has hit older people and those with chronic health conditions the hardest. She doesn’t want her mother, her sister or herself to end up in a nursing home or other long-term care facility — the settings with the most outbreaks of COVID-19.

“This is the wrong approach,” she said. “This will make disabled people end up in nursing homes.”

States across the country are eyeing Medicaid cuts to balance their budgets, in part because health care is usually the biggest portion of state spending, after education. They also project that more people will sign up for the public health care program, as the number of unemployed Americans hits astronomical heights. More than 20 million Americans filed for unemployment in April, raising the unemployment rate at least to 14.7%, the worst since the Great Depression of the 1930s.

New York approved Medicaid cuts that will take effect after the federal emergency ends, while Georgia has instructed all its agencies to reduce spending by 14%.

In California, where almost 2.9 million people have filed for unemployment in the past two months, Newsom described the proposed budget cuts as “prudent” and “strategic,” a huge pivot from the grand plans he unveiled earlier this year to expand health care to some of the neediest residents.

To address an estimated $54 billion deficit in the 2020-21 state budget, Newsom proposes a $205 million cut — or a 7% reduction in caregiver hours — to the In-Home Supportive Services program the Maddens rely on. The program, primarily funded by Medi-Cal, pays caregivers to make meals for people who need help to live independently, do their laundry, bathe them, administer medical treatments and keep their home clean.

The list of his other proposed cuts is lengthy: He would scale back or eliminate other programs intended to keep low-income seniors and people with disabilities in their own homes, such as adult day health care and support from social workers. He proposes to make it easier for the state to collect posthumous payback from deceased Medi-Cal enrollees 55 and older for a broad range of medical costs through the controversial “Estate Recovery Program.” He suggests reinstituting stricter income requirements for some older people and those with disabilities to qualify for free Medi-Cal.

And he is calling on lawmakers to remove $54.7 million in “optional” Medi-Cal benefits, such as adult podiatry care, eyeglasses, speech therapy and hearing exams — benefits that lawmakers recently restored after they were cut during the last recession.

“These don’t feel optional to people if they have had a stroke or need teeth to eat their food,” said Tricia Berke Vinson, an attorney with the Legal Aid Society of San Mateo County.

“I understand we are in a budget crisis,” she added. “I just don’t think it can be balanced on the old and the sick.”

Physicians, dentists and other health care providers who treat Medi-Cal patients also stand to lose $1.2 billion in supplemental Medi-Cal payments that flow from Proposition 56, a tobacco tax that voters approved in 2016.

The Democratic governor’s proposal includes an automatic “trigger” to restore the cuts if the state gets more federal COVID relief dollars, shifting the responsibility to Congress to negotiate another stimulus package.

Whether lawmakers will make the sweeping Medi-Cal cuts the governor has proposed is uncertain. For example, the state Senate plan preserves Medi-Cal funding and assumes Congress will pass another stimulus bill.

Both houses of the legislature must come to an agreement and present their version of the budget to the governor for consideration by June 15.

“Save these programs and you save lives and money,” said Assembly member Jim Wood (D-Santa Rosa), chair of the Assembly Health Committee. “Cut these programs and costs will increase and lives will be lost.”

Health care experts and some lawmakers also fear Newsom’s approach could jeopardize billions of dollars in emergency federal health funding already allotted to California.

States that drop Medicaid enrollees or reduce benefits risk losing out on additional federal health payments authorized by Congress this spring, said Edwin Park, an expert on Medicaid and a professor at Georgetown University McCourt School of Public Policy.

“The federal government has said you can’t cut eligibility or disenroll or cut benefits,” Park said. He noted that New York lawmakers delayed their state Medicaid cuts until after the federal emergency ends to ensure they still receive the added federal help now.

The Centers for Medicare & Medicaid Services did not respond to requests for comment. Guidance posted on its website suggests states must keep Medicaid programs intact.

California is expected to receive $5.1 billion in additional federal funding for Medi-Cal through June 30, 2021, according to the proposed budget Newsom released in mid-May.

The Newsom administration is not convinced its Medi-Cal budget cuts will cost the state the additional federal money already approved by Congress.

“There’s never a guarantee until we have that conversation with the federal government. So until then, it’s hard for us to tell what the fed’s going to do,” said Yang Lee, an analyst at the state Department of Finance.

Newsom’s administration predicts about 2 million Californians will sign up for Medi-Cal by July as a result of the pandemic, bringing the program’s enrollment to 14.5 million, more than one-third of all Californians.

The administration anticipates $3.1 billion in added costs to cover the new enrollees. The Legislative Analyst’s Office believes that figure is $750 million too high, in part because new sign-ups will primarily be younger and healthier individuals who do not need as much care as low-income seniors and people with disabilities.

For many current enrollees, Newsom’s proposals would cut into multiple benefits.

Cynde Soto, 63, said it felt like “someone had punched me in the gut” when she heard about the governor’s plan to cut the In-Home Supportive Services budget. As a quadriplegic, the Long Beach resident worries state cutbacks could force her into a nursing home. On top of that, she fears she might lose her Medi-Cal dental and vision care if Newsom’s other cuts are approved.

“I’ve had nightmares about it. I don’t know what I’m going to do,” Soto said. “Why do we always get hit first?”

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

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Hate Unmasked In America

“You are the most selfish f—ing people on the planet.”

I jerked my head to the left, where I saw a neighbor glaring at us from his driveway while unloading groceries from his trunk.

“Where’s your f—ing mask?” he said. “Unbelievable.”

My jaw dropped. I had just walked three blocks home with my toddler and my dad in our leafy, mostly empty Los Angeles neighborhood because my kid had thrown a tantrum in the car.

And we had forgotten our masks. Four days earlier, Mayor Eric Garcetti had ordered protective face coverings anytime we left home, not just when we entered essential businesses.

I pointed out my house to the neighbor to explain how close we were, just a few doors down from him. He cut me off.

“I don’t give a f– where you live, and I don’t give a f– what your reason is.”

Then my dad jumped in. “Sorry, sir, we forgot our masks. I’m sorry, sir.”

Still, the man didn’t soften.

“You should be sorry. And you should make her be sorry, too,” he gestured toward me. After a few more agonizing seconds, he dismissed us.

Our neighbor’s mask, by the way? It was off his face, hanging loosely around his neck. All the better to shout at us.

As a health care reporter, I had covered America’s evolution on masks as the coronavirus spread across the globe. Back in January, I wrote an article about why Chinese immigrants insisted on wearing surgical and construction masks in the U.S., even though it went against official health recommendations at the time. In February, I wrote about Asian families in California clashing with schools over whether their children should be allowed to wear masks in class.

At that time, Asian people wearing masks were targets for verbal and physical abuse. Attackers saw masks on Asian faces as signs of disease and invasion; people were punched and kicked, harassed in the supermarket, bullied at school and worse.

Now, of course, masks are the norm. And they’ve become more than just personal protection; they are symbols of courtesy and scientific buy-in. They have, to some extent, also become political signifiers. In a new poll from the Kaiser Family Foundation, 70% of Democrats said they wear a protective mask “every time” they leave their house, versus 37% of Republicans. (Kaiser Health News is an editorially independent program of KFF.)

After our verbal beatdown, my dad and I walked home stone-faced, and then retreated to our separate rooms to nurse our wounds.

I have no idea if the neighbor’s comments had a racist undertone. But it felt like the times in my childhood, first in New Zealand, then in a Bay Area suburb, when I had seen my Philippines-born parents, stunned and silent, get dressed down or humiliated by angry, callous white people. Now it was my 3-year-old daughter’s turn to see me dumbstruck. As I began telling my husband the story, I started crying so hard that I got a headache.

Marigold, 3, wore this mask for five minutes outside and then threw it away. We haven’t been able to find it since. In the background is her grandfather, Jovit Almendrala, trying his own mask out for the first time. (Courtesy of Anna Almendrala)

After my tears came reflection, and an attempt at empathy.

My neighbor was obviously scared. He was older, and potentially more medically vulnerable. His trunk had been packed with overstuffed shopping bags ― probably enough food for weeks, to avoid leaving his house.

He had just come from the grocery store, an enclosed space full of things and people that could potentially infect him. I understand the stress that comes with shopping during the pandemic.

Like many of us, my neighbor could be struggling with how to live in mortal fear of the coronavirus. And for him, at least that morning, that struggle got the better of him.

Later that day, I wrote the neighbor a card introducing ourselves. I apologized for making him feel unsafe and acknowledged that he was right about the masks. But I also said he had unfairly used us as a target for his fear and frustration, and I told him I was shocked and saddened he would treat a neighbor with so much hate. I haven’t heard back from him.

My dad spent the rest of that morning praying that the man didn’t get the coronavirus — lest he blame us and all Asians, forever.

Since that day, no one in my family has left the house without a mask on their face, and I’m anxious to train my daughter to wear one, although she resists it the way she has refused hats and headbands in the past.

We can’t stop noticing that most other exercisers and dog-walkers in our neighborhood ― all white ― fly past us without them. They don’t seem to worry about getting caught on the wrong side of whatever America happens to believe about masks on any given day. But my family can’t risk it.

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Some Ivory Towers Are Ideal For A Pandemic. Most Aren’t.

Saint Mary’s College in Moraga, California, is open for business this fall — but to get there, you really have to want it. Tucked amid verdant hills 23 miles east of San Francisco, accessible by a single road and a single entrance, the small, private Roman Catholic school receives almost no visitors by accident.

This, in the age of a pandemic, is good news indeed for its administrators.

“We can control who comes in or out in a way that larger, urban campuses perhaps can’t do,” said William Mullen, the school’s vice provost for enrollment. “Those campuses are in many cases more permeable.”

As colleges and universities across the country juggle student and staff safety, loss of opportunities and loss of revenue during the COVID-19 pandemic, even seemingly secondary considerations — how many entrances a school has, how close it sits to community foot traffic, how food is served — loom large.

And while officials are loath to make broad guarantees about safety, they can’t ignore public health advice and thus are immersed in an effort to at least minimize the potential for harm. What that looks like will vary wildly from campus to campus, but in almost every case it will include attempts to limit close contact with others — a difficult job for educational institutions.

The stakes are enormous. Some universities are already projecting financial losses in the tens of millions due to declining enrollment and the uncertainty ahead. But at its core, this is a health problem that remains both simple and vexing: How do you open up a campus without inviting mass infection?

One preliminary answer: Don’t let too many people hang around at the same time.

“I would never use the term ‘make it safe,’” said Dr. Sarah Van Orman, who oversees student health services at the University of Southern California, a private school in the heart of Los Angeles. “I would say we’re going to reduce the risk to the degree possible to have everything in place.”

On many campuses, that means reducing class size (even if it requires adding new sections), making large survey courses online-only, cutting dorm residencies by as much as 50%, limiting or eliminating common-area food service, and perhaps even alternating students’ in-person attendance according to class level (freshman, sophomore, etc.) by quarters or semesters.

That’s in addition to the protocols recommended by the American College Health Association. The ACHA, to which more than 800 institutions belong, has called for a phased reopening of campuses “based on local public health conditions as well as [school] capacity.” Its guidelines include widespread testing, contact tracing, and isolation or quarantine of both ill and exposed individuals.

The Centers for Disease Control and Prevention laid out even more daunting instructions for what a campus should do in the event of a positive test, calling for potential short-term closures of buildings and classrooms that might extend into weeks in the middle of a semester. Among other things, the CDC said, the scenario could include having to move some on-campus residents into short-term alternative housing in the surrounding community.

Van Orman is a past president of the ACHA, but her school has yet to announce a definitive plan for the fall. That puts USC in good company. Although a rolling survey by the Chronicle of Higher Education suggests that nearly 70% of schools are planning for on-campus education, almost every institution directly contacted by Kaiser Health News was actually planning for all contingencies, with fully or partly opened campuses simply being the best-case and most publicly touted scenarios.

Making a campus virus-ready could take all summer, according to officials at several schools. Most of them don’t yet know how many students will return, and about half the schools contacted by KHN said they’ve pushed back the decision deadline for incoming freshmen to June 1, a month later than usual.

Those decisions have huge ramifications for university budgets. Ben Kennedy, whose Kennedy & Co. consults higher education institutions, said most are planning for an enrollment drop of 5% to 10%. “They’ll experience the big financial hit this fall,” Kennedy said.

At Georgetown University in Washington, D.C., a projected $50 million shortfall prompted voluntary furloughs, suspended retirement contributions and construction stops. The Massachusetts Institute of Technology reported $50 million in unexpected costs, while Janet Napolitano, president of the University of California’s 10-campus system, estimated combined losses of $1.2 billion from mid-March through April in announcing salary cuts and some freezes.

At the same time, large-scale restructuring will be required at bigger campuses in response to the pandemic. Converting some multiperson dorm rooms to singles will become the norm at many schools, although not every campus — or community — is prepared to handle a surge of students needing to find other housing as a result. Solutions are still being studied to address those who will be in close quarters in shared dining halls, bathrooms and common rooms. Some schools plan to set aside dorms for students who test positive and need to be isolated or quarantined.

“Students with existing health issues will have priority for single occupancy,” said Debbie Beck, executive director of health services for the University of South Carolina’s 33,000-student Columbia campus. “Testing in the residence halls will be critical.”

Several schools are considering ending their fall semesters before Thanksgiving, which Beck said “would further reduce risks and control the spread of COVID” as students are sent home until January. Stanford University, meanwhile, is pondering a range of possibilities that include permitting only a couple of class years on campus, perhaps alternating by quarters.

A common misperception, several officials said, is that college campuses have been “closed” since the outbreak of the coronavirus. Although student life has been restricted, other parts of many campuses have remained in operation, particularly at research institutions.

“We have research departments and laboratories that really don’t work if you’re not there,” said Dr. Jorge Nieva of USC’s Keck School of Medicine. “It’s difficult to do mouse experiments with cancer if you’re not doing mouse experiments with cancer.”

California’s two massive public university systems embody that dichotomy. California State University Chancellor Timothy White said the 23-campus CSU system, primarily instruction-focused, will mostly conduct remote learning. Napolitano expects the research-heavy University of California campuses to be open “in some kind of hybrid mode,” which many other schools likely will adopt.

“These kids are digital natives,” said Nieva, whose son was a freshman living on campus at USC before students were sent home. “A lot of what they’re experiencing, they’re perhaps better equipped to handle than another generation might be.”

Back in Moraga, Saint Mary’s will reduce dorm capacity, record lectures for online retrieval and institute strict guidelines to prevent the spread of illness — but it plans to continue a 150-plus-year tradition of close, personal education for its 2,500 undergraduates. In its case, being small is the biggest advantage.

“If we already only have 15 or 18 students in a classroom that can hold 30, then it becomes much easier to adapt to the new guidelines and protocols,” said Dr. Margaret Kasimatis, the school’s provost. “That’s a pretty good start.”

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

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Going The Distance By Bus Through A Pandemic

L.A. Metro bus driver Voris Lombard sits behind a partial Plexiglas shield and wears gloves and a mask while driving. After each shift, Lombard removes his uniform and shoes before entering his home, he says. “It’s almost like you’re going through a hazmat routine.”(Heidi de Marco/KHN)

LOS ANGELES — Mary Pierson boarded a nearly empty L.A. Metro bus at the corner of Atlantic Boulevard and Riggin Street in Monterey Park one recent afternoon.

Pierson, 69, uses a wheelchair and relies on public transportation to get around. She takes the bus a few times a week from Long Beach to various parts of Los Angeles to run errands and shop for groceries. Today, she took the No. 68 to the bank.

“I’m glad they’re still running,” said Pierson, who wears a mask, gloves and sunglasses on board and disinfects her wheelchair after every trip. “I live alone and need to get out of the house.”

She’s also often alone on the bus. Transit ridership has plummeted since mid-March, when states began imposing stay-at-home orders. The Los Angeles County Metropolitan Transportation Authority, known as L.A. Metro, said ridership has fallen 64% on buses — about 1.2 million people rode them each day before COVID-19 hit — and by 76% on rail.

Despite the risk of the coronavirus in public places, people are still boarding public buses and trains because they have no other options to get to work, go shopping and fill prescriptions.

“We’re still seeing over 400,000 people per day,” said Brian Haas, communications manager for L.A. Metro. “What that tells us is that we’re a lifeline for people.”

Perhaps the most vulnerable are the bus drivers and train operators. The Transport Workers Union of America has lost 96 members to COVID-19, the vast majority in New York City, the union says. None of the fatalities have been in California.

New methods of sanitation and decontamination, like ultraviolet lighting, should be used, said John Samuelsen, the union’s president. “Masks are the very minimum of what can be done to increase everybody’s safety,” he said. “We need to be thinking about what post-pandemic public transport will look like.”

To date, L.A. Metro has supplied front-line employees with more than 715,000 pairs of gloves, 385,000 masks and 40,000 bottles of personal hand sanitizer.

Until recently, face coverings had been optional on public transit in L.A. County.

But in early May, Los Angeles Mayor Eric Garcetti announced that all passengers on all Los Angeles Department of Transportation buses would be required to wear face coverings to reduce the spread of the virus. The department is a municipal agency that operates within the city and is separate from L.A. Metro. L.A. Metro started requiring passengers to wear face coverings May 11.

Because of the low ridership numbers, social distancing is usually not a problem on buses, said L.A. Metro bus driver Voris Lombard. “When people get on the bus, they have plenty of room to sit.”

Lombard, 59, checks out his bus at 10 a.m. before starting his route, which goes from downtown to Montebello. Lombard, a bus operator for 20 years, says he feels fortunate to still be working. “The people that require our services are essential workers,” he says. “That’s the satisfaction I get out of the job.”(Heidi de Marco/KHN)


Only two passengers ride Lombard’s bus on a recent morning.(Heidi de Marco/KHN)


Jose Salazar, 63, prepares to disembark. Salazar has depended on public transportation exclusively since he took his car to the shop a few weeks ago, and rides the bus several times a day to get around East L.A. and Monterey Park.(Heidi de Marco/KHN)




A sign near the front entrance of the bus asks passengers to board from the rear door. Rear-door boarding was implemented in March to help maintain proper social distancing and keep drivers safe. L.A. Metro asks its bus riders to “have” their fares, but is not requiring them to pay them, says Brian Haas, the system’s communications manager.(Heidi de Marco/KHN)


Rojelio Artalejo, 45, waits to board the No. 770 bus in Monterey Park. Artalejo is a janitor at a grocery store and depends on public transportation to get to work.(Heidi de Marco/KHN)




For extra protection, Mary Pierson wears batting gloves when she takes public transportation.(Heidi de Marco/KHN)


The front door of the bus is reserved for people with mobility devices, such as wheelchairs or walkers.(Heidi de Marco/KHN)

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

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‘We Miss Them All So Much’: Grandparents Ache As The COVID Exile Grinds On

Back home in Bloomfield Hills, Michigan, Richard and Denise Victor would get to see their four grandchildren almost every day. One set of kids lives around the block; the others are half an hour away, all close enough for frequent visits and sleepovers.

“With the younger ones, we have a routine of stories when they spend the night,” Richard Victor said.

But when the coronavirus hit, the couple were at their vacation home in Florida and, suddenly, it wasn’t safe to leave. They’ve been sheltering there for three months, missing the grandkids, struggling with an absence that FaceTime just can’t fill.

“It’s very, very difficult,” said Victor, a 70-year-old lawyer and founder of the nonprofit Grandparents Rights Organization. “You have to try your best because we don’t know when this will be over with.”

Of all the hardships imposed by the coronavirus pandemic, few are as poignant as the reshaping of relationships between children and the grandparents who love them.

Across America, where more than 70 million people are grandparents, efforts to prevent infection in older people, who are most at risk of serious COVID-19 illness, have meant self-imposed exile for many. At the opposite extreme, some grandparents have taken over daily child care duties to help adult children with no choice but to work.

“All the grandparents in the country are aching,” said Madonna Harrington Meyer, a sociology professor at Syracuse University in New York. “Some are aching because they can’t see their grandchildren — and some are aching because they can’t get away from them.”

Both situations are the result of the fast-moving pandemic, which forced families to decide quickly whether to isolate with grandparents “inside the bubble or out,” Harrington Meyer said. Three months later, many are still grappling with those decisions — and worrying about an uncertain future.

“I think we all have the exact same set of issues,” said Harrington Meyer, author of the 2014 book “Grandmothers at Work: Juggling Families and Jobs.” “What will August bring? All of us need to be prepared for this to be fluctuating.”

For grandparents separated from their grandchildren, the risks posed by gathering in person haven’t changed, said Dr. Krutika Kuppalli, an affiliated clinical assistant professor of medicine in the infectious diseases division at Stanford University. Rates of serious illness and death caused by COVID-19 remain much higher in older people than the young, and children can easily spread the disease.

“It’s hard to know if a child has been exposed or whether they have asymptomatic infection,” Kuppalli said. “I would definitely recommend staying away or definitely continuing to wear masks and perform good hand hygiene.”

At the same time, maintaining a connection with grandkids is important for the well-being of everyone, said Dr. Preeti Malani, chief health officer and professor of medicine at the University of Michigan in Ann Arbor.

“There’s an incredible health benefit to them to interact with their grandparents,” she said. “There’s nobody who loves children like their grandparents.”

In Highland Beach, Florida, Victor said he and wife Denise, who’s in her 60s, have relied heavily on Zoom, FaceTime and videos to stay connected to their grandchildren. Still, it’s been difficult. Since February, the two older boys, ages 10 and 13, have gotten taller and better at basketball. The baby has gone from crawling to walking. And their precocious 4-year-old grandson has paid close attention to the passing time.

“He let me know I’d been gone long enough that he’s not 4½ anymore. He’s 4¾,” Victor said. “We miss them all so much.”

Richard and Denise Victor of Bloomfield Hills, Michigan, haven’t seen their grandkids since February. In happier times — before the coronavirus pandemic — they had regular visits with grandsons (from left) Daren Cosola, Stirling Victor, Davis Victor and Lucas Cosola.(Courtesy of the Victor family)

Some grandparents have calculated that the need to care for their families outweighs the fear of infection. Fran Layton, 73, a lawyer who lives in Berkeley, California, rushed to pick up her 2-year-old grandson in San Francisco in late March when his newborn sister arrived earlier than planned.

“My son called and said, ‘Mom, they’re going to induce. Can you get here?’ I did not hesitate,” Layton recalled.

She kept the toddler for a couple of days at that time. A month later, she started caring for him at her home a few days each week so his parents could juggle work and the new baby.

“He would take his naps in a stroller in the afternoon,” Layton said. “I walked the Berkeley Hills while he napped. It got me my exercise.”

Recently, Layton’s son and daughter-in-law decided to return to using their son’s nanny. Layton agreed with that decision, but also knew that widened the circle of infection risk. For now, she is choosing to stay away and doesn’t know when she’ll be together again with her grandson — or her new granddaughter.

“I was a mess when he left,” she said. “It’s sadness that we all feel forced apart with children and grandchildren.”

Some grandparents continue to see their grandchildren in person, finding ways to stay apart while still being together. “The outdoors is safer than the indoors, in general,” said Malani, the University of Michigan professor. “To me, a walk in a park, without a play structure, without other kids around, is OK.”

About 4% of grandparents live with their grandchildren, so staying away isn’t an option.

As of mid-May, Beth Kashner has joined that group. Her daughter’s family, including an 11-year-old granddaughter and 10-year-old grandson, relocated from Brooklyn to Kashner’s large Seattle home “while normal life is on hold,” or at least for the summer.

“They even brought their two cats,” said Kashner, 73. “I’m really happy that everyone will be part of the same safe community.”

Kashner already lived less than a mile from her four other grandchildren, who range in age from 3 to 10. For weeks, she saw them only from afar. Now, the whole family is gathering. It may be risky, but they’re taking pains to stay as safe as possible, she said.

“We did just go to the park wearing masks and trying to keep our distance,” she said.

For those who must be physically close to their grandchildren, there are ways to reduce the risk. Frequent hand-washing and sanitizing of high-touch surfaces is essential. Avoid contact with those outside the household. Masks and gloves can help.

And it’s not just the little ones. Adult grandchildren must consider carefully how to visit their grandparents, too. Malani recently took her family to visit her 97-year-old grandmother, Haridevi Malani, at home.

“It was a bit of a dilemma,” she said. “But I had a need to go visit her.”

Until a treatment or vaccine for the coronavirus is available, every interaction will be fraught with questions, she said. Going forward, families will need to weigh risks and benefits.

“We’re not going to have a situation where we can mitigate the risk to nothing,” Malani said. “It’s about how much risk you’re willing to take.”

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El coronavirus pone a prueba el valor de la inteligencia artificial en la atención médica

El doctor Albert Hsiao y sus colegas del sistema de salud de la Universidad de California-San Diego habían estado trabajando durante 18 meses en un programa de inteligencia artificial diseñado para ayudar a los médicos a identificar neumonía en una radiografía de tórax.

Cuando el coronavirus golpeó a los Estados Unidos, decidieron ayudar.

Los investigadores rápidamente compartieron la aplicación, que resalta con colores manchas en las imágenes de rayos X en donde puede haber daño pulmonar u otros signos de neumonía.

La aplicación ya se ha utilizado en más de 6,000 radiografías de tórax, y está sumando cierto valor en el diagnóstico, dijo Hsiao, director del Laboratorio de Análisis de Datos de Inteligencia Artificial de UCSD.

Su equipo es uno de varios en todo el país que ha puesto estos programas, desarrollados en tiempos más calmos, al servicio de la crisis de COVID-19. La meta es ayudar en tareas como decidir qué pacientes enfrentan el mayor riesgo de complicaciones, y cuáles pueden recibir una atención de menor intensidad.

Estos programas navegan a través de millones de datos para detectar patrones que pueden ser difíciles de discernir para los médicos. Sin embargo, pocos de los algoritmos han sido rigurosamente probados para compararlos con los procedimientos estándar.

Entonces, aunque a menudo parecen útiles, su implementación en medio de una pandemia podría ser confusa para los médicos o incluso peligrosa para los pacientes, advierten algunos expertos en inteligencia artificial (IA).

“En este momento, la IA se está utilizando para cosas que son cuestionables”, dijo el doctor Eric Topol, director del Scripps Research Translational Institute.

Topol destacó un sistema creado por Epic, un importante proveedor de software de registros de salud electrónicos, que predice qué pacientes con coronavirus pueden enfermarse gravemente. Usar la herramienta antes de que se haya validado es “sensacionalismo pandémico”, dijo.

Epic dijo que el modelo de la compañía había sido validado con datos de más de 16,000 pacientes hospitalizados con COVID-19 en 21 establecimientos de salud.

No se ha publicado ninguna investigación sobre la herramienta, pero, en cualquier caso, fue “desarrollada para ayudar a los médicos a tomar decisiones de tratamiento y no es un sustituto de su juicio”, dijo James Hickman, desarrollador de software en el equipo de computación cognitiva de Epic.

Otros ven la crisis de COVID-19 como una oportunidad para aprender sobre el valor de las herramientas de IA.

“Mi intuición es que tiene cosas buenas y malas”, dijo Eric Perakslis, investigador de ciencias de la información en la Universidad de Duke y ex director de información de la Administración de Alimentos y Medicamentos (FDA). “La investigación en este entorno es importante”.

En 2019, compañías invirtieron cerca de $2mil millones para promover la IA en la atención médica. Las inversiones en el primer trimestre de 2020 totalizaron $635 millones, frente a los $155 millones en el primer trimestre de 2019, según el sitio de tecnología de salud digital Rock Health.

Según Rock Health, al menos tres compañías de tecnología de IA para atención de salud han realizado acuerdos de financiación específicos para la crisis COVID-19, incluida Vida Diagnostics, una compañía de análisis de imágenes de pulmón impulsada por esta tecnología.

La crisis del coronavirus ha inspirado a algunos sistemas hospitalarios a acelerar aplicaciones prometedoras.

UCSD aceleró su proyecto de imágenes de IA y lo implementó en solo dos semanas.

El proyecto de Hsiao, con fondos de investigación de Amazon Web Services, la Universidad de California y la National Science Foundation, analiza todas las radiografías de tórax tomadas en el hospital a través de un algoritmo de IA.

Si bien aún no se han publicado datos sobre la implementación, los médicos informan que la herramienta influye en su toma de decisiones clínicas aproximadamente un tercio del tiempo, dijo el doctor Christopher Longhurst, director de información de UC San Diego Health.

“Los resultados hasta la fecha son muy alentadores, y no estamos viendo ninguna consecuencia no deseada”, dijo. “Sentimos que es útil, no daña”.

La IA ha avanzado más en imágenes que en otras áreas de la medicina clínica porque las imágenes radiológicas tienen toneladas de datos para que los algoritmos procesen, y más datos hacen que los programas sean más efectivos, agregó Longhurst.

Especialistas en IA han tratado de hacer que esta tecnología logre cosas como predecir la sepsis y la dificultad respiratoria aguda. E investigadores de la Universidad Johns Hopkins recientemente ganaron una subvención de la National Science Foundation para usarla para predecir el daño cardíaco en pacientes con COVID-19.

Sin embargo, ha sido más fácil aplicar IA en áreas menos riesgosas como la logística del hospital.

En la ciudad de Nueva York, dos grandes sistemas hospitalarios están utilizando algoritmos habilitados para IA para ayudarlos a decidir cuándo y cómo los pacientes deben pasar a otra fase de atención o ser dados de alta.

En el Sistema de Salud Mount Sinai, un algoritmo de inteligencia artificial indica qué pacientes podrían estar listos para ser dados de alta del hospital dentro de las 72 horas, dijo Robbie Freeman, vicepresidente de innovación clínica en Mount Sinai.

Freeman destacó que la tecnología ayuda a los médicos, pero no está tomando las decisiones.

NYU Langone Health ha desarrollado un modelo de IA similar. Predice si un paciente con COVID-19 que ingresa al hospital sufrirá eventos adversos en los próximos cuatro días, dijo el doctor Yindalon Aphinyanaphongs, quien dirige el equipo de análisis predictivo de NYU Langone.

El modelo se ejecutará en un ensayo de cuatro a seis semanas con pacientes asignados al azar en dos grupos: los médicos de un grupo recibirán las alertas y los del otro, no. El algoritmo debería ayudar a los médicos a generar una lista de cosas que pueden predecir si los pacientes están en riesgo de complicaciones después de ser internados, dijo Aphinyanaphongs.

Algunos sistemas de salud desconfían de implementar una tecnología que requiera validación clínica en medio de una pandemia. Otros dicen que no necesitaban IA para lidiar con el coronavirus.

Stanford Health Care no está utilizando IA para manejar pacientes hospitalizados con COVID-19, dijo Ron Li, director de informática médica del centro para la integración clínica de IA. El área de la Bahía de San Francisco no ha visto el aumento esperado de pacientes que habrían proporcionado la gran cantidad de datos necesarios para asegurarse de que la IA funcionara en una población, dijo.

Fuera del hospital, el modelo de factores de riesgo habilitado por IA se está utilizando para ayudar a los sistemas de salud a rastrear a los pacientes que no están infectados con el coronavirus pero que podrían ser susceptibles a complicaciones si lo contraen.

En Scripps Health, en San Diego, los médicos están estratificando a los pacientes para evaluar su riesgo de desarrollar COVID-19 y experimentar síntomas graves utilizando un modelo de calificación de riesgo que considera factores como la edad, afecciones crónicas y visitas recientes al hospital.

Cuando un paciente obtiene un puntaje de 7 o más, una enfermera puede programar una cita.

Aunque las emergencias brindan oportunidades únicas para probar herramientas avanzadas, es esencial para los sistemas de salud garantizar que los médicos se sientan cómodos con ellas y usarlas herramientas con precaución, con pruebas y validación exhaustivas, enfatizó Topol.

“Cuando las personas están en el fragor de la batalla, sería genial tener un algoritmo para apoyarlas”, dijo. “Solo tenemos que asegurarnos de que el algoritmo y la herramienta de inteligencia artificial no sean engañosos, porque hay vidas en juego”.

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

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

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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.

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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.

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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.

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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.”

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