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In Los Angeles, Latinos Hit Hard By Pandemic’s Economic Storm

Working as a fast-food cashier in Los Angeles, Juan Quezada spends a lot of his time these days telling customers how to wear a mask.

“They cover their mouth but not their nose,” he said. “And we’re like, ‘You gotta put your mask on right.’”

Quezada didn’t expect to be enforcing mask-wearing. Six months ago, he was a restaurant manager, making $30 an hour, working full time and saving for retirement. But when Los Angeles County health officials shut down most restaurants in March because of the spreading pandemic, Quezada lost his job. The only work he could find pays a lot less and is part time.

“I only work three hours and four hours rather than eight or 10 or 12 like I used to work,” he said.

Quezada doesn’t know anyone who has gotten COVID-19, but the pandemic has affected nearly every aspect of his life. “I am just draining my savings — draining and draining and draining,” he said. “I have to sell my car. Uber is a luxury.” Mostly, he now bikes or rides the bus to his part-time job.

Quezada is one of hundreds of people who responded in a newly published poll by NPR, the Robert Wood Johnson Foundation and the Harvard T.H. Chan School of Public Health. Among other things, the poll, which surveyed people from July 1 to Aug. 3, found that a whopping 71% of Latino households in Los Angeles County have experienced serious financial problems during the pandemic, compared overall with 52% of Black households there and 37% of whites. (Latinos can be of any race or combination of races.)

Like Quezada, many are burning through their savings and are having a hard time paying for necessities such as food. Quezada estimated he has about six months of savings left.

In Los Angeles, more than 35% of households report serious problems with paying credit cards, loans or other bills, while the same percentage report having depleted all or most of their savings. Eleven percent of Angelenos polled said they didn’t have any savings at the start of the outbreak.

Nationally, the picture is similar. In results released last week, the poll found that 72% of Latino households around the country reported they’re facing serious financial problems, double the share of whites who said so. And 46% of Latino households reported they have used up all or most of their savings during the pandemic.

How Poverty Differs for Latinos

Nationally, the poll found that 63% of Latinos reported loss of household income either through reduced hours or wages, furloughs or job loss since the start of the pandemic.

But Latinos have kept working through the crisis, said David Hayes-Bautista, a professor of medicine and public health at UCLA.

“In Washington, the idea is you’re poor because you don’t work. That’s not the issue with Latinos,” he said. “Latinos work. But they’re poor. The problem is, we don’t pay them.”

Latinos have the highest rate of labor force participation of any group in California. In March, when state and local officials shut down many businesses, Latinos lost jobs like everyone else. But Latinos got back to work faster.

“In April, the Latino [labor force participation] rate bounced right back up and actually has continued to increase slowly, whereas the non-Latino rate is dropping,” Hayes-Bautista said. “The reward that Latinos have for their high work ethic is a high rate of poverty.”

That work ethic has also contributed to a much higher rate of COVID-19. Hayes-Bautista pointed out that in California, as in some other regions in the U.S., Latinos tend to hold many of the jobs that have been deemed essential, and that’s made them highly susceptible to the coronavirus. Latinos now account for 60% of COVID-19 cases in California, even though they’re about 40% of the population.

Not only are they getting infected, but there’s been nearly a fivefold increase in working-age Latinos dying from the coronavirus since May.

“These are workers usually in their prime years — peak earning power and everything else,” Hayes-Bautista said. “Latinos between 50 and 69, those are the ones that are being hit the hardest. That’s pretty worrying.”

Exposed — And Often Without Health Insurance

Nationally, according to the poll, 1 in 4 Latino households report serious problems affording medical care during the pandemic.

Many of the essential jobs that Latinos are more likely to perform — farmworker or nursing home aide or other contract work, for example — lack benefits. That means some Latinos are more exposed to the coronavirus and less likely to have health insurance because they don’t get coverage through an employer.

Others, such as Mariel Alvarez, lack health insurance because of citizenship restrictions. She lives with her parents and sisters in Los Angeles County’s San Fernando Valley. Alvarez lost her sales job and her employer-sponsored health insurance when the pandemic hit in March, she said. Then she got sick.

Eventually, her whole family was ill. Alvarez had to pay out-of-pocket to go to a CVS clinic near her home. But after a couple of $50 visits, it got too expensive.

“I just couldn’t afford to continue to go to the doctor,” she said. She suspected it was COVID-19 but was unable to get tested.

Now that she’s recovered, getting a job with health insurance is crucial because she doesn’t qualify for any state or federal support. Alvarez is undocumented and was brought to the U.S. by her parents as a child from Bolivia. She’s one of roughly 640,000 immigrants who has a permit allowing her to work and defer deportation under the Deferred Action for Childhood Arrivals program, or DACA.

“I don’t want to jeopardize that,” Alvarez said. “You’re not supposed to use any of the government assistance when you’re on that. You’re only supposed to work, and that’s it.”

The pandemic has created a big need for one job: contact tracers. So Alvarez completed a free certificate online in the hope it will give her an edge. She’s going through the application process; if she gets hired, she hopes to have benefits again.

In the meantime, she’ll do her best not to get sick.

Jackie Fortiér is a health reporter for KPCC and LAist.com.

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

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En Los Angeles, la tormenta económica por la pandemia ha pegado fuerte en los latinos

Al trabajar como cajero de comida rápida en Los Angeles, Juan Quezada pasa mucho de su tiempo estos días diciéndole a los clientes cómo usar una máscara.

“Se cubren la boca pero no la nariz”, dijo. “Y nosotros les decimos: ‘Tienes que ponerte la máscara bien’”.

Quezada nunca imaginó que acabaría haciendo cumplir el uso de la máscara. Hace seis meses, era gerente de un restaurante, ganaba $30 la hora, trabajaba a tiempo completo y ahorraba para su jubilación.

Pero cuando los funcionarios de salud del condado de Los Angeles cerraron la mayoría de los restaurantes, en marzo, por la pandemia, Quezada perdió su trabajo. El único que pudo encontrar paga mucho menos y es de medio tiempo.

“Sólo trabajo tres o cuatro horas en lugar de ocho, 10 o 12 horas como solía trabajar”, contó.

No conoce a nadie que haya contraído COVID-19, pero la pandemia ha afectado casi todos los aspectos de su vida. “Estoy agotando mis ahorros, agotando y agotando y agotando”, dijo. “Tengo que vender mi coche. Uber es un lujo”. Ahora va en bicicleta o en autobús a su trabajo.

Quezada es una de las cientos de personas que respondieron a una encuesta publicada recientemente por NPR, la Fundación Robert Wood Johnson y la Escuela de Salud Pública T.H. Chan de la Universidad de Harvard.

Entre otras cosas, el sondeo, que encuestó a la gente del 1 de julio al 3 de agosto, encontró que un cifra enorme, el 71% de los hogares latinos en el condado de Los Angeles han experimentado serios problemas financieros durante la pandemia, en comparación con el 52% de los hogares afroamericanos, y el 37% de los blancos. (Los latinos pueden ser de cualquier raza o combinación de razas).

Como Quezada, muchos están quemando sus ahorros y tienen dificultades para pagar necesidades básicas como la comida. Al hombre le quedan unos seis meses de ahorros.

En Los Angeles, más del 35% de los hogares reportan serios problemas para pagar tarjetas de crédito, préstamos u otras cuentas, mientras que el mismo porcentaje dice haber agotado todos o la mayoría de sus ahorros.

El 11% de los angelinos encuestados dijo que no tenían ahorros al comienzo del brote.

A nivel nacional, el panorama es similar. En los resultados publicados, la encuesta reveló que el 72% de los hogares latinos en todo el país enfrentan serios problemas financieros, el doble de la proporción de los blancos no hispanos que participaron en la encuesta.

Y el 46% de los hogares latinos reportaron que han usado todos o la mayoría de sus ahorros durante la pandemia.

A nivel nacional, la encuesta encontró que el 63% de los latinos reportaron pérdida de ingresos familiares ya sea por reducción de horas o salarios, permisos o pérdida de trabajo, desde el comienzo de la pandemia.

Pero los latinos han seguido trabajando durante la crisis, dijo David Hayes-Bautista, profesor de medicina y salud pública en la UCLA.

“En Washington, la idea es que eres pobre porque no trabajas. Ese no es el problema con los latinos”, señaló. “Los latinos trabajan. Pero son pobres. El problema es que no les pagamos”.

Los latinos tienen la mayor tasa de participación en la fuerza laboral de cualquier grupo en California. En marzo, cuando los funcionarios estatales y locales cerraron muchos negocios, los hispanos perdieron sus trabajos como todos los demás. Pero volvieron a trabajar más rápido.

“En abril, la tasa de participación de los latinos [en la fuerza laboral] se recuperó y ha seguido aumentando lentamente, mientras que la tasa de los no latinos está bajando”, explicó Hayes-Bautista. “La recompensa que tienen los latinos por su alta ética de trabajo es una alta tasa de pobreza”.

Esa ética de trabajo también ha contribuido a una tasa mucho más alta de COVID-19. Hayes-Bautista señaló que en California, como en algunas otras regiones de los Estados Unidos, los latinos suelen hacer muchos de los trabajos que se han considerado esenciales, y eso los ha hecho altamente susceptibles al coronavirus.

Los latinos ahora representan el 60% de los casos de COVID-19 en California, aunque son alrededor del 40% de la población.

No sólo se están infectando, sino que, desde mayo, casi se ha quintuplicado el número de latinos en edad laboral  que mueren por el coronavirus.

“Estos son trabajadores que normalmente están en sus mejores años, con mayores ingresos y todo lo demás”, expresó Hayes-Bautista. “Los latinos de entre 50 y 69 años son los más afectados. Es muy preocupante”.

Expuestos y, a menudo, sin seguro médico

A nivel nacional, según la encuesta, 1 de cada 4 hogares latinos reportan serios problemas para pagar por la atención médica durante la pandemia.

Muchos de los trabajos esenciales que los latinos suelen realizar —como el agrícola o asistente en residencia de mayores u otro trabajo por contrato, por ejemplo— carecen de beneficios. Esto significa que algunos latinos están más expuestos al coronavirus y es menos probable que tengan seguro médico porque no reciben cobertura a través de un empleador.

Otros, como Mariel Álvarez, carecen de cobertura debido a las restricciones al no tener la ciudadanía. Vive con sus padres y hermanas en el Valle de San Fernando, condado de Los Angeles. Álvarez perdió su trabajo de ventas y su seguro médico patrocinado por el empleador cuando la pandemia golpeó en marzo, dijo. Luego se enfermó.

Luego, toda su familia se enfermó. Álvarez tuvo que pagar de su bolsillo para ir a una clínica de CVS cerca de su casa. Pero después de un par de visitas a $50 cada una, le resultó demasiado caro.

“No podía permitirme seguir yendo al médico”, explicó. Sospechaba que era COVID-19 pero no pudo hacerse la prueba.

Ahora que se ha recuperado, conseguir un trabajo con seguro médico es crucial porque no califica para ninguna ayuda estatal o federal. Álvarez es indocumentada y fue traída a los Estados Unidos por sus padres, cuando era niña, desde Bolivia. Es una de los aproximadamente 640,000 inmigrantes que tiene un permiso que le permite trabajar y aplazar la deportación bajo el programa de Acción Diferida para los Llegados en la Infancia, o DACA.

“No quiero poner en peligro eso”, dijo Álvarez. “Se supone que no debes usar ninguna de las ayudas del gobierno cuando estás en eso. Se supone que sólo debes trabajar, y eso es todo”.

La pandemia ha creado gran demanda de un trabajo: los rastreadores de contactos. Así que Álvarez completó un certificado gratuito en línea para estar más preparada. Ahora está en el proceso de solicitud; si la contratan, espera tener beneficios de nuevo.

Mientras tanto, hará todo lo posible para no enfermarse.

Fortiér es reportera de salud para KPCC y LAist.com

Esta historia es parte de una asociación que incluye a KPCC, NPR y KHN, un programa editorialmente independiente de KFF.

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California Expands Privacy Protection to Public Health Workers Amid Threats

SANTA CRUZ, Calif. — California will allow public health officials to participate in a program to keep their home addresses confidential, a protection previously reserved for victims of violence, abuse and stalking and reproductive health care workers.

The executive order signed by Democratic Gov. Gavin Newsom late Wednesday is a response to threats made to health officers across California during the coronavirus pandemic. More than a dozen public health leaders have left their jobs amid such harassment over their role in mask rules and stay-at-home orders.

“Our public health officers have all too often faced targeted harassment and stalking,” wrote Secretary of State Alex Padilla in a statement. This “program can help provide more peace of mind to the public health officials who have been on the frontlines of California’s COVID-19 response.”

A community college instructor accused of stalking and threatening Santa Clara health officer Sara Cody was arrested in late August. The Santa Clara County sheriff said it believes the suspect, Alan Viarengo, has ties to the “Boogaloo” movement, a right-wing, anti-government group that promotes violence and is associated with multiple killings, including the murders of a federal security officer and a sheriff deputy in the Bay Area. Thousands of rounds of ammunition, 138 firearms and explosive materials were found in his home, the sheriff’s office said.

In Santa Cruz County, two top health officials have received death threats, including one allegedly signed by a far-right extremist group.

In May, a member of the public read aloud the home address of former Orange County health officer Nichole Quick at a supervisors’ meeting and called for protesters to go to her home. “You have seen firsthand how people have been forced to exercise their First Amendment. Be wise, and do not force the residents of this county into feeling they have no other choice than to exercise their Second Amendment,” said another attendee. Quick later resigned.

Protesters angry over mask mandates and stay-at-home orders have gone to the homes of health officers in multiple counties, including Orange and Contra Costa.

The executive order would allow health officials to register with the Secretary of State’s Safe at Home program. Those in the program are given an alternative mailing address to use for public records so that their home addresses are not revealed.

Threats of violence have added to the already immense pressure public health officials have experienced since the beginning of the year. Amid chronic underfunding and staffing shortages, they have been working to limit the spread of the coronavirus, while also deflecting political pressure from other officials and anger from the public over business closures and mask mandates.

“California’s local health officers have been working tirelessly since the start of the pandemic, using science to guide policy,” said Kat DeBurgh, the executive director of the Health Officers Association of California. “It is regrettable that this order was necessary — but we are grateful for it nevertheless.”

Nationwide, at least 61 state or local health leaders in 27 states have resigned, retired or been fired since April, according to a review by The Associated Press and KHN, a figure that has doubled since the newsrooms first began tracking the departures in June.

Thirteen of those departures have been in California, including 11 county health officials and the state’s two top public health officials.

Dr. Sonia Angell, former director of the California Department of Public Health and state public health officer, quit in early August after a series of glitches in the state’s infectious disease reporting system caused weeks-long delays in reporting cases of COVID-19.

In Placer County, north of Sacramento, health officer Dr. Aimee Sisson resigned effective Sept. 25 after the county Board of Supervisors voted to end its local COVID-19 health emergency. “It is with a heavy heart that I submit this letter of resignation,” she wrote in her resignation letter. “Today’s action by the Placer County Board of Supervisors made it clear that I can no longer effectively serve in my role.”

Organizations across the state have expressed concern over the treatment of health officials during the pandemic, including the California Medical Association.

“Basic science has become politicized in so many parts of our state, and our country,” wrote California Medical Association president Dr. Peter N. Bretan Jr. in a statement after Sisson’s departure. “Public health officers are public servants who seek to do what their job description states — to protect public health.”

The executive order also directs the state to assess impacts of the pandemic on health care providers and health care service plans, and halts evictions for commercial renters through March 31, 2021, among other pandemic-related matters.

KHN and California Healthline correspondent Angela Hart contributed to this report.

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

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A Fair to Remember: County Fairs Weigh Risk of Outbreak Against Financial Ruin

Laura Stutzman had no doubts that this year’s Twin Falls County Fair should go on despite the pandemic still raging across the U.S. — and several outbreaks tied to such community fairs.

Though she saw few people wearing masks from her volunteer station in the fair’s hospitality tent in southern Idaho earlier this month, she said she wasn’t concerned. Stutzman, 63, had been attending the fair off and on for 30 years, and she didn’t consider this year that different. People in rural communities know how to respect one another’s space, she said, and don’t have time to “fret and worry” about the coronavirus.

“Common sense is knowing that COVID-19 is in the picture,” she said, yet not allowing fear to “dictate how we live.”

Hundreds of state and county fairs typically take place across the U.S. each year. They are a centerpiece for the agricultural industry — particularly for the 4-H kids who raise livestock all year to show off at their local events. Thousands of people are drawn to small towns for the concerts, rodeos, races and carnivals that flesh out the experience.

But only about 1 in 5 fairs took place as scheduled this summer, while the rest were dramatically modified or outright canceled because of the pandemic, according to data provided by the International Association of Fairs & Expositions.

Fairs are the economic lifeblood and cultural high point of the year for many rural communities, so the decision to cancel one is especially consequential. Scaling back can have devastating effects on the finances of the fair organizers and local community. And organizers fear that skipping a single year could mean losing a fair permanently.

“With very few exceptions, most fairs get most of their income from one single annual event,” said Marla Calico, president and CEO of the International Association of Fairs & Expositions. “Some fairs are trying to figure out how they will survive after this.”

In pressing on with their events, many organizers cited the fair’s importance to their counties, precisely because of the pandemic — people have been isolated from one another and communities are struggling economically.

One, the Montrose County Fair and Rodeo in Colorado, wanted to give students a chance to show and sell their livestock in person, Montrose County Fairgrounds & Event Center director Emily Sanchez said. Organizers promoted the event on social media with the hashtag #spreadingjoy, which Sanchez said was not intended to be a tongue-in-cheek reference to the pandemic.

“What we noticed was a lot of people saying that this was the worst year,” Sanchez said. “We were just giving people a minute to enjoy the small things.”

Montrose and most other fairs that took place scaled back events and made other changes to try to prevent coronavirus transmission. Fairs posted signs encouraging mask use and social distancing, and some canceled concerts and carnival-type attractions. The Fresno County fair in California, which is scheduled for October and typically draws 600,000 people, has been rebranded as a “series of drive-thru and virtual experiences.”

Often, those precautions haven’t worked, though, as fairgoers shed masks and gathered in large groups to watch rodeos and other attractions.

Health officials have since traced some COVID outbreaks to fairs. For example, Ohio Gov. Mike DeWine announced restrictions to county fairs after at least 22 cases of COVID-19 were traced back to the Pickaway County Fair in June.

Another fair linked to a COVID outbreak is the Phillips County Fair in the vast plains of northeastern Montana. The organizers of the event in Dodson, a small farming community about 40 miles south of the Canadian border, have long proclaimed that theirs was the longest continuously running fair in the state.

Until the fair took place in early August, Phillips County had another unique distinction: It was one of just a handful of Montana’s 56 counties to have no confirmed cases of COVID-19.

By mid-August, an outbreak of COVID-19 occurred — 68 cases within a week in the county of 4,000 people. The county’s small public health team scrambled to perform contact tracing. They concluded the fair and other events held at the same time, including a softball tournament and a large wedding, caused the spread.

“It was really just a perfect storm that led to an outbreak,” said public health nurse Jenny Tollefson.

The number of infections in Phillips County eventually rose to 114, but county officials have since curbed the outbreak. There were no active cases in the county as of mid-September, according to state health officials.

Sue Olsen, chairperson of the Phillips County Fair board, said organizers did everything they could to safely hold a large community event amid a global pandemic. They purchased 500 gallons of hand sanitizer and encouraged attendees to wear masks, although she said few did. They also improved cleaning procedures in the bathrooms.

They canceled events in which social distancing would not be possible, such as the carnival games and rides, face painting and a clown show. The county’s Native American neighbors on the Fort Belknap Reservation disagreed with the decision to hold the fair and canceled the relay races that are a traditional part of the event.

But organizers felt they needed to hold the fair.

“If you don’t have an event one year, you might just lose it,” Olsen said.

The outbreak opened up the county to criticism. Montana Gov. Steve Bullock, a Democrat, called Phillips County an example of how the state hasn’t learned to live with the coronavirus.

Other fair organizers took notice but pressed ahead. Near Montana’s Glacier National Park, Flathead County held the Northwest Montana Rodeo and Fair in mid-August despite 140 local health care professionals writing a letter urging organizers to cancel it. Among the medical community’s chief concerns: Schools were reopening just a week after the fair.

Fair manager Mark Campbell said his team worked closely with local health officials to ensure that the event, which normally attracts upward of 80,000 people, could proceed safely.

“We had a health department that was willing to work with us on a plan when a lot of other counties or states just simply said no to public events,” he said.

Campbell said the fair was different than in past years, with a bigger focus on 4-H and agricultural education. They canceled the carnival and parade, plus ditched the beer garden during the concerts and rodeos. Masks were required to enter the fair and the grandstands, although images posted by a local newspaper that quickly circulated on social media showed many people simply took off their masks once inside.

Interim county health officer Tamalee St. James Robinson said the images of so many maskless people in the grandstands were concerning, and fair organizers should have ensured compliance. Campbell said that the organizers took corrective actions to make sure people did wear masks after the images surfaced but that his staff didn’t have time to constantly remind people.

Two weeks later, contact tracers found seven people with COVID-19 had gone to the fair.

Back in Twin Falls, Idaho, about 3,500 people — half the usual number — showed up at the fair’s opening on Sept. 2, according to news reports. Despite the smaller crowd, the carnival games and rides went ahead and so did the rodeo.

Stutzman said she spent some of her time during the rodeo sanitizing the hospitality tent — but not necessarily because of the coronavirus.

“We were all raised with manners and good hygiene and consideration for others in our neck of the woods,” she said. “So everything pretty much goes on as it always has.”

The fair ended on Sept. 7, and it remains to be seen what effect, if any, it will have on Twin Falls County’s COVID-19 cases.

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Public Health States

How Families Are Keeping Halloween From Turning Into a COVID Nightmare

DENVER — For Laura Stoutingburg and her family, Halloween has always been a monthlong celebration of corn mazes, pumpkin patches and, of course, trick-or-treating in their suburban Denver neighborhood.

However, the COVID-19 pandemic has forced the mother of two to change their plans.

“Traditional trick-or-treating house to house does not feel like a smart choice to me this year,” Stoutingburg said.

Families across the nation are haunted by the same dilemma: How can they safely keep the pandemic from overshadowing Halloween? Can families trick-or-treat and go to haunted houses, or should they opt for lower-risk activities at home?

Health experts say families should err on the side of caution when it comes to trick-or-treating and other traditional fall activities. Much depends on each family’s comfort with taking risks and ensuring they adhere to safety standards and common sense, they said. Masks should be worn by all, even if not part of a costume.

“My kids love going to the farm … to go pumpkin-picking, apple-picking and all those things we do in the fall,” said Dr. Aaron Milstone, a professor of pediatrics and an associate epidemiologist at Johns Hopkins University in Baltimore. But, he added, “if you show up at the pumpkin patch and it’s packed with people, that’s not the right time for you to be there.”

The Centers for Disease Control and Prevention recently released Halloween guidelines that warn against high-risk activities like traditional trick-or-treating, haunted houses and costume parties, as well as hay and tractor rides, among other things. The federal agency is also clear on the need for social distancing, mask-wearing and hand-washing to continue.

Many parents are coming up with creative alternatives for Halloween night. For Stoutingburg, 30, that means hosting a small sleepover with relatives that features pumpkin-carving, cupcake-decorating and a scavenger hunt.

Jody Allard and her family also will forgo their usual tricks and treats. Allard, 42, lives in Seattle and has a rare genetic disease putting her at higher risk for COVID-19. The mother of seven said her family will make new traditions this year.

“We’re going to make a bunch of different fun foods from the Halloween shows they like to watch on the Food Network, and we’re going to watch kid-friendly Halloween movies,” Allard said.

In Lancaster, Pennsylvania, 44-year-old writer Jamie Beth Cohen’s daughter came up with the idea that she and her brother dress up in costumes and trick-or-treat inside their own home, with their parents behind the doors of various rooms, waiting with candy.

“She’s excited to wear a costume without a jacket and get lots of the kind of candy she likes,” Cohen said.

Maya Brown-Zimmerman and her family of six never miss out on trick-or-treating in Cleveland. But they will this year, with Brown-Zimmerman, 35, at higher risk for COVID-19 because of multiple lung diseases. Instead, her family will use their costume money on new Halloween decor, and her four kids, ages 3 to 11, will search for candy at home.

“I’ll hide eggs of candy in the front yard for my little kids,” she said. “After they go to bed, the older kids will have a hunt for eggs in the dark in our backyard with flashlights.”

For families still hoping to trick-or-treat this year, though, what can be done to stay as safe as possible?

The Harvard Global Health Institute created a website to help parents assess their risk level for Halloween activities with a color-coded map of county COVID data. It shows which counties are “lower-risk” zones for COVID (green and yellow), where parents might feel more comfortable allowing their children to trick-or-treat, and which are higher-risk areas (orange and red), where online parties and very small gatherings are recommended instead.

Milstone said families should think less in terms of green versus red zones and more in terms of staying safe no matter what, especially considering asymptomatic carriers.

“Rather than people getting a false sense of security that ‘My area is a low-risk area, so I’m just gonna go and do whatever,’ I would say ideally everyone practices the same safe things,” he said.

Dr. Heather Isaacson, a pediatrician with UCHealth in Longmont, Colorado, said masks must be worn by all and has a simple suggestion for the reluctant: “Decorate those masks and incorporate them into the costumes.”

People who hand out candy also should wear masks, added Dr. Alok Patel, a pediatrician and co-host of the “Nova” and PBS Digital Studios show “Parentalogic.” If trick-or-treaters see candy-givers without masks, he suggested wishing them a “Happy Halloween” and passing them by for the next home.

“If people are outside serving candy without a mask, consider the added risk of potential respiratory droplets flying around, including in the candy bowl,” said Patel.

When it comes to handing out candy, it’s a good idea to maintain as much distance as possible.

“Think outside of the box with ideas like a reverse trick-or-treating, where kids stay home and dress up and neighbors do a parade and throw candy,” said Isaacson. She also recommended creating individual goody bags in place of bowls of treats.

“You could go all out and make candy chutes or a giant spider web with candy trapped in it. In some ways, the physically distanced candy-delivery ideas sound more fun,” said Patel.

As for the candy itself, Milstone isn’t as concerned about wrappers as about hand-washing. The primary message is, “Don’t let your kid eat candy with dirty hands,” he said. That means no eating candy until they’re able to get home to wash properly.

While you could technically sanitize wrappers, said Dr. Rita Nasseri, a Los Angeles physician and mother of three, “the safest solution is to buy your own candy and give your children that as a treat.”

As for teens, who may want more independence, Dr. Sam Dominguez, a pediatrician specializing in infectious diseases and medical director of the microbiology lab at Children’s Hospital Colorado, recommended that small groups of friends get together outside and carve pumpkins or watch a projected movie — while wearing masks, of course.

Nasseri advised something similar, adding that food served buffet-style and communal candy should be avoided.

In Boone County, Missouri, currently experiencing a rapid uptick in COVID-19 cases, Karina Koji said her family will stay home on Halloween night. They plan to dress up in costumes and face masks and give out bags of individually wrapped candies. They’ll also leave candy bags in the driveway for anyone who doesn’t feel comfortable coming up to the door.

“We shouldn’t let the pandemic take Halloween from us,” said Koji, 45. “We’ve all had to give up so much. It’s entirely possible to celebrate this fun holiday while staying healthy and keeping ourselves and others safe.”

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Public Health States

Reapertura de universidades generó 3,000 nuevos casos de COVID por día, según estudio

La reapertura de universidades en los Estados Unidos provocó un aumento de 3,000 nuevos casos de COVID-19 por día, según un nuevo estudio.

El estudio, realizado por investigadores de la Universidad de Carolina del Norte-Greensboro, la Universidad de Indiana, la Universidad de Washington y el Davidson College, rastreó los datos de teléfonos celulares y los comparó con las fechas de reapertura de 1,400 facultades, junto con las tasas de infección del condado.

“Nuestro estudio buscaba ver si podíamos observar aumentos tanto en el movimiento como en el recuento de casos, es decir, informes de casos, en los condados y en todo los Estados Unidos”, dijo Ana Bento, experta en enfermedades infecciosas y profesora asistente en la Escuela de Salud Pública de la Universidad de Indiana.

“Luego tratamos de entender si esta información era diferente en los condados donde había universidades o colegios comunitarios. En particular para ver si estos aumentos eran de mayor magnitud en los colegios con instrucción en persona”, dijo.

Casi 900 de esas escuelas abrieron principalmente a clases en persona, según el estudio.

La investigación examina el período desde el 15 de julio hasta el 13 de septiembre. No nombra instituciones o ubicaciones específicas, pero los investigadores encontraron una correlación entre las escuelas que intentaron la instrucción en persona y mayores tasas de transmisión de enfermedades.

Los investigadores comprobaron que solo reabrir una universidad agregó 1.7 nuevas infecciones por día por cada 100,000 personas en un condado, y tener clases en persona se asoció con un aumento diario de 2.4 casos por cada 100,000.

“No se observa tal aumento en los condados sin universidades, con universidades cerradas, o aquéllas que abrieron principalmente en formato virtual”, dice el estudio.

Al tener en cuenta si los estudiantes provenían de lugares donde la incidencia de la enfermedad era alta, se agregaron 1.2 casos diarios por cada 100,000 personas.

Los recuentos diarios de casos nuevos en todo el país durante el período analizado en el estudio oscilaron entre un máximo de 70,000 nuevos casos por día y un mínimo de 30,000, según datos compilados por The New York Times.

Los autores no dicen exactamente que fue un error que se hayan abierto universidades, considerando las muchas variables que enfrentó cada escuela.

Pero informes anteriores sobre los planes de reapertura en todo el país fueron confusos y caóticos, y  no se ajustaban a ningún estándar, lo que ya pronosticaba un potencial de desastres cuando los estudiantes regresaran.

De hecho, surgieron numerosos informes en todo el país que mostraban picos de COVID-19 en ciudades universitarias, a menudo atribuidos a las fiestas de los estudiantes. Incluso en la Universidad de Illinois, elogiada por sus preparativos, ha habido más de 2,000 casos en el campus desde que los estudiantes comenzaron a regresar en agosto.

Los casos alcanzaron su punto máximo una semana después de que comenzaran las clases y han disminuido desde entonces.

Los autores tampoco culpan a los jóvenes irresponsables, ya que estudiaron métodos de estudio, no comportamientos fuera del campus, donde algunos estudiantes han actuado de manera extremadamente pobre.

“Creo que es un poco injusto decir: ‘Oh, los estudiantes se están reuniendo y generando estos malos comportamientos que conducen a brotes’”, dijo Bento. “Creo que es más la idea de cuando ves una gran afluencia de todo el país, o de diferentes condados, a una ciudad universitaria que sabemos que tuvo una carga muy baja de COVID durante los primeros meses y, de repente, tenemos esta mayor probabilidad de infección, porque tenemos una gran comunidad de individuos que aún eran susceptibles”.

Agregó que, en lugar de buscar responsables, la idea del estudio era medir el problema y luego usar esos datos para averiguar cómo responder mejor, que es el tema de un estudio futuro.

“Para que la escuela pueda abrir en línea, en formato híbrido o cara a cara, debe haber una combinación diferente de estrategias que permitan detectar [casos] temprano, de modo que se pueda controlar la propagación en la comunidad, que es el mayor problema aquí “, dijo Bento.

Los investigadores esperan terminar ese trabajo relativamente pronto, mucho antes de que las universidades comiencen los nuevos semestres de primavera.

Algunas preguntas se respondieron, como cuánto del aumento en los casos se debe simplemente a que los estudiantes enfermos dan positivo cuando llegan, y cuánto proviene de la propagación del virus después de su llegada.

Otro es qué tan bien funcionaron acciones específicas para frenar la propagación, y si las diferentes medidas de seguridad locales ayudaron o perjudicaron.

Y hay una advertencia alarmante. Es casi seguro que el trabajo no capturó todo el alcance del aumento vinculado a los campus.

“Si bien este estudio estima alrededor de un aumento de 3,000 casos diarios, debemos tener en cuenta que es probable que esto sea una subestimación, porque todavía no vemos a las personas que son asintomáticas”, dijo Bento.

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Colleges’ Opening Fueled 3,000 COVID Cases a Day, Researchers Say

Reopening colleges drove a coronavirus surge of about 3,000 new cases a day in the United States, according to a draft study released Tuesday.

The study, done jointly by researchers at the University of North Carolina-Greensboro, Indiana University, the University of Washington and Davidson College, tracked cellphone data and matched it to reopening schedules at 1,400 schools, along with county infection rates.

“Our study was looking to see whether we could observe increases both in movement and in case count — so case reports in counties and all over the U.S.,” said Ana Bento, an infectious disease expert and assistant professor at Indiana University’s School of Public Health.

“Then we tried to understand if these were different in counties where, of course, there were universities or colleges, and particularly, to see if these increases were larger in magnitude in colleges with face-to-face instruction primarily,” she said.

Nearly 900 of those schools opened primarily with in-person classes, according to the draft study.

The research examines the period from July 15 to Sept. 13. It does not name specific institutions or locations, but researchers found a correlation between schools that attempted in-person instruction and greater disease transmission rates.

Just reopening a university added 1.7 new infections per day per 100,000 people in a county, and teaching classes in person was associated with a 2.4 daily case rise, the study found.

“No such increase is observed in counties with no colleges, closed colleges or those that opened primarily online,” the study says.

Factoring in whether students came from places where disease incidence was high added 1.2 daily cases per 100,000 people.

Daily new case counts nationwide during the study period ranged from a high of 70,000 to a low of 30,000, according to data compiled by The New York Times.

The authors are not calling it a mistake for colleges to have opened, considering the many variables each school faced. But earlier reporting on reopening plans around the country found a welter of chaotic efforts that did not conform to a single standard, suggesting the potential for disaster when students returned.

In fact, numerous reports surfaced around the country showing frightening COVID spikes in college towns, often blamed on partying by students. Even at the University of Illinois, a school lauded for its preparations and robust testing, more than 2,000 cases have been reported on campus since students went back last month. Cases there peaked about a week after classes began and have fallen since then.

The authors are not faulting irresponsible young people, either, since they studied class instruction methods, not behavior off campus, where some students have acted extremely poorly.

“I think that it’s slightly unfair, perhaps, to say, ‘Oh, students are congregating and creating these bad behaviors that lead to outbreaks,’” Bento said. “I think it’s more this idea of when you see a huge influx from all over the country, or from different counties, into a college town that we know had a very low burden of COVID throughout the first months, all of a sudden we have this increased probability of infection, because we have a large community of individuals that were susceptible still.”

Rather than lay blame, she said, the idea of the study was to measure the problem and then use that data to better figure out how to respond, which is the subject of a future study.

“In order for you to open online, hybrid or meet face to face, there needs to be a different combination of strategies that allows you to catch [cases] early so you’re able to control community spread, which is the biggest problem here,” Bento said.

The researchers hope to have that work done relatively soon, well before colleges start spring semesters.

There are some unanswered questions, such as how much of the surge in cases is simply from sick students testing positive when they arrive versus catching COVID-19 after they arrive — and how much students spread the virus to the community or the other way around.

Another is how well specific types of responses mitigated the spread, and whether different local safety measures helped or hurt.

And there is an alarming caveat: The work almost certainly did not capture the full extent of the campus-linked surge.

“While this study estimates around a 3,000 increase in daily cases, we have to take into account that this is actually likely an underestimate, because we still don’t see” people who are asymptomatic, Bento said.

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Native Americans Feel Double Pain of COVID and Fires ‘Gobbling Up the Ground’

When the first fire of the season broke out on the Hoopa Valley Reservation in Northern California in July, Greg Moon faced a dilemma.

As Hoopa’s fire chief and its pandemic team leader, Moon feared the impact of the blaze on the dense coniferous forests of the reservation, near Redwood National and State Parks, where 3,000 tribal members depend on steelhead trout and coho salmon fishing. He was even more terrified of a deadly viral outbreak in his tribe, which closed its land to visitors in March.

“We’re a high-risk community because we have a lot of diabetes, heart disease and elders that live in multigenerational homes. If a young person gets it, the whole household is going to get it,” Moon said.

Eventually, the three major blazes that burned nearly 100,000 acres around Hoopa were too much for the tribe’s 25-member fire team. Moon had no choice but to request help from federal wildland rangers and other tribal firefighters.

Native American tribes are no strangers to fire. Working with flames to burn away undergrowth and bring nutrients and biodiversity back to lands is an ingrained part of their heritage. But epidemics are also a familiar scourge. With the devastation that pathogens like smallpox and measles brought to Native populations following the arrival of Europeans, tribes are especially wary of COVID-19’s impact.

“When thinking about the potential of COVID-19 repeating history and wiping out entire communities and tribes, there is concern,” said Vernon Stearns, who as the fuels manager for the Spokane Tribe in eastern Washington is responsible for organizing controlled burns.

Some tribes have abandoned traditional fire suppression techniques, watching large swaths of land burn in order to protect a more fragile and essential resource: their people.

“The biggest fear the tribe had was COVID would hit our elders. And they are a very valuable resource of knowledge and connection to our ancestry and teaching of our ways to our children, who we also felt were at risk, and we obviously want to protect them,” said Ron Swaney, fire management officer for the Confederated Salish and Kootenai Tribes in Montana.

“I’ve seen how [the virus] has affected families close to me. I know the grief,” said Don Jones, fire chief of the Yakama Nation reservation in central Washington, where there have been at least 28 COVID-19 deaths. “I’m not going to send sick people out to fight the fire. I’m not going to say, ‘Come on, guys, toughen up, go out there.’ Life takes precedence over that.”

Around the country, many tribes have full-time fire crews that traditionally aid one another and federal firefighters, sending out teams to help with blazes. But COVID-19 has pushed them to reconsider how much help they can give and receive. (CSKT Division of Fire)

Around the country, many tribes have full-time fire crews that traditionally aid one another and federal firefighters, sending out teams to help with blazes. But this year’s COVID-19 pandemic has pushed them to reconsider how much help they can give and receive in the face of encroaching infernos.

A Centers for Disease Control and Prevention study found Native Americans and Alaskans were 3.5 times more likely than whites to test positive for the coronavirus. The rapid spread of the virus within tribes early in the pandemic led many reservations to aggressively control outside access. Casinos closed. Entrances to tourist areas such as lakes, hiking trails and fisheries were blocked off. Economically many tribes suffered, but COVID caseloads stabilized or declined.

The ongoing fire season is now threatening that progress.

Tribal families often live in multigenerational housing, sometimes in trailers or other small homes with no running water. Their isolated, tightknit communities can be sequestered from COVID-19 spikes in nearby towns but are ripe for an outbreak if the virus enters. Social distancing is a challenge on small, remote reservations. There may be only a single gas station or supermarket, where visiting fire crews would be likely to interact with the tribal population. Many tribes also lack strong internet connections, forcing fire crews to meet in person rather than stage briefings via Zoom, as federal crews have done elsewhere during the pandemic.

On the Flathead Reservation north of Missoula, Montana, COVID-19 hit the fire crew of the Confederated Salish and Kootenai Tribes before the fires did. A firefighter who came in direct contact with someone who was sick with the virus in early July took the tribe’s entire 12-person aviation team, consisting of an air attack plane and a helicopter crew, out of business for four days. While no fires were burning at the time, it was a worrisome wake-up call for Swaney.

“For a minute there, I really thought we would all be infected with COVID-19 and I was wondering who would be responding to the fires,” he said.

It was enough to convince Swaney that this year the tribe wouldn’t share any of its 60 firefighters with neighbors. It was a tough call because historically “in fire, when our neighbors need help, we go help,” he said.

At the end of July, Swaney had to accept help from nearly 300 outside firefighters when lightning started a blaze in the mountains surrounding the bison-dotted grass valley his tribe calls home.

After the 3,500-acre Magpie Rock Fire was under control, Swaney learned that a federal wildland firefighter involved had tested positive for COVID-19 during his next assignment. He didn’t appear to have infected Swaney’s team, though four members have tested positive this season.

“We’ve had a lot of close calls,” he said.

Other tribes have sought to bolster their fire crews to do without the help of off-reservation teams. The Spokane Tribe in Washington earmarked some of the $19 million it received from the CARES Act to hire an additional 10-person seasonal crew. It hoped to aggressively attack any fire and keep it small, thereby avoiding the need for outside firefighters who might also bring in the coronavirus, Stearns said.

The Yakama Nation, near the Oregon border, was still struggling with a coronavirus outbreak that had infected at least 6% of its population when fires started in July. The crews learned quickly that facing wildfire and a pandemic simultaneously would be an exercise in trade-offs.

Early in the effort, five fire crew members were taken off the line when several people got sick, leaving the 20 remaining members to make do. Federal firefighting is stretched thin as megafires consume vast areas of the West Coast — and other tribes were no help because they’ve restricted their fire teams’ movement to prevent COVID spread.

“We had no one else to call on. … It was pretty tough,” said Jones. “The stress level has gone up. You’re worried about exposure all the time.”

Ultimately, eight Yakama crew members tested positive for COVID-19. One of the firefighters who tested positive had already lost two family members to the virus. Another spread COVID-19 to a family member who ended up at the hospital on a ventilator but survived.

“Everyone in my program was affected one way or another,” Jones said. “Everyone lost somebody.”

The West’s brutal fire season is forcing tribes to concentrate on fires that start by lightning or accident, with no resources to give to prescribed burning.

“These fires are just gobbling up the ground,” said Jones. His tribe canceled the carefully controlled fires it normally conducts in September to avoid bringing together the large numbers of people needed to do them.

“Fires are just going to get bigger,” Jones said. “If we can’t do anything about it, we can’t do anything about it. We have to make sure everyone’s healthy first.”

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

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Rural Hospitals Teeter on Financial Cliff as COVID Medicare Loans Come Due

Note to Readers: Sarah Jane Tribble spent more than a year and half reporting on a small town in Kansas that lost its only hospital. This month, KHN and St. Louis Public Radio will launch “Where It Hurts,” a podcast exploring the often painful cracks growing in America’s health system that leave people vulnerable — and without the care they need. Season One is “No Mercy,” focusing on the hospital closure in Fort Scott, Kansas — and what happens to the people left behind, surviving the best way they know how. You can listen to Episode One on Tuesday, Sept. 29.

David Usher is sitting on $1.7 million he’s scared to spend.

The money lent from the federal government is meant to help hospitals and other health care providers weather the COVID-19 pandemic. Yet some hospital administrators have called it a payday loan program that is now, brutally, due for repayment at a time when they still need help.

Coronavirus cases have “picked up recently and it’s quite worrying,” said Usher, chief financial officer at the 12-bed Edwards County Medical Center in rural western Kansas. Usher said he would like to use the money to build a negative-pressure room, a common strategy to keep contagious patients apart from those in the rest of the hospital.

But he’s not sure it’s safe to spend that cash. Officially, the total repayment of the loan is due this month. Otherwise, according to the loan’s terms, federal regulators will stop reimbursing the hospitals for Medicare patients’ treatments until the loan is repaid in full.

The federal Centers for Medicare & Medicaid Services has not yet begun trying to recoup its investment, with the coronavirus still affecting communities nationwide, but hospital leaders fear it may come calling for repayment any day now.

Hospital leaders across the country said there has been no communication from CMS on whether or when they will adjust the repayment deadline. A CMS spokesperson had not responded to questions by press time.

“It’s great having the money,” Usher said. “But if I don’t know how much I get to keep, I don’t get to spend the money wisely and effectively on the facility.”

Usher took out the loan from Medicare’s Accelerated and Advance Payments program. The program, which existed long before the pandemic, was generally used sparingly by hospitals faced with emergencies such as hurricanes or tornadoes. It was expanded for use during the coronavirus pandemic — part of billions approved in federal relief funds for health care providers this spring.

A full repayment of a hospital’s loan is technically due 120 days after it was received. If it is not paid, Medicare will stop reimbursing claims until it recoups the money it is owed — a point spelled out in the program’s rules. Medicare reimburses nearly $60 billion in payments to health care providers nationwide under Medicare’s Part A program, which makes payments to hospitals.

More than 65% of the nation’s small, rural hospitals — many of which were operating at a deficit before the pandemic — jumped at the Medicare loans when the pandemic hit because they were the first funds available, said Maggie Elehwany, former vice president of government affairs for the National Rural Health Association.

CMS halted new loan applications to the program at the end of April.

“The pandemic has simply gone on longer than anyone anticipated back in March,” said Joanna Hiatt Kim, vice president of payment policy and analysis for the American Hospital Association. The trade association sent a letter to CMS in late July asking for a delay in the recoupment.

On Monday, the House Appropriations Committee included partial relief for all hospitals in a new government funding plan. The committee’s proposal would extend the start of the repayment period for hospitals and the amount of time they are allowed to take to repay.

The continuing resolution that includes this language about relief for hospitals (among many, many other things) is still being hammered out, though it does face its own deadline: It must be approved by the House and the Senate within the next nine days or the federal government faces a shutdown.

Tom Nickels, executive vice president at the AHA, said his organization appreciates the House committee’s effort to address the loans in the new bill, but full forgiveness of the loans is still needed.

Sen. Jeanne Shaheen (D-N.H.) has called for changes to the loan repayment period for months and said Monday “our work is far from over.”

“We are still in the middle of this crisis — from both health and economic standpoints,” Shaheen said.

Meanwhile, hospital administrators like Peter Wright are holding their breath, waiting to see if, in order to settle the debt, Medicare will stop making payments to hospitals, even as facilities continue to grapple with coronavirus in their communities.

“The feds, if you owe them money, they just take it,” said Wright, who oversees two small hospitals for Central Maine Healthcare in Bridgton, Maine. He said his health care system took the money because “we had no other choice; it was a cash flow issue.”

For many hospitals, Medicare payments make up 40% or more of their revenue. Not being reimbursed by Medicare would be crippling — akin to a household losing nearly half its income.

“We have no idea what we’re going to do if we have to pay it back as quickly as they say,” Wright said.

In rural Kentucky, hospital executive Sheila Currans said she “vacillated” for about a week or so trying to decide whether to tap the loan program for her hospital — she knew it would have to be repaid and worried that could prove difficult.

Sheila Currans, chief executive of Harrison Memorial Hospital in Cynthiana, Kentucky, with Senate Majority Leader Mitch McConnell during his recent tour of the small, rural hospital. McConnell has visited more than 30 health care providers in Kentucky since the beginning of summer, staff members say. (Lesley Roark)

“It was a desperate time,” said Currans, chief executive of Harrison Memorial Hospital in Cynthiana, Kentucky. Harrison Memorial was the first hospital in Kentucky to treat a COVID-19 patient in early March, she said.

The hospital immediately quarantined dozens of staff members and shut down elective procedures. And with COVID confirmed in the community, there was a “horrible fear,” Currans said, of getting infected that kept people from seeking outpatient care as well.

“Through March and April and most of May, I was in a complete spiral,” Currans said. By the end of April, Currans said, her hospital was losing millions of dollars. To cope with the pandemic, she furloughed staff and turned one wing of the hospital into a “cough clinic” to be used exclusively by patients whose symptoms suggested they might be infected with the coronavirus.

Currans said the hospital is still seeing COVID cases, but patients are beginning to return for other services, such as outpatient clinics.

In terms of the hospital’s finances, “it’s still not a wonderful time,” Currans said. The Medicare loan “as well as all the other support from the federal government helped us at least — for now — survive it.”

She’s hoping the repayment demand will be pushed back to 2021 or, perhaps the loan will be forgiven.

“I know it’s a pipe dream,” Currans said. “But this has been a historic event.”

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It’s Not Just Insulin: Lawmakers Focus on Price of One Drug, While Others Rise Too

Michael Costanzo, a Colorado farmer diagnosed with multiple sclerosis in 2016, has a well-honed ritual: Every six months, he takes an IV infusion of a medicine, Rituxan, to manage his disease, which has no cure. Then he figures out how to manage the bill, which costs thousands of dollars.

For a time, the routine held steady: The price billed to his health insurance for one infusion would cost $6,201 to $6,841. Costanzo’s health insurance covered most of it, and he paid the rest out-of-pocket.

But last fall the cost for the same 20-year-old drug and dosage jumped to $10,320, even though he was covered by the same insurance.

“Why does it have to increase in price all of a sudden?” wondered Costanzo, who lives in a small town about 50 miles north of Denver.

“I think greed is a huge problem,” he said.

As drug prices spiral upward, politicians in Washington, D.C., and in state governments across the country have sought to address the problem in limited ways, focusing mostly on one drug: insulin, a drug more than 7 million Americans rely on to manage diabetes and whose price tag more than doubled from 2012 to 2017.

With comprehensive drug price legislation stalled in Washington during the COVID-19 state of emergency, seven states in the midst of the pandemic enacted insulin payment caps of less than $100 per month, bringing the total to eight; five more have proposed legislation. In March, President Donald Trump’s health officials announced a Medicare test project limiting seniors’ monthly out-of-pocket costs to $35. In July, he signed four executive actions targeting insulin and a handful of other medications, boasting, “It’s going to have an incredible impact.”

Insulin took center stage last year, after moving demonstrations by mothers who caravanned to Canada to buy lifesaving medicine for their children at a tenth of the U.S. price; they swarmed the halls of Congress.

The measures that have resulted so far have not solved a far more widespread problem: escalating drug prices across the board — a problem that voters, left and right, say Congress must fix.

Underlying the problem is that lawmakers spent much of last year at loggerheads about whether the federal government should have the power to set prices or limit price increases. Prospects of comprehensive legislation already in the works slipped away this spring as Congress turned its focus to the COVID-19 pandemic that has killed more than 150,000 Americans and tanked the country’s economy.

So state lawmakers played whack-a-mole, targeting the drug with the most notoriety, and tackled insulin’s cost to patients. But patients like Costanzo — among the millions who rely on other vital drugs — struggle evermore to afford unchecked price increases for everything from HIV/AIDS and depression to asthma, autoimmune disorders and Type 2 diabetes.

A 2019 survey from the Scripps Research Translational Institute published in the Journal of the American Medical Association found that the costs of 17 top-selling brand-name drugs more than doubled from 2012 to 2017. Many of the drugs that made the list are household names: Lipitor and Zetia for high cholesterol, Advair and Symbicort for asthma, Lyrica for pain and Chantix for smoking cessation.

“The general public doesn’t realize this is happening with all sorts of drugs,” Costanzo said. “We’re all suffering from increased prices.”

***

Insulin was a natural poster child for pharmaceutical greed, encapsulating America’s problem with high drug prices in a neat package that few, if any, other medications do as effectively.

“You have an illustration of the problem — politics gone awry and capitalism gone awry,” said Celinda Lake, a veteran Democratic pollster. “They think of it as being emblematic of everything that’s going on with the system.”

Three pharmaceutical companies dominate the market for the diabetes treatment that has essentially the same formula as when it was introduced in the 1920s. Not taking insulin can quickly turn fatal. In 2017, Minnesota resident Alec Smith died at age 26 after rationing his insulin because he couldn’t afford it.

People dying “is what it takes for Congress to actually commit money and act, and then we solve these problems eventually,” said Andy Slavitt, who was acting head of the U.S. Centers for Medicare & Medicaid Services in the Obama administration.

Yet proponents of lowering drug costs say an effort centered on a single drug could backfire, and it did when COVID captured center stage.

“Everywhere in this country people are angry about their drug prices,” said David Mitchell, founder of Patients for Affordable Drugs Now, a Washington, D.C.-based group that lobbies Congress and runs campaign ads in support of lower prices. “The people with cancer, the people with autoimmune problems, the people with multiple sclerosis, the people who are taking a variety of drugs that are wildly overpriced, are going to say, ‘Now, wait a minute, what about me?’”

In early March, University of Pittsburgh researchers published research finding that, without discounts, list prices of brand-name drugs were rising about 9% a year. Late last year, House Democrats passed a bill that would let the federal government set prices for hundreds of drugs and cap seniors’ out-of-pocket costs for medication at $2,000. Trump opposed the bill, calling on Congress to send him a drug pricing bill that has bipartisan support.

“Let’s be clear — these price hikes aren’t because the medicines got better or there was a significant increase in research and development,” said Sen. Chuck Grassley (R-Iowa) in a March 5 floor speech. The chairman of the Senate’s powerful Finance Committee spearheaded a bipartisan drug pricing bill with Oregon Sen. Ron Wyden, a Democrat. “No, this was because the pharmaceutical companies could do it and get away with it.”

While Congress dithers and the topic periodically becomes the subject of a presidential tweet, patients continue to fend for themselves.

Tara Terminiello has seen the total underlying cost of her son’s anti-seizure medication, Topamax, skyrocket to about $1,300 a month, hundreds more than when he started taking it over a decade ago.

In Texas, Joseph Fabian, a public school teacher in San Antonio with health insurance through his job, has relied on inhalers since childhood to manage his allergy-induced asthma. In February 2019, he paid $330.98 for a three-pack of Symbicort inhalers, which he typically uses twice a day but more frequently during allergy season.

A year later and after a change in his health insurance plan, Fabian’s costs tripled, to $348.95 for a single inhaler, he said in an interview. According to the Scripps’ drug pricing study, the median cost of Symbicort rose from $225 in January 2012 to $308 in December 2017.

“There’s no way I can keep working out $350 every month and a half,” Fabian said.

***

Chances that Congress will pass comprehensive drug pricing legislation before the 2020 election have slipped away as lawmakers focus on additional COVID-19 relief. Moreover, the Trump administration, Congress and the public are now hoping for pandemic deliverance by the very same drug companies that have been raising prices as they develop potential virus treatments and vaccines. PhRMA, the powerful industry trade group, has seized the moment with ad campaigns emphasizing the sector’s enormous value.

The stalemate provides little solace for patients like Costanzo, whose medicine, Rituxan, made by Genentech, was first approved by the Food and Drug Administration in 1997 to treat lymphoma and can be used off-label for MS. It is one of seven medications with price increases unsupported by new clinical evidence, according to a report from the Institute for Clinical and Economic Review. ICER noted that over 24 months, the net price — the price after any discounts from drug companies are factored in — “increased by almost 14%, which results in an estimated increase in drug spending of approximately $549 million.”

In a statement, Genentech spokesperson Priscilla White said ICER’s analysis was “significantly limited” because it didn’t account for “meaningful, high-quality, and peer-reviewed evidence supporting the clinical and economic benefits of Rituxan.” White said the company did not increase Rituxan’s price during the period in which Costanzo’s bill rose and wouldn’t speculate on the change without knowing “other factors” that may have contributed.

“We take decisions related to the prices of our medicines very seriously, taking into consideration their value to patients and society, the investments required to continue discovering new treatments, and the need for broad access,” she said.

Costanzo was prescribed the drug by two neurologists and hasn’t had any acute relapses since he started the infusions. He eventually did get a financial reprieve, not thanks to Washington, but by enrolling in a patient discount program operated by the very drug company that sets Rituxan’s price, a program he said was an “absolute lifesaver” financially.

Genentech said its patient foundation provides free medicine to more than 50,000 patients each year. Costanzo got his first free dose in July.

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Medicare Pharmaceuticals Public Health States

Trump-Biden Race Could Hinge on How Florida’s Pinellas County Swings

CLEARWATER, Fla. — Betty Jones voted for President Donald Trump in 2016, but the lifelong Republican has her doubts she will do it again this year.

The federal response to the coronavirus pandemic that has killed about 200,000 Americans and forced older adults to restrict their activities has her contemplating a leadership change.

It “makes me unsure,” said Jones, 78, of Largo, in Pinellas County, Florida. Before COVID-19, she said, she would have definitely voted for Trump.

Polls show that many people will have the pandemic and its public health and economic consequences on their minds when they cast their votes — whether by mail or in person — this fall. Early in-person voting starts Oct. 19 in most Florida counties, including Pinellas.

Even if the issue leads a tiny proportion of them to change their choice for president, it could have huge consequences in battleground states like Florida, which Trump carried in 2016 by about 1 percentage point.

Within the Sunshine State, few places loom as large in the race for the White House as here in Pinellas County, the largest swing county in the ultimate swing state.

Pinellas, with nearly 1 million residents, has been a political bellwether in recent years, having voted for the winning presidential candidate in every election since 1980 — except for the disputed race between George W. Bush and Al Gore in 2000.

This county just east of Tampa known for its sugar-white beaches is nearly evenly split between the major parties, with 251,000 registered Democrats and 245,000 registered Republicans. An additional 200,000 voters registered as independents.

The city of St. Petersburg, in the southern part of the county, is a Democratic stronghold, while the northern half of the county is more Republican. The county is largely a white suburban area, with a large, older middle-class electorate.

President Barack Obama twice won Pinellas — and Florida — but Trump outpaced Hillary Clinton here by 5,500 votes out of the nearly 500,000 cast.

Democrats are hoping Pinellas will help tip the statewide balance to former Vice President Joe Biden this fall — and they expect a boost from residents spooked by the pandemic. The county has been hit hard by COVID-19 with more than 20,000 cases, 2,000 hospitalizations and 700 deaths. It has the highest COVID-19 death rate of the state’s most populous counties.

Older voters have been deeply affected by the coronavirus since they face a high risk of serious complications and have had to curtail their lives dramatically to avoid the virus. Steve Schale, a Democratic strategist in Tallahassee, said those factors should help Biden do well with this key voting group. About 1 in 4 Pinellas voters are 65 or older.

“There is no world where we win Florida without Pinellas,” Schale said. “If we win there by a few points, it’s a harbinger of good things.”

A tiny shift in voter preferences could have major implications, he added.

“We are talking like 4% to 5% of the electorate in Florida is truly up for grabs, but in a state where the vote was decided by 1%, that is a huge chunk of the electorate,” Schale said.

While about one-third of Florida voters said the economy was their leading issue in the presidential campaign, Democrats were seven times more likely than Republicans to cite the coronavirus outbreak as their top issue, according to a KFF and Cook Political Report survey of three Sun Belt states released Thursday. Nearly a third of Democrats said the pandemic is their most important issue, while just 4% of Republicans and 17% of independents chose the coronavirus outbreak.

The poll of 1,009 Florida voters was conducted Aug. 29 to Sept. 13. The margin of error for Florida results is plus or minus 4 percentage points.

The survey found Biden and Trump virtually tied in Florida with 11% undecided.

National surveys show the pandemic — and its impact on the U.S. economy — are key issues for voters.

A Pew Research Center poll in August found that 62% of voters overall say the outbreak will be a very important factor in their decision about whom to support in the fall. For Trump supporters, however, the economy (88%) and violent crime (74%) are the most salient issues.

By contrast, the largest shares of Biden supporters view health care (84%) and the coronavirus outbreak (82%) as very important. According to an August Georgetown University poll of Florida and other battleground states, 38% of respondents said they approve of how Trump is handling COVID-19, while 60% said they disapprove.

John Andrew Barnes, 33, of Largo, said he knew he liked Biden before the pandemic, but the Trump administration’s response to COVID-19 reinforced his decision. Trump’s “blatant distrust” of the Centers for Disease Control and Prevention and other experts and what Barnes viewed as a lack of national response left him unsatisfied, he said.

Yet, among Republicans, the president’s decisions on coronavirus policies have played well and some are nervous that Biden’s efforts to curb the virus might undercut the economy even more.

Ricard Gregorie, 54, of Largo, said the federal government’s response to the pandemic has “absolutely been incredible.” For Gregorie, the quick distribution of ventilators and maintaining an open economy were decisions that reaffirmed his support for Trump. “We can’t ask for miracles,” he said.

Carl Joyner, 35, a firefighter who lives in St. Petersburg, said COVID-19 has not affected his support for Trump. He opposes anyone who wants to force him to wear a mask. He backs Trump’s position to quickly open businesses and schools.

“People are living paycheck to paycheck here and the hospitality industry here really got lambasted,” he said.

Anthony Pedicini, a GOP political consultant based in Tampa, said the pandemic may not have a big influence because most voters were locked in on their choice for president before the pandemic hit. “If you didn’t like the president before the pandemic you don’t like him after,” Pedicini said. “But if you liked him before you still will.”

That’s also what more than a dozen Pinellas voters said in interviews in shopping centers over the past month.

Pinellas has a large working-class community that is trending Republican, Pedicini said. It’s a county in transition with many elders aging out and a younger, more diverse population moving in.

Most political experts say that even in swing counties fewer than 10% of voters switch their party support from election to election. As a result, victory likely depends on who can turn out his base of voters.

In Florida, Hispanic as well as Black turnout declined markedly in 2016, from 59% in 2012 to 52%, according to the nonpartisan Brookings Institution.

Given Trump’s poor approval ratings, the upheaval in the economy and polls showing voters’ disdain of the federal response to the pandemic, there is just no way you would expect the president to win reelection, said Stephen Craig, a political science professor at the University of Florida. “If history holds, Joe Biden will be president. But Trump is a candidate who breaks all the rules.”

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California’s Deadliest Spring in 20 Years Suggests COVID Undercount

The first five months of the COVID-19 pandemic in California rank among the deadliest in state history, deadlier than any other consecutive five-month period in at least 20 years.

And the grim milestone encompasses thousands of “excess” deaths not accounted for in the state’s official COVID death tally: a loss of life concentrated among Blacks, Asians and Latinos, afflicting people who experts say likely didn’t get preventive medical care amid the far-reaching shutdowns or who were wrongly excluded from the coronavirus death count.

About 125,000 Californians died from March through July, up by 14,200, or 13%, from the average for the same five months during the prior three years, according to a review of data from the state Department of Public Health.

By the end of July, California had logged about 9,200 deaths officially attributed to COVID-19 in county death records. That left about 5,000 “excess” deaths for those months — meaning deaths above the norm not attributed to COVID-19. Deaths tend to increase from year to year as the population grows, but typically not by that much.

A closer look at California’s excess deaths during the period reveal a disturbing racial and ethnic variance: All the excess deaths not officially linked to COVID infection were concentrated in minority communities. Latinos make up the vast majority, accounting for 3,350 of those excess deaths, followed by Asians (1,150), Blacks (860) and other Californians of color (350).

The overall number of excess deaths across all races and ethnicities was ultimately tempered because, compared with the three prior years, there were actually 383 fewer deaths among white Californians than would be expected in the absence of COVID-19. In addition, California Healthline adjusted the overall numbers to reflect more than 320 COVID deaths that could not be categorized by race or ethnicity because that information was missing from state records.

Several epidemiologists interviewed said they believe a sizable portion of the excess deaths among people of color did, in fact, stem from COVID infections but went undetected for a variety of reasons. Among them: a shortage of coronavirus tests in the early months of the pandemic; an uneven strategy for how and when to administer those tests, which persists; and inadequate access to health care providers in many low-income and immigrant communities.

Dr. Kirsten Bibbins-Domingo, chair of the Department of Epidemiology and Biostatistics at the University of California-San Francisco, is among those who suspect the excess deaths reflect a COVID undercount in minority communities. She noted that several chronic health conditions that disproportionately affect Blacks and Latinos — including diabetes, high blood pressure and heart disease — also place them at higher risk for severe complications from COVID-19.

In addition, Bibbins-Domingo said, the prolonged shutdown of medical offices in the early months of the pandemic — and with them non-urgent surgeries and routine medical care — likely accelerated death among people with those chronic conditions.

“Shutdowns always come at a cost,” she said. “It is our most marginalized communities that experience the cost of a shutdown.”

According to state Department of Public Health data, deaths in California attributed to diabetes rose 12% from March through July when compared with the average for the same period over the past three years. In addition, deaths attributed to Alzheimer’s disease rose 11%.

“Dementia is also a disease where we have racial, ethnic minorities already at greater risk,” said Andrea Polonijo, a medical sociologist at the University of California-Riverside. “Now that we have the pandemic, they’re more socially isolated. Social isolation we know can cause deeper cognitive decline.”

It’s hard to determine whether a death is due to COVID-19 if the victim never sought medical care, said Jeffrey Reynoso, executive director of the nonprofit Latino Coalition for a Healthy California. Latinos in California are less likely to have health insurance, he said. They may face language barriers if their medical provider — or contact tracer — does not speak Spanish. Latino immigrants working in the U.S. without authorization may hesitate to visit the doctor.

“Immigration is definitely a driver in creating a fear and a mistrust of systems, and that includes our health care system,” Reynoso said.

Polonijo said the fact that Latinos make up the bulk of the excess deaths correlates with their dominant role in farming, meat processing, manufacturing and food service, jobs all deemed essential during the pandemic.

“This population is also more likely to live in more crowded conditions,” she said. “So not only are they exposed at work, but they are bringing disease home and with it the possibility of spreading it to their family, bringing it to the community.”

Bibbins-Domingo noted that, while a major portion of COVID deaths overall have occurred among seniors and nursing home residents, a disproportionate number of the state’s excess deaths are of working-age adults.

“The excess deaths that we’re seeing in communities of color and in low-income communities are deaths that are occurring at younger ages,” she said. “These are deaths that are occurring in these ages from 20 to 60, generally speaking — the ages when people would be out working.”

Kathy Ko Chin, president of the Oakland-based Asian & Pacific Islander American Health Forum, said Asian Americans also tend to be overrepresented in essential worker occupations, noting that a large proportion of the state’s nurses are Filipino. In addition, she said, government officials have not done enough to translate COVID educational materials into the many languages spoken by California’s Asian Americans. The Trump administration’s rhetoric on immigration during the past four years, she added, has had a “chilling effect” that has kept many foreign-born Asian Americans from visiting a doctor.

“People were really, really scared,” Chin said.

Counties in Southern California and the largely rural Central Valley — places with a high proportion of Latino residents — tended to have high rates of excess deaths from March to July. Among counties with at least 100,000 people, Kings County, an arid expanse north of Los Angeles that is home to industrial-scale agriculture, had the highest rate of excess deaths per capita.

Officials at the Kings County Department of Public Health did not return a message seeking comment.

Bibbins-Domingo and others said it is important for state and county health officials to take a hard look at their excess death numbers. Excess deaths matter, she said, because they expose shortcomings in health care delivery. In addition, local and state responses to COVID-19 are grounded in data; if that data is inaccurate, the responses may be misguided.

“Deaths are important because they also help us to understand how much severe COVID is there in the community that we have to worry about,” Bibbins-Domingo said. “I think when we undercount that, we both fly blind for the overall pandemic management, and we might fly particularly blind in understanding the impact of the pandemic in particular communities.”

Phillip Reese is a data reporting specialist and an assistant professor of journalism at California State University-Sacramento.

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

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¿Regalo para Florida? Trump aprobaría pronto importación de medicamentos de Canadá

A pesar de las objeciones de las farmacéuticas, se espera que la administración Trump finalice, en pocas semanas, el plan que permitiría a los estados importar de Canadá algunos medicamentos de venta bajo receta.

Seis estados —Colorado, Florida, Maine, New Hampshire, New México y Vermont— tienen leyes que les permiten solicitar la aprobación federal para comprar medicamentos de Canadá a fin de dar a sus residentes acceso a medicamentos de menor costo.

Pero los expertos dicen que la importación de medicamentos propuesta por el gobierno se ha hecho pensando en Florida, el estado más poblado y disputado en las elecciones de noviembre. El apoyo de Trump a esta idea surgió, en un principo, a petición del gobernador de Florida, Ron DeSantis, un estrecho aliado republicano.

El gobierno de DeSantis confía tanto en que Trump seguirá adelante con la importación de medicamentos que, el 30 de junio, solicitó a las empresas que licitaran por un contrato de tres años y $30 millones para llevar a cabo el programa. Espera adjudicar el contrato en diciembre.

Los expertos de la industria dicen que es probable que Florida sea el primer estado en obtener la aprobación federal para un plan de importación de medicamentos, algo que podría ocurrir antes de las elecciones de noviembre.

“Aprobar a Florida sería lo más astuto políticamente”, dijo Mara Baer, una consultora de salud con sede en Colorado que ha trabajado con el estado en su propuesta de importación.

Ben England, CEO de FDAImports, una consultora de Glen Burnie, Maryland, indicó que la OMB normalmente tiene 60 días para revisar la normativa final, aunque espera que ésta se complete antes del 3 de noviembre y vaticinó que hay una pequeña posibilidad de que se finalice y se apruebe la solicitud de Florida para entonces. “Es un año de elecciones, así que veo a la actual administración tratando de usar esto como un tema electoral para decir ‘Mira lo que hemos logrado’”, señaló.

Florida es también una opción lógica debido al gran número de jubilados que se enfrentan a los altos costos de los medicamentos, a pesar de la cobertura de Medicare.

La administración de DeSantis no respondió a las solicitudes de comentarios.

Trump alardeó de su plan de importación durante un discurso, en octubre, en The Villages, una gran comunidad de jubilados a unas 60 millas al noroeste de Orlando. “Pronto permitiremos la importación segura y legal de medicamentos de venta con receta de otros países, incluido Canadá, donde, lo crean o no, pagan mucho menos por el mismo medicamento”, dijo Trump, hablando al lado de DeSantis.

La Administración de Alimentos y Medicamentos (FDA) hizo pública una detallada propuesta, en diciembre pasado, y solicitó comentarios. El plan final llegó el 10 de septiembre a la Oficina de Administración y Presupuesto para su revisión, señalando que podría ver la luz en semanas.

La propuesta regularía la forma en que los estados establecen sus propios programas para importar medicamentos de Canadá.

Los precios son más baratos porque Canadá limita la cantidad que las farmacéuticas pueden cobrar por los medicamentos. Estados Unidos deja que el mercado dicte los precios de los medicamentos.

La industria farmacéutica señaló que probablemente demandará a la administración Trump si sigue adelante con sus planes de importación, alegando que el plan incumple varias leyes federales y la Constitución de los Estados Unidos.

Pero la reprimenda más dura al plan de importación de Trump llegó de Canadá. El gobierno canadiense se quejó diciendo que ese plan haría más difícil el acceso a los medicamentos para sus ciudadanos, poniendo en riesgo su salud.

“Canadá empleará todas las medidas necesarias para salvaguardar el acceso de los canadienses a los medicamentos”, escribió el gobierno canadiense en una carta a la FDA sobre la propuesta. “El mercado de medicamentos canadiense y su capacidad de fabricación son demasiado pequeños para satisfacer la demanda de medicamentos de venta con receta, de los consumidores canadienses y estadounidenses”.

Sin la participación de Canadá, es poco probable que un plan de importación de medicamentos tenga éxito, aseguraron las autoridades.

Ena Backus, directora de Reforma de Salud en Vermont, que ha trabajado en el establecimiento de un programa de importación, señaló que los estados necesitarán ayuda de Canadá. “Nuestro programa de importación estatal depende de que Canadá se asocie con nosotros”, comentó.

Durante décadas, los estadounidenses han estado comprando medicamentos de Canadá para uso personal, ya sea conduciendo al otro lado de la frontera, ordenando medicamentos por Internet o por medio de comercios que los conectan con farmacias extranjeras. Aunque es ilegal, la FDA ha permitido, por lo general, compras para uso individual.

Unos 4 millones de estadounidenses importan cada año medicamentos de bajo costo para uso personal, y unos 20 millones dicen que ellos o alguien de su familia lo han hecho porque los precios son mucho más bajos en otros países, según las encuestas.

Esta práctica está muy extendida en Florida. Más de una docena de comercios en todo el estado ayudan a los consumidores a conectarse con las farmacias de Canadá y otros países. Varias ciudades, estados y distritos escolares de Florida ayudan a los empleados a obtener medicamentos de Canadá.

La propuesta de la administración se basa en una ley del año 2000 que abrió la puerta para permitir la importación de medicamentos de Canadá. Sin embargo, esa ley sólo podría entrar en vigor si el Secretario del Departamento de Salud y Servicios Humanos (HHS) certificara que la importación es segura, algo que administraciones demócratas y republicanas se han negado a hacer.

La industria farmacéutica ha dicho, durante años, que permitir la importación de medicamentos de Canadá perturbaría la cadena de suministro del país y facilitaría la entrada en el mercado de medicamentos inseguros o falsificados.

Trump, que hizo de la reducción de los precios de los medicamentos con receta una promesa de su campaña en 2016, ha presionado para cumplir con lo prometido. En julio de 2019, por orden de Trump, el Secretario del HHS, Alex Azar, dijo que el gobierno federal estaba “abierto al negocio” de la importación de medicamentos, cuando un año antes había calificado la importación de medicamentos como “un truco”.

La administración prevé un sistema en el que un mayorista con licencia canadiense compra directamente a un fabricante medicamentos aprobados para su venta en Canadá y los exporta a un mayorista/importador de Estados Unidos que tiene contrato con un estado.

La legislación de Florida, aprobada en 2019, establecería dos programas de importación. El primero se centraría en la obtención de medicamentos para programas estatales como Medicaid, el Departamento de Prisiones y los departamentos de Salud de los condados. Los funcionarios estatales dijeron que esperan que los programas ahorren al estado unos $150 millones anuales.

El segundo programa estaría dirigido a la población del estado en general.

En respuesta al borrador de la normativa, los estados que desean iniciar un programa de importación de medicamentos sugirieron cambios a la propuesta de la administración.

“Si la normativa final no aborda estas áreas de preocupación, Colorado tendrá dificultades para encontrar socios apropiados y lograr ahorros significativos para los consumidores”, le comunicó a la FDA, en marzo, Kim Bimestefer, directora ejecutiva del Departamento de Políticas y Financiación de Atención Médica de Colorado.

Entre las preocupaciones del estado figura la limitación a trabajar con un solo mayorista canadiense, ya que al no haber competencia el estado teme que los precios no sean tan bajos como los funcionarios esperaban. Bimestefer también señaló que, según la propuesta, el gobierno federal aprobaría el programa de importación por sólo dos años y los estados necesitan un plazo más largo para conseguir la participación de los mayoristas y otros socios.

Los funcionarios de Colorado estiman que la importación de medicamentos de Canadá podría reducir los precios en un 54% para los medicamentos contra el cáncer y en un 75% para los medicamentos del corazón. El estado también señaló que el medicamento para la diabetes Jardiance cuesta $400 al mes en los Estados Unidos y se vende por $85 en Canadá.

A algunos estados les preocupa que medicamentos caros, incluyendo los inyectables y los biológicos, no figuren en la propuesta federal. Según la ley del 2000, no se permite la importación de ese tipo de medicamentos.

Pero, según una orden ejecutiva de julio, Trump aseguró que permitiría la importación de insulina si Azar determinaba que era necesaria para la atención médica de emergencia. Un portavoz del HHS no pudo confirmar si Azar ha hecho eso.

Jane Horvath, consultora de políticas de salud en College Park, Maryland, dijo que la administración enfrenta varios desafíos para poner en marcha un programa de importación, incluyendo la posible oposición de la industria farmacéutica y los límites a las clases de medicamentos que se pueden vender al otro lado de la frontera.

“A pesar de las dificultades, vale la pena seguir solicitando estos programas”, expresó.

El principal funcionario de salud de Maine dijo que la administración debe trabajar con el gobierno canadiense para atender las preocupaciones de Canadá. Los funcionarios del HHS se negaron a decir si tales discusiones han comenzado.

Los funcionarios de Vermont, donde el programa también incluiría a los consumidores cubiertos por seguros privados, siguen esperanzados.

“Dado que queremos reducir la carga de los costos de atención médica para los residentes de nuestro estado, es importante seguir esta opción si hay un camino claro hacia adelante”, señaló Backus.

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Wildfires’ Toxic Air Leaves Damage Long After the Smoke Clears

SEELEY LAKE, Mont. — When researchers arrived in this town tucked in the Northern Rockies three years ago, they could still smell the smoke a day after it cleared from devastating wildfires. Their plan was to chart how long it took for people to recover from living for seven weeks surrounded by relentless smoke.

They still don’t know, because most residents haven’t recovered. In fact, they’ve gotten worse.

Forest fires had funneled hazardous air into Seeley Lake, a town of fewer than 2,000 people, for 49 days. The air quality was so bad that on some days the monitoring stations couldn’t measure the extent of the pollution. The intensity of the smoke and the length of time residents had been trapped in it were unprecedented, prompting county officials to issue their first evacuation orders due to smoke, not fire risk.

Many people stayed. That made Seeley Lake an ideal place to track the long-term health of people inundated by wildfire pollution.

So far, researchers have found that people’s lung capacity declined in the first two years after the smoke cleared. Chris Migliaccio, an immunologist with the University of Montana, and his team found the percentage of residents whose lung function sank below normal thresholds more than doubled in the first year after the fire and remained low a year after that.

“There’s something wrong there,” Migliaccio said.

While it’s long been known that smoke can be dangerous when in the thick of it — triggering asthma attacks, cardiac arrests, hospitalizations and more — the Seeley Lake research confirmed what public health experts feared: Wildfire haze can have consequences long after it’s gone.

That doesn’t bode well for the 78 million people in the western United States now confronting historic wildfires.

Toxic air from fires has blanketed California and the Pacific Northwest for weeks now, causing some of the world’s worst air quality. California fires have burned roughly 2.3 million acres so far this year, and the wildfire season isn’t over yet. Oregon estimates 500,000 people in the state have been under a notice to either prepare to evacuate or leave. Smoke from the West Coast blazes has drifted as far away as Europe.

Extreme wildfires are predicted to become a regular occurrence due to climate change. And, as more people increasingly settle in fire-prone places, the risks increase. That’s shifted wildfires from being a perennial reality for rural mountain towns to becoming an annual threat for areas across the West.

Dr. Perry Hystad, an associate professor in the College of Health and Human Sciences at Oregon State University, said the Seeley Lake research offers unique insights into wildfire smoke’s impact, which until recently had largely been unexplored. He said similar studies are likely to follow because of this fire season.

“This is the question that everybody is asking,” Hystad said. “‘I’ve been sitting in smoke for two weeks, how concerned should I be?’”

Migliaccio wants to know whether the lung damage he saw in Seeley Lake is reversible — or even treatable. (Think of an inhaler for asthma or other medication that prevents swollen airways.)

But those discoveries will have to wait. The team hasn’t been able to return to Seeley Lake this year because of the coronavirus pandemic.

Migliaccio said more research is needed on whether wildfire smoke damages organs besides the lungs, and whether routine exposure makes people more susceptible to diseases.

The combination of the fire season and the pandemic has spurred other questions as well, like whether heavy smoke exposure could lead to more COVID-19 deaths. A recent study showed a spike in influenza cases following major fire seasons.

“Now you have the combination of flu season and COVID and the wildfires,” Migliaccio said. “How are all these things going to interact come late fall or winter?”

A Case Study

Seeley Lake has long known smoke. It sits in a narrow valley between vast stretches of thick forests.

On a recent September day, Boyd Gossard stood on his back porch and pointed toward the mountains that were ablaze in 2017.

Gossard, 80, expects to have some summer days veiled in haze. But that year, he said, he could hardly see his neighbor’s house a few hundred feet away.

“I’ve seen a lot of smoke in my career,” said Gossard, who worked in timber management and served as a wildland firefighter. “But having to just live in it like this was very different. It got to you after a while.”

When Missoula County health officials urged people to leave town and flee the hazardous smoke, many residents stayed close to home. Some said their jobs wouldn’t let them leave. Others didn’t have a place to go — or the money to get there.

Health officials warned those who stayed to avoid exercising and breathing too hard, to remain inside and to follow steps to make their homes as smoke-free as possible. The health department also worked to get air filters to those who needed them most.

But when flames got too close, some people had to sleep outside in campsites on the other side of town.

Understanding the Science of Smoke

One of the known dangers of smoke is particulate matter. Smaller than the width of a human hair, it can bypass a body’s defenses, lodging deep into lungs. Lu Hu, an atmospheric chemist with the University of Montana, said air quality reports are based on how much of that pollution is in the air.

“It’s like lead; there’s no safe level, but still we have a safety measure for what’s allowable,” Hu said. “Some things kill you fast and some things kill you slowly.”

While air quality measurements can gauge the overall amount of pollution, they can’t assess which specific toxins people are inhaling. Hu is collaborating with other scientists to better predict how smoke travels and what pollutants people actually breathe.

He said smoke’s chemistry changes based on how far it travels and what’s burning, among other factors.

Over the past few years, teams of researchers drove trucks along fire lines to collect smoke samples. Other scientists boarded cargo planes and flew into smoke plumes to take samples right from a fire’s source. Still others stationed at a mountain lookout captured smoke drifting in from nearby fires. And ground-level machines at a Missoula site logged data over two summers.

Bob Yokelson, a longtime smoke researcher with the University of Montana, said scientists are getting closer to understanding its contents. And, he said, “it’s not all bad news.”

Temperature and sunlight can change some pollutants over time. Some dangerous particles seem to disappear. But others, such as ozone, can increase as smoke ages.

Yokelson said scientists are still a long way from determining a safe level of exposure to the 100-odd pollutants in smoke.

“We can complete the circle by measuring not only what’s in smoke, but measuring what’s happening to the people who breathe it,” Yokelson said. “That’s where the future of health research on smoke is going to go.”

Coping With Nowhere to Flee

In the meantime, those studying wildland smoke hope what they’ve learned so far can better prepare people to live in the haze when evacuation isn’t an option.

Joan Wollan, 82, was one of the Seeley Lake study participants. She stayed put during the 2017 fire because her house at the time sat on a border of the evacuation zone.

The air made her eyes burn and her husband cough. She ordered air filters to create cleaner air inside her home, which helped.

On a recent day, the air in Wollan’s new neighborhood in Missoula turned that familiar gray-orange as traces of fires from elsewhere appeared. Local health officials warned that western Montana could get hit by some of the worst air quality the state had seen since those 2017 fires.

If it got bad enough, Wollan said, she’d get the filters out of storage or look for a way to get to cleaner air — “if there is someplace in Montana that isn’t smoky.”

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Election Gift for Florida? Trump Poised to Approve Drug Imports From Canada

Over the objections of drugmakers, the Trump administration is expected within weeks to finalize its plan that would allow states to import some prescription medicines from Canada.

Six states — Colorado, Florida, Maine, New Hampshire, New Mexico and Vermont — have passed laws allowing them to seek federal approval to buy drugs from Canada to give their residents access to lower-cost medicines.

But industry observers say the drug importation proposal under review by the administration is squarely aimed at Florida — the most populous swing state in the November election. Trump’s support of the idea initially came at the urging of Florida Gov. Ron DeSantis, a close Republican ally.

The DeSantis administration is so confident Trump will move ahead with allowing drug importation that it put out a request June 30 for private companies to bid on a three-year, $30 million contract to run the program. It hopes to award the contract in December.

Industry experts say Florida is likely to be the first state to win federal approval for a drug importation plan — something that could occur before the November election.

“Approving Florida would feel like the politically astute thing to do,” said Mara Baer, a Colorado-based health consultant who has worked with Florida on its importation proposal.

Ben England, CEO of FDAImports, a consulting firm in Glen Burnie, Maryland, said the OMB typically has 60 days to review final rules, although he expects this one could be completed before Nov. 3 and predicted there’s a small chance it could get finalized and Florida’s request approved by then. “It’s an election year, so I do see the current administration trying to use this as a talking point to say ‘Look what we’ve accomplished,’” he said.

Florida also makes sense because of the large number of retirees, who face high costs for medicines despite Medicare drug coverage.

The DeSantis administration did not respond to requests for comment.

Trump boasted about his importation plan during an October speech in The Villages, a large retirement community about 60 miles northwest of Orlando. “We will soon allow the safe and legal importation of prescription drugs from other countries, including the country of Canada, where, believe it or not, they pay much less money for the exact same drug,” Trump said, with DeSantis in attendance. “Stand up, Ron. Boy, he wants this so badly.”

The Food and Drug Administration released a detailed proposal last December and sought comments. A final plan was delivered Sept. 10 to the Office of Management and Budget for review, signaling it could be unveiled within weeks.

The proposal would regulate how states set up their own programs for importing drugs from Canada.

Prices are cheaper because Canada limits how much drugmakers can charge for medicines. The United States lets free markets dictate drug prices.

The pharmaceutical industry signaled it will likely sue the Trump administration if it goes forward with its importation plans, saying the plan violates several federal laws and the U.S. Constitution.

But the most stinging rebuke of the Trump importation plan came from the Canadian government, which said the proposal would make it harder for Canadian citizens to get drugs, putting their health at risk.

“Canada will employ all necessary measures to safeguard access for Canadians to needed drugs,” the Canadian government wrote in a letter to the FDA about the draft proposal. “The Canadian drug market and manufacturing capacity are too small to meet the demand of both Canadian and American consumers for prescription drugs.”

Without buy-in from Canada, any plan to import medicines is unlikely to succeed, officials said.

Ena Backus, director of Health Care Reform in Vermont, who has worked on setting up an importation program there, said states will need help from Canada. “Our state importation program relies on a willing partner in Canada,” she said.

For decades, Americans have been buying drugs from Canada for personal use — either by driving over the border, ordering medication on the internet or using storefronts that connect them to foreign pharmacies. Though illegal, the FDA has generally permitted purchases for individual use.

About 4 million Americans import lower-cost medicines for personal use each year, and about 20 million say they or someone in their household have done so because the prices are much lower in other countries, according to surveys.

The practice has been popular in Florida. More than a dozen storefronts across the state help consumers connect to pharmacies in Canada and other countries. Several cities, state and school districts in Florida help employees get drugs from Canada.

The administration’s proposal builds on a 2000 law that opened the door to allowing drug importation from Canada. But that provision could take effect only if the Health and Human Services secretary certified importation as safe, something that Democratic and Republican administrations have refused to do.

The drug industry for years has said allowing drugs to be imported from Canada would disrupt the nation’s supply chain and make it easier for unsafe or counterfeit medications to enter the market.

Trump, who made lowering prescription drug prices a signature promise in his 2016 campaign, has been eager to fulfill his pledge. In July 2019, at Trump’s direction, HHS Secretary Alex Azar said the federal government was “open for business” on drug importation, a year after calling drug importation a “gimmick.”

The administration envisions a system in which a Canadian-licensed wholesaler buys directly from a manufacturer for drugs approved for sale in Canada and exports the drugs to a U.S. wholesaler/importer under contract to a state.

Florida’s legislation — approved in 2019 — would set up two importation programs. The first would focus on getting drugs for state programs such as Medicaid, the Department of Corrections and county health departments. State officials said they expect the programs would save the state about $150 million annually.

The second program would be geared to the broader state population.

In response to the draft rule, the states seeking to start a drug importation program suggested changes to the administration’s proposal.

“Should the final rule not address these areas of concern, Colorado will struggle to find appropriate partners and realize significant savings for consumers,” Kim Bimestefer, executive director of the Colorado Department of Health Care Policy & Financing, told the FDA in March.

Among the state’s concerns is that it would be limited to using only one Canadian wholesaler, and without competition the state fears prices might not be as low as officials hoped. Bimestefer also noted that under the draft rule, the federal government would approve the importation program for only two years and states need a longer time frame to get buy-in from wholesalers and other partners.

Colorado officials estimate importing drugs from Canada could cut prices by 54% for cancer drugs and 75% for cardiac medicines. The state also noted the diabetes drug Jardiance costs $400 a month in the United States and sells for $85 in Canada.

Several states worry some of the most expensive drugs — including injectable and biologic medicines — were exempt from the federal rule. Those drug classes are not allowed to be imported under the 2000 law.

However, in an executive order in July, Trump said he would allow insulin to be imported if Azar determined it is required for emergency medical care. An HHS spokesman would not say whether Azar has done that.

Jane Horvath, a health policy consultant in College Park, Maryland, said the administration faces several challenges getting an importation program up and running, including possible opposition from the pharmaceutical industry and limits on classes of drugs that can be sold over the border.

“Despite the barriers, the programs are still quite worthwhile to pursue,” she said.

Maine’s top health official said the administration should work with the Canadian government to address Canada’s concerns. HHS officials refused to say whether such discussions have started.

Officials in Vermont, where the program would also include consumers covered by private insurance, remain hopeful.

“Given that we want to reduce the burden of health care costs on residents in our state, then it is important to pursue this option if there is a clear pathway forward,” Backus said.

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In Face of COVID Threat, More Dialysis Patients Bring Treatment Home

Maria Duenas, 60, has kidney failure and is on the kidney transplant list. But until she finds a match, she will administer her own dialysis treatment at home.(Heidi de Marco/KHN)

NIPOMO, Calif. — After Maria Duenas was diagnosed with Type 2 diabetes about a decade ago, she managed the disease with diet and medication.

But Duenas’ kidneys started to fail just as the novel coronavirus established its lethal foothold in the U.S.

On March 19, three days after Duenas, 60, was rushed to the emergency room with dangerously high blood pressure and blood sugar, Gov. Gavin Newsom implemented the nation’s first statewide stay-at-home order.

Less than one week later, Duenas was hooked up to a dialysis machine in the Century City neighborhood of Los Angeles, 160 miles from her Central Coast home, where tubes, pumps and tiny filters cleansed her blood of waste for 3½ hours, doing the work her kidneys could no longer do.

In the beginning, Duenas said she didn’t understand the severity of COVID-19, or her increased vulnerability to it. “It’s not going to happen to me,” she thought. “We’re in a small little town.”

But she was unable to find a spot in a dialysis clinic in, or near, Nipomo. So, with her husband, Jose, at her side, Duenas made long road trips to Century City for more than two months.

In May, Duenas’ doctor told her she was a good candidate for home dialysis, which would save her drive time and stress — and reduce her exposure to the virus.

The closet in Duenas’ grandchildren’s playroom is crammed with peritoneal dialysis solution, a mixture of dextrose, calcium and magnesium. She uses two bags for every treatment. Cabinets and drawers in her bedroom are filled with disinfectant wipes, gauze, masks and gloves.(Heidi de Marco/KHN)

Now, Duenas assiduously sterilizes herself and her surroundings five nights a week so she can administer dialysis to herself at home while she sleeps.

“There’s always a chance going in that somebody’s going to have COVID and still need dialysis” in a clinic, Duenas said. “I’m very grateful to have this option.”

The increase in home dialysis has accelerated recently, spurred by social-distancing requirements, increased use of telehealth and remote monitoring technologies — and fear of the virus.

Duenas starts her home dialysis routine around 8 p.m. She must maintain a sterile environment and uses masks and gloves. Her husband, Jose, installed an automatic paper towel dispenser in their bathroom to help ensure proper hygiene.(Heidi de Marco/KHN)

While recent, comprehensive data is hard to come by, experts confirm the trend based on what they’re seeing in their own practices. Fresenius Medical Care North America, one of the country’s two dominant dialysis providers, said it conducted 25% more home dialysis training sessions in the first quarter of 2020 than in the same period last year, according to Renal & Urology News.

“People recognized it would be better if they did it at home,” said Dr. Susan Quaggin, president-elect of the American Society of Nephrology. “And certainly from a health provider’s perspective, we feel it’s a great option.”

Duenas vigorously washes her hands before she cleans the area around the catheter in her abdomen. She also sterilizes the dialysis equipment before hooking herself up for the night.(Heidi de Marco/KHN)

Nearly half a million people in the United States are on dialysis, according to the National Institute of Diabetes and Digestive and Kidney Diseases. Roughly 85% of them travel to a clinic for their treatments.

Dialysis patients are at higher risk of contracting COVID-19 and getting seriously ill with it, said Dr. Anjay Rastogi, director of the UCLA CORE Kidney Program, where Duenas is a patient.

In an analysis of more than 10,000 deaths in 15 states and New York City, the Centers for Disease Control and Prevention found about 40% of people killed by COVID-19 had diabetes. That percentage rose to half among people under 65.

But people on dialysis are also vulnerable to COVID-19 because they usually visit dialysis clinics two to three times a week for an average of four hours at a time, exposing themselves to other patients and, potentially, the virus, Rastogi said.

“Now even more so, we are strongly urging our patients to consider home dialysis,” he said.

Although patients on home dialysis reduce their exposure to COVID-19 by avoiding clinics, they face other challenges. Home dialysis requires supplies such as dialysis fluid, drain bags, tubing, disinfectant and personal protective equipment. According to a recent study, patients may have problems obtaining dialysis supplies because supply chains are strained.(Heidi de Marco/KHN)

Duenas uses her bedroom mirror to make sure her catheter is properly covered with gauze before she goes to bed. She will be tethered to the machine overnight.(Heidi de Marco/KHN)

There are two kinds of dialysis: hemodialysis and peritoneal dialysis. In hemodialysis, which is administered in a hospital or clinic, or sometimes at home, a dialysis machine pumps blood out of the body and through a special filter called a dialyzer, which clears waste and extra fluid from the blood before it is returned to the body.

Dialysis treatment centers that offer hemodialysis have intensified their infection-control procedures in response to COVID-19, said Dr. Kevin Stiles, a nephrologist at Kaiser Permanente in Bakersfield. Visitors are no longer allowed to accompany patients, and patients get temperature checks and must wear masks during treatment, he said. (KHN, which produces California Healthline, is not affiliated with Kaiser Permanente.)

In peritoneal dialysis, which is the more popular home option because it is less cumbersome and restrictive, the inside lining of the stomach acts as a natural filter. Dialysis solution cleanses waste from the body as it is washed into and out of the stomach through a catheter in the abdomen.

It takes Duenas about 45 minutes to prepare her overnight treatment. Her tubing allows her to get as far as her bathroom, but she sometimes gets tangled in it at night.(Heidi de Marco/KHN)

Not everyone is eligible for home dialysis, which comes with its own challenges.

Home dialysis requires patients or their caregivers to lift bags of dialysis solution that weigh 5 to 10 pounds, Stiles said. Good eyesight and hand dexterity are also critical because patients must be able to maintain sterile environments.

Home patients need dialysis equipment and regular deliveries of supplies such as dialysis fluid, drain bags, tubing, disinfectant and personal protective equipment. In response to COVID-19, some clinics have arranged courier services and contracted with labs to deliver supplies to patients.

The Trump administration has encouraged greater use of home dialysis and in July proposed increasing Medicare reimbursement rates for home dialysis machines, citing “the importance that this population stay at home during the public health emergency to reduce risk of exposure to the virus.”

The morning after her treatment, Duenas disinfects the dialysis machine and then disconnects her catheter tube from the machine so that she can move around freely.(Heidi de Marco/KHN)

Medicare covers almost all patients who receive dialysis treatment, including home dialysis, and patients typically pay 20% as coinsurance.

Medicare, which spends an average of $90,000 per hemodialysis patient annually, spent more than $35 billion on patients with end-stage renal disease in 2016.

Duenas is awaiting a kidney transplant. Until she finds a match, she’ll be administering her own peritoneal dialysis at home.

Duenas inspects her drain bag in the morning for fibrin, a protein that can clog her catheter. She must alert her doctor if she finds any floating in the fluid.(Heidi de Marco/KHN)

“To be honest, I didn’t want to do it,” she said of home dialysis. “It was scary having to think about taking care of my own treatment.”

Now, three months later, guided by training and the prompts on the dialysis machine, Duenas feels comfortable, capable and safe.

Looking back, she said, “it was a blessing in disguise.”

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

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Urban Hospitals of Last Resort Cling to Life in Time of COVID

Victor Coronado felt lightheaded one morning last month when he stood up to grab an iced tea. The right side of his body suddenly felt heavy. He heard himself slur his words. “That’s when I knew I was going to have a stroke,” he said.

Coronado was rushed to Mercy Hospital & Medical Center, the hospital nearest his home on Chicago’s South Side. Doctors there pumped medicine into his veins to break up the clot that had traveled to his brain.

Coronado may outlive the hospital that saved him. Founded 168 years ago as the city’s first hospital, Mercy survived the Great Chicago Fire of 1871 but is succumbing to modern economics, which have underfinanced the hospitals serving the poor. In July, the 412-bed hospital informed state regulators it planned to shutter all inpatient services as soon as February.

“If something else happens, who is to say if the responders can get my husband to the nearest hospital?” said Coronado’s wife, Sallie.

While rural hospitals have been closing at a quickening pace over the past two decades, a number of inner-city hospitals now face a similar fate. And experts fear that the economic damage inflicted by the COVID-19 pandemic on safety-net hospitals and the ailing finances of the cities and states that subsidize them are helping push some urban hospitals over the edge.

By the nature of their mission, safety-net hospitals, wherever they are, struggle because they treat a large share of patients who are uninsured — and can’t pay bills — or are covered by Medicaid, whose payments don’t cover costs. But metropolitan hospitals confront additional threats beyond what rural hospitals do. State-of-the-art hospitals in affluent city neighborhoods are luring more of the safety-net hospitals’ best-insured patients.

These combined financial pressures have been exacerbated by the pandemic at a time their role has become more important: Their core patients — the poor and people of color — have been disproportionately stricken by COVID-19 in metropolitan regions like Chicago.

“We’ve had three hospital closures in the last year or so, all of them Black neighborhoods,” said Dr. David Ansell, senior vice president for community health equity at Rush University Medical Center, a teaching hospital on Chicago’s West Side. He said the decision to close Mercy “is really criminal in my mind, because people will die as a result.”

Mercy is following the same lethal path as did two other hospitals with largely lower-income patient bases that shuttered last year: Hahnemann University Hospital in Philadelphia, and Providence Hospital in Washington, D.C., which ended its inpatient services. Washington’s only public hospital, United Medical Center — in the city’s poorest ward — is slated to close in 2023 as well, and some services are already curtailed.

Slow Death of Urban Safety Nets

So far, urban hospital closures have remained infrequent compared with the cascading disappearance of their rural counterparts. But the closing of a few could portend problems at others. Even some of those that remain open may cut back crucial specialties like labor and delivery services or trauma care, forcing patients to travel farther for help when minutes can matter.

Nancy Kane, an adjunct professor at Harvard T.H. Chan School of Public Health who has studied urban safety-net hospital changes since 2010, said that “some close, but most of them have tried to get into a bigger system and hang on for a few more years until management closes them.”

For much of the 20th century, most cities ran their own hospitals to care for the indigent. But after the creation of Medicare and Medicaid, and as the rising cost of health care became a burden for local budgets, many jurisdictions turned away from that model. Today only 498 of 5,230 general hospitals in the country are owned by governments or a public hospital district.

Instead, many hospitals in low-income urban neighborhoods are run by nonprofits — often faith-based — and in some cases, for-profit corporations. In recent years owners have unloaded safety-net hospitals to entities with limited patience for keeping them alive.

In 2018, the for-profit hospital chain Tenet Healthcare Corp. sold Hahnemann to Joel Freedman, a California private equity investor, for $170 million. A year later, Freedman filed for bankruptcy on the hospital, saying its losses were insurmountable, while separating its real estate, including the physical building, into another corporation, which could ease its sale to developers.

In 2018, Tenet sold another safety-net hospital, Westlake Hospital in Melrose Park, Illinois, a suburb west of Chicago, to a private investment company. Two weeks after the sale, the firm announced it would close the hospital, which ultimately led the owners to pay Melrose Park $1.5 million to settle a lawsuit alleging they had misled local officials by claiming before the sale they would keep it open.

Some government-run hospitals are also struggling to stay open. Hoping to stem losses, the District of Columbia outsourced management of United Medical Center to private consulting firms. But far from turning the hospital around, one firm was accused of misusing taxpayer funds, and it oversaw a string of serious patient safety incidents, including violations in its obstetrics ward so egregious that the district was forced to shut the ward down in 2017.

Earlier this year, the district struck a deal with Universal Health Services, a Fortune 500 company with 400 hospitals and $11 billion in revenues, to run a new hospital that would replace United, albeit with a third fewer beds. Universal also operates George Washington University Hospital in the city in partnership with George Washington University. That relationship has been contentious: Last year the university accused the company of diverting $100 million that should have stayed in the medical system. In June, a judge dismissed most of the university’s complaint.

Victor Coronado was rushed to Chicago’s Mercy Hospital & Medical Center after exhibiting signs of a stroke. Doctors pumped medicine into his veins and broke the clot that had traveled to his brain. (Taylor Glascock for KHN)

No Saviors for Mercy

Chicago has three publicly owned hospitals, but much of the care for low-income patients falls on private safety-net hospitals like Mercy that are near their homes and have strong reputations. These hospitals have been sources of civic pride as well as major providers of jobs in neighborhoods that have few.

Fifty-five percent of Chicagoans living in poverty and 62% of its African American residents live within Mercy’s service area, according to Mercy’s 2019 community needs assessment, a federally mandated report. The neighborhoods served by Mercy are distinguished by higher rates of death from diabetes, cancer and stroke. Babies are more likely to be born early and at low weight or die in infancy. The nearest hospitals from Mercy can be 15 minutes or more away by car, and many residents don’t have cars.

“You’re going to have this big gap of about 7 miles where there’s no hospital,” Ansell said. “It creates a health care desert on the South Side.”

Dr. Maya Rolfe, who was a resident at Mercy until July, said the loss of the hospital’s labor and delivery department would cause substantial harm, especially since African American women suffer from a higher rate of maternal mortality than do white women. “Mercy serves a lot of high-risk women,” she said.

Mercy, a nonprofit, has been in financial trouble for a while. In 2012, it joined Trinity Health, a giant nonprofit Roman Catholic health system headquartered in Michigan with operations in 22 states. In the next seven years, Trinity invested $124 million in infrastructure improvements and $112 million in financial support.

During that time, the hospital continued to be battered by headwinds facing hospitals everywhere, including the migration of well-reimbursed surgeries and procedures to outpatient settings. Likewise, patients with private insurance, which provides higher reimbursements than government programs do, departed to Chicago’s better-capitalized university hospitals, including Rush, the University of Chicago Medical Center and Northwestern Memorial Hospital. Seventy-five percent of Mercy’s revenues come from government insurance programs Medicare and Medicaid.

Only 42% of its beds were occupied on average, according to the most recent state data, from 2018. Mercy told state regulators it is losing $4 million a month and required at least $100 million in additional building upgrades to operate safely.

Trinity said it spent more than a year shopping for a buyer. After that yielded no success, Mercy joined forces with three other struggling South Side hospitals to consolidate into a single health system planning to build one hospital and a handful of outpatient facilities to replace their antiquated buildings. They sought state financial help.

The plan would have cost $1.1 billion over a decade. At the close of the legislative session, Illinois lawmakers — already strapped for funding because of the economic effects of the pandemic — balked at the hospitals’ request for the state to cover half the cost. Lamont Robinson, a Democratic state representative whose district includes Mercy Hospital, said that was because the group did not declare where the new hospital would be built.

“We were all supportive of the merger but not with the lack of information,” Robinson said.

Mercy said in an email that the location would have been chosen after the hospital organizations combined and chose new leaders. Trinity said in a statement: “We are committed to continuing to serve the Mercy Chicago community through investment in additional ambulatory and community-based services that are driven by high-priority community needs.”

Blame for Mercy’s closure has been spread widely to include the city and state governments as well as Mercy’s owner. Trinity Health had $8.8 billion in cash and liquid investments at the end of March and until the pandemic hit had been running a slight profit. Earlier this year in Philadelphia, Trinity Health announced it would phase out inpatient services at another of its safety-net hospitals, Mercy Catholic Medical Center-Mercy Philadelphia Campus, a 157-bed hospital that has been around since 1918.

“People put their money where they want to,” said Rolfe, the former medical resident at Mercy in Chicago. Noting that the city has no qualms about spending large sums to beautify its downtown while other neighborhoods are in danger of losing a major institution, she said: “It shows to me that those patients are not that important as patients that exist in other communities.”

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Es difícil decir si es COVID, síntomas por inhalar humo… o la gripe que ya llega

Los pacientes entran en las clínicas comunitarias de la doctora Melissa Marshall, en el norte de California, con síntomas reveladores. Tienen problemas para respirar, tos, y dolor de garganta.

¿Un caso claro de COVID-19? No tan rápido. Esta es una región de incendios forestales.

A lo largo de la costa oeste, hospitales y centros de salud reportan pacientes con problemas relacionados con la inhalación de humo.

A medida que los incendios se propagan de forma descontrolada, por el calor seco y los fuertes vientos, el humo y las cenizas se expanden y se asientan en zonas costeras como San Francisco, y en ciudades y pueblos a cientos de kilómetros tierra adentro, haciendo que el cielo se vuelva naranja o gris y dificultando incluso la respiración normal.

Pero eso, dijo Marshall, es sólo una parte del desafío. Los centros, que ya están al límite de suministros para hacer pruebas y de equipos de protección personal (EPP), deben descartar primero la presencia de COVID-19 en estos pacientes, porque muchos de los síntomas que presentan son los mismos que los que causa el virus.

“Obviamente, existe una coincidencia en los síntomas”, señaló Marshall, que es CEO de CommuniCare, una red de seis clínicas en el condado de Yolo, cerca de Sacramento, que trata principalmente a pacientes con poca cobertura o sin seguro médico. “Cada vez que alguien llega con algunos de esos síntomas, nos preguntamos, ‘¿Es COVID?’ Clínicamente hablando, debo descartar el virus”.

El protocolo es tratar los síntomas, cualquiera que sea su causa, y recomendar que el paciente se ponga en cuarentena hasta que lleguen los resultados de las pruebas del virus, afirmó Marshall.

Es una escena que se repite en numerosos hospitales. Administradores y médicos, atentos a la rápida propagación de COVID-19, no se arriesgan cuando observan síntomas que podrían revelar al virus.

“Hemos visto un aumento en el número de pacientes que llegan a la sala de emergencias con problemas respiratorios”, expresó la doctora Nanette Mickiewicz, presidenta y CEO del Dominican Hospital en Santa Cruz.

“Al llegar con síntomas que podrían ser de COVID-19, tratamos a estos pacientes como lo haríamos con cualquier persona sospechosa de coronavirus hasta que podamos descartarlos con nuestro proceso de detección”. Durante el proceso, los síntomas más específicos de COVID-19, como la fiebre, se harían evidentes.

Para los trabajadores de Dominican, el tema pronto se vivió con urgencia. Los condados de Santa Cruz y San Mateo han sido los más afectados por los incendios del CZU Lightning Complex, que hasta el 10 de septiembre habían quemado más de 86,000 acres, destruyendo 1,100 edificios y amenazando a otros 7,600. Casi un mes después de que comenzaran, los incendios fueron contenidos en un 84%, pero miles de personas permanecían evacuadas.

Dominican, un hospital de Dignity Health, permanece “abierto, es seguro y proporciona atención médica”, aseguró Mickiewicz. Múltiples tiendas de campaña, levantadas en el exterior del centro, sirven como una extensión de la sala de espera para el servicio de Urgencias. También se utilizan para llevar a cabo lo que se considera una función esencial: separar a los que tienen síntomas de COVID-19 de los que no.

En los dos hospitales del condado de Solano, operados por NorthBay Healthcare, la trayectoria de algunos de los incendios forestales llevó a los funcionarios a revisar sus procedimientos de evacuación, explicó el vocero Steve Huddleston. Al final, no hubo necesidad de evacuar a los pacientes, y los nuevos llegaron con síntomas parecidos a los de COVID que, en realidad, podían deberse a la inhalación de humo.

Huddleston dijo que el proceso de admisión de NorthBay “requiere que cualquier persona con síntomas de COVID se considere sospechosa para el coronavirus, lo que significa que son separados, examinados y manejados por personal con EPP”.

En los dos hospitales, que hasta ahora han tratado casi 200 casos de COVID, el protocolo está bien establecido.

Los hospitales de California, aunque en su mayoría no están saturados, se enfrentan a múltiples problemas que normalmente sólo se presentan de forma esporádica.

En el condado de Napa, el hospital Adventist Health St. Helena evacuó a 51 pacientes en una sola noche de agosto ante la cercanía del fuego, trasladándolos a otros 10 centros según sus necesidades y la disponibilidad de camas. Tras un cierre de 10 días, se permitió la reapertura del hospital al finalizar las órdenes de evacuación, ya que el incendio se había contenido.

Los incendios forestales también afectan de manera personal a los trabajadores de salud. La doctora Marshall, de CommuniCare, perdió la casa de su familia en la zona rural de Winters, junto con 20 acres de olivos y otras plantaciones que la rodeaban, en los incendios del 19 de agosto que arrasaron el condado de Solano.

“Lo llamaron un ‘fogonazo’”, contó Marshall. Una confluencia de tres incendios que se desató fuera de control, arrasando miles de acres. Con su familia a salvo y una vivienda temporal proporcionada por un amigo, volvió al trabajo. “Nuestras clínicas interactúan con una población muy vulnerable”, dijo, “y este es un momento crítico para ellos”.

Mientras pensaba en cómo reconstruiría su hogar, la doctora debió enfrentarse a otra crisis: la escasez de suministros de la clínica. El mes pasado, CommuniCare sólo contaba con 19 kits para pruebas de COVID, y la escasez de hisopos era tal “que literalmente nos dirigimos a nuestros amigos veterinarios en busca de refuerzos”, explicó.

Mientras tanto, los resultados de las pruebas de COVID de la clínica tardaban casi dos semanas en llegar, desde un abrumado laboratorio exterior, haciendo que el rastreo de contactos fuera casi inútil.

Esas situaciones ya están controladas, al menos temporalmente, aseguró Marshall. Y aunque la Costa Oeste se encuentra en la época más peligrosa del año para los incendios forestales, generalmente de septiembre a diciembre, ahora surge otra complicación para los proveedores de salud: la temporada de gripe.

Las tendencias de la temporada de gripe en el hemisferio sur, que coincide con nuestros meses de verano, por lo general predicen lo que nos espera en los Estados Unidos. Pero este año, se ha visto muy poco de la enfermedad, presumiblemente debido a la restricción de los viajes, el distanciamiento social y el uso de máscaras. Y es demasiado pronto para saber lo que traerá la temporada de gripe a los Estados Unidos.

“Se pueden empezar a ver algunos casos de gripe a finales de octubre”, apuntó Marshall, “y la realidad es que van a llegar con una serie de características que también podrían ser sintomáticas de COVID. Y nada cambia: tienes que descartarlo, para eliminar el riesgo”.

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Lack of Antigen Test Reporting Leaves Country ‘Blind to the Pandemic’

More than 20 states either don’t release or have incomplete data on the rapid antigen tests now considered key to containing the coronavirus, which has sickened more than 6 million Americans. The lapses leave officials and the public in the dark about the true scope of the pandemic as untold numbers of cases go uncounted.

The gap will only widen as tens of millions of antigen tests sweep the country. Federal officials are prioritizing the tests to quickly detect COVID-19’s spread over slower, but more accurate, PCR tests.

Relying on patchy data on COVID testing carries enormous consequences as officials decide whether to reopen schools and businesses: Go back to normal too quickly and risk even greater outbreaks of disease. Keep people at home too long and risk an even greater economic crisis.

“The absence of information is a very dangerous thing,” said Janet Hamilton, executive director of the Council for State and Territorial Epidemiologists, which represents public health officials. “We will be blind to the pandemic. It will be happening around us and we will have no data.”

The states that don’t report antigen test results or don’t count antigen positives as COVID cases are California, Colorado, Georgia, Illinois, Maryland, Minnesota, Missouri, Montana, New Hampshire, New Jersey, North Carolina, North Dakota, Ohio, Pennsylvania, South Dakota, Tennessee, Texas, Vermont, Virginia, Washington, Wisconsin and Wyoming, as well as the District of Columbia.

So far, most of the COVID tests given in the U.S. have been PCR tests, which are processed in medical labs and can take days to return results. By contrast, antigen tests offer results in minutes outside of labs, appealing to everyone from medical clinics to sports teams and universities.

Each relies on swabs to test patients. But unlike using tests run through labs, many providers who would use antigen tests don’t have an easy way to send data electronically to public health authorities.

Since July, though, the federal government has pushed roughly 5 million antigen tests into nearly 14,000 nursing homes to contain outbreaks among staff members and residents. The Department of Health and Human Services also awarded a $760 million contract to buy 150 million rapid antigen tests from Abbott, the Illinois-based diagnostics behemoth. It plans to send 750,000 of those to nursing homes starting this week, Brett Giroir, the HHS official heading the Trump administration’s testing efforts, told industry executives on Sept. 8. Federal officials have not elaborated on how many tests will be sent elsewhere but have suggested many will go to governors to distribute as schools reopen.

The rush of antigen tests, however, won’t be particularly useful to officials if the results are not publicly and uniformly reported.

KHN surveyed 50 states and the District of Columbia on their collection of antigen test results and what is reported publicly. Forty-eight responded between Sept. 3 and 10, revealing significant variation over whether people who test positive for COVID-19 with an antigen test are counted as cases and whether states even publicly report antigen data in their testing numbers:

  • 21 states and D.C. do not report all antigen test results.
  • 15 states and D.C. do not count positive results from antigen tests as COVID cases.
  • Two states do not require antigen test providers to report results, and five others require only positive results to be reported.
  • Nearly half of states believe their antigen test results are underreported.

Consequently, many state counts of infected people could be artificially low. For instance, the lack of reporting could imply infection rates are declining because the virus isn’t spreading as widely — when really more antigen tests are being used and not counted, public health officials and experts say.

“It’s going to look like your cases are coming down when they’re not,” said Jeffrey Morris, a biostatistics professor at the University of Pennsylvania.

HHS recognizes that antigen tests are underreported but maintained that officials are not missing the full scale of the pandemic, an agency spokesperson said.

“There is sufficient testing to achieve all objectives outlined in the testing strategy, including identifying newly emergent outbreaks, supporting public health isolation and contact tracing, protecting the vulnerable, supporting safe reopening of schools and businesses, and enabling state testing plans,” spokesperson Mia Heck said.

Part of the problem on antigen test reporting stems from what counts as a COVID case. Guidance from the Centers for Disease Control and Prevention defines a “confirmed” COVID case as one that is determined from a PCR test. Positive results from antigen tests are considered “probable” cases because the tests can be less accurate.

Months after the first COVID antigen test received emergency authorization from the Food and Drug Administration, the CDC revised its COVID case definition in early August to allow a positive antigen test to count as a probable case without assessing whether a person had clinical symptoms or was in close contact with a confirmed infected person.

That prompted many states — including Arkansas, starting Sept. 2 — to adjust how they report cases.

“It’s easy for people to think since we use the word ‘probable’ that maybe it’s a case, maybe it isn’t. But that’s not how we think of it,” said Dr. Jennifer Dillaha, medical director for the Arkansas Department of Health. “It is a real case in the same way that a PCR is a real case.”

Dr. Karen Landers, an assistant state health officer for the Alabama Department of Public Health, said her biggest concern was the potential undercounting of antigen test results as they continue to grow in popularity. While the state has been trying to work with each urgent care or other medical provider, some struggle to submit the results.

“We can’t afford to miss a case,” she said.

The CARES Act, which Congress passed in March, requires a broad range of health care providers to report any COVID test result to state or local health departments. Nonetheless, two states — Montana and New Jersey — said they weren’t requiring antigen test providers to report results, positive or negative. Colorado, Maine, Mississippi, New Hampshire and Wyoming require only positive results to be reported, which can distort the positivity rate.

Sara Mendez, the support services manager for the Brazos County Health Department in Texas, said the department saw an increase of antigen tests being administered as Texas A&M University students returned. Even though the state health department was not including positive COVID cases from antigen tests in its public reports, the local health department felt obligated to do so.

“A lot of the college students will just go and get those done as opposed to the PCR tests,” Mendez said, “so we felt like we were missing out.”

Indiana University undertook a massive antigen testing operation for students living on campus in August, administering 14,870 antigen tests across four campuses through drive-thrus, according to Graham McKeen, an assistant university director for public health. The test results were delivered while students waited in cars for about 30 minutes, with 159 coming back positive. Each night, a university staff member would manually download the spreadsheet off each of the test machines and securely email it to the state health department.

But Indiana began reporting antigen testing only on Aug. 24, adding over 16,000 antigen tests into its public dashboard that day and saying in a news release that it plans to retroactively add in earlier antigen testing figures.

McKeen said that, even though the state is now reporting some antigen data, tests are still missed under the cumbersome reporting system. The state said some of the data is being sent by fax.

“It doesn’t give the community a good handle on the infection in the community,” McKeen said.

Heck, the HHS spokesperson, said that federal agencies are working to improve the reporting of results and that problems were likely to be eased in the future, citing that Abbott’s antigen test includes an electronic reader for automated reporting. By October, 48 million of those tests will be in circulation each month, she said.

Still, to date, “what this is exposing is the antiquated systems that public health agencies have had for years,” said Scott Becker, executive director of the Association of Public Health Laboratories. “So much of the data we’ve gotten is incomplete.”

That data barrier is playing out in nursing homes as well.

Victoria Crenshaw is holding off on using antigen tests to screen residents and staff members at Westminster Canterbury on Chesapeake Bay nursing home in Virginia Beach, Virginia. As senior director, she sees one major holdup: No technology platform is in place to easily send results to health officials. Instead, she and colleagues would need to resort to taping pieces of paper together to deliver details of who was tested, and hope local officials would accept it.

The Trump administration is pushing for nursing homes to use the tests for required screenings at least once a month and as often as twice a week. Under new federal regulations, nursing homes that don’t comply with regular testing and reporting requirements are subject to citations or fines.

“We have no technology today to submit this information,” Crenshaw said, “which leaves us in a vulnerable position.”

Related Topics

Multimedia Public Health States

COVID Vaccine Trials Move at Warp Speed, But Recruiting Black Volunteers Takes Time

Participation in clinical trials among Black people is low, according to Food and Drug Administration statistics. Still, including them in coronavirus vaccine trials has been a stated priority for the pharmaceutical companies involved, since African American communities, along with those of Latinos, have suffered disproportionately from the pandemic.

The ongoing trials are moving at a pace that is unprecedented for medical research, with the Trump administration’s vaccine acceleration effort dubbed “Operation Warp Speed.” Yet recruiting minority participants requires sensitivity to a mistrust borne of past and current medical mistreatment. Trust-building cannot be rushed.

So far, participation by minority volunteers in coronavirus trials has increased only slightly compared with typically low levels for other clinical trials — and targeted outreach efforts to recruit more minorities have been slow to launch.

Some of that outreach is taking place at historically black colleges and universities, which are trusted institutions for many Black Americans. At Meharry Medical College in Nashville, Tennessee, researchers have set up in-person meetings with patients they already know. Earlier this month, a half-dozen patients gathered in a cramped conference room on campus. They snacked on turkey sandwiches and potato chips and listened to the pitch from their physician, Dr. Vladimir Berthaud.

“What’s the best hope to get rid of this virus?” he asked them.

“Vaccination,” they replied.

Then Berthaud followed up: “So raise your hand if you would like to take the vaccine?”

Some hands shot up, but not all.

“I ain’t going to be the first one, now,” said Lanette Hayes.

Katrina Thompson said she does eventually want to get a shot for protection against the coronavirus. She explained she’s especially worried about all the residents of her apartment building who don’t seem to be doing the basics of covering their coughs.

“The word ‘vaccination’ don’t scare me,” she said. “The word ‘trial’ do.”

Black Americans have reason to be suspicious — stemming beyond the well-known Tuskegee experiments, in which Black men with syphilis were deceived and mistreated as part of an experiment that went on for decades. Many Black Americans report ongoing mistreatment by medical providers today.

Berthaud is recruiting patients for a clinical trial site he will oversee in Nashville, and he would like more than 300 people of color to enroll. Berthaud, who is Black and from Haiti, appeals to his patients’ sense of duty.

“If you don’t have enough people like you in those vaccine trials, you will not know if it works for you,” he told them. “You will not know.”

For most of the current coronavirus vaccine trials, recruitment mainly takes place online — which often results in mostly white people enrolling.

That’s why Meharry researchers are wooing Black patients with a personal invitation. But they’re not recruiting for the phase 3 trials underway. Meharry’s first trial, for a vaccine candidate by Novavax, doesn’t launch until October.

Other pharmaceutical companies are nearly done recruiting. Moderna said it chose nearly 100 trial sites for their “representative demography.”

The company did not respond to requests for comment but publicizes demographic statistics about the clinical volunteers every week. While somewhat more inclusive than the typical clinical trial, it still is not a good representation of the diversity of the U.S.

For the coronavirus vaccine in particular, the National Institutes of Health has suggested minorities should be overrepresented in testing — perhaps at rates that are double their percentage of the U.S. population.

“We say we want to have everybody included, but really the effort for the vaccinations — in a sense — [is] starting the same way they’ve always been,” said Dr. Dominic Mack, of Morehouse School of Medicine in Atlanta.

Dr. Vladimir Berthaud and Dr. Rajbir Singh recruit patients for a COVID-19 vaccine trial at Meharry Medical College in Nashville, Tennessee.(Blake Farmer)

He’s working with the NIH to make sure people of color are included in COVID-19 research. Mack said there are no shortcuts if medical research is going to reflect the diversity of the U.S. It takes time to build trust and meaningful relationships with people who have endured a history of abuse or neglect by medical providers, and exclusion from biomedical research and decision-making.

“Now, that being said, the only thing we can do is what we’re doing,” he said — by which he means respectful, unrushed outreach and dialogue.

The primary effort, called the COVID-19 Prevention Network, taps into four existing clinical trial networks designed to advance HIV research. Those networks are based in Seattle, Atlanta, Los Angeles and Durham, North Carolina.

One project will be led by the Rev. Edwin Sanders II of the Metropolitan Interdenominational Church in Nashville. It will involve seven “faith ambassadors” and 30 “clergy consultants” in the African American community working to dispel myths and increase trust in the clinical trial process. But Sanders cautioned this is not about a hard sell. It’s not his job to preach trial participation from the pulpit, he said.

“We are not out beating the drum,” he said, acknowledging that congregants may have legitimate concerns. “I am not going to do anything more than make sure people are able to make an informed choice.”

The danger in lunging for big diversity goals is that it could spark a backlash, meaning minorities might be even less willing to participate, said associate professor Rachel Hardeman, who studies health equity at the University of Minnesota. It’s important that the doctors doing the asking look like the people they’re appealing to, she said.

“It’s racial concordance,” she explained. “It offers this feeling of, ‘You know who I am, you know where I come from, you have my best interests at heart.’”

Historically Black medical institutions in the U.S. are uniquely positioned to do this work. While they haven’t been on the leading edge of recruitment for vaccine trials, they intend to play an important part. The president of Nashville’s Meharry Medical College, Dr. James Hildreth, is an infectious disease researcher. But instead of overseeing the trial site being hosted on his campus, Hildreth has a more modest goal in mind: He plans to participate as a patient, and urge others to join him.

“I think my role is more important in advocating for people to be involved in vaccine studies than to be one of the leaders of the study,” he said.

So at Meharry, Berthaud is the principal investigator. As lunch wraps up in the crowded conference room, he has managed to win over some holdouts.

“Where is the line?” asked Robert Smith. “Where do we sign?”

Smith, with his young grandson in tow, didn’t raise his hand at first when asked if he’d take the vaccine. But after listening to Berthaud, Smith agreed to participate in the clinical trial — for no other reason than the trust he has in Berthaud, his longtime physician.

“He’s not only my doctor; he’s proven that he cares about me,” Smith said.

Persuading hundreds or thousands of Black Americans to sign up will be difficult. But researchers hope their outreach efforts will at least result in more minorities agreeing to take an approved vaccine when available.

This story is part of a partnership that includes Nashville Public Radio, NPR and KHN.

Related Topics

Pharmaceuticals Public Health States

COVID Exodus Fills Vacation Towns With New Medical Pressures

The staff at Stony Brook Southampton Hospital is accustomed to the number of patients tripling or even quadrupling each summer when wealthy Manhattanites flee the city for the Hamptons. But this year, the COVID pandemic has upended everything.

The 125-bed hospital on the southern coast of Long Island has seen a huge upswing in demand for obstetrics and delivery services. The pandemic has families who once planned to deliver babies in New York or other big cities migrating to the Hamptons for the near term.

From the shores of Long Island to the resorts of the Rocky Mountains, traditional vacation destinations have seen a major influx of affluent people relocating to wait out the pandemic. But now as summer vacation season has ended, many families realize that working from home and attending school online can be done anywhere they can tether to the internet, and those with means are increasingly waiting it out in the poshest destinations.

Many of the medical facilities in these getaway spots are used to seeing summer visitors for bug bites or tetanus shots, hiring an army of temporary doctors to get through the summer swells. Now they face the possibility of needing to treat much more serious medical conditions into the fall months — and for the foreseeable future.

Such increase in demand could strain or even overwhelm the more remote towns’ hospitals and health care providers, threatening the availability of timely care for both the newcomers and the locals. The Southampton hospital has just seven intensive care unit beds, with the capacity to expand to as many as 30, but it wouldn’t take much for the hospital to be swamped by patients.

“For health care, the bottom line is: As our population grows, we have to have the infrastructure to support it,” said Tamara Pogue, CEO of Peak Health Alliance, a nonprofit community health insurance-purchasing cooperative in Colorado ski country.

And many communities do not.

Home Sales Soar

Sunny shores and mountain vistas are prompting people to relocate to second homes if they have them, or to purchase new homes in those areas if they don’t. Renters who used to come for a month are now staying for two or three, and summer renters are becoming buyers. Multimillion-dollar residences in the ski resort town of Aspen, Colorado, for example, that once sat on the market for nearly a year now move in weeks.

“Some of the most experienced and seasoned real estate brokers have never seen activity like what we have experienced in July and August,” said Tim Estin, a broker in Aspen, whose firm draws clients from COVID hot spots such as Dallas, Houston, New York, Miami, Los Angeles and Chicago.

Many destinations tried to discourage second-home owners from coming, particularly early in the pandemic after Colorado ski resorts became an epicenter of COVID cases. Gunnison County, Colorado, home to the Crested Butte ski resort, banned out-of-towners, prompting the Texas attorney general to take up the matter on behalf of Texans with homes in the area. In Lake Tahoe, along the California-Nevada border, second-home owners were told to go back to the Bay Area. And in New York vacation destinations, online messages targeted big-city transplants with classic New York aplomb.

The ski resort town of Vail, Colorado, on the other hand, welcomed them with open arms with its Welcome Home Neighbor campaign in May.

“We have long held the belief that in a resort community with so many second homes, that lights on are good, lights off are bad,” said Chris Romer, president and CEO of the Vail Valley Partnership, the region’s chamber of commerce.

Romer said the 56-bed Vail Health Hospital supported the campaign, particularly after visits to the town plummeted 90% in April once the ski lifts stopped running.

“We never would have launched the program if the hospital didn’t sign off on it,” Romer said.

Demand for Health Care

The influx of patients to these rural areas is helping hospitals and clinics rebound from the drop in typical patient visits during the pandemic, but there is concern that additional growth could overwhelm local resources. So far, though, enough people seem reluctant to seek care during the pandemic, unless it’s an emergency or COVID-related, that it hasn’t reached a tipping point. Others might be seeking care with their providers in the big city through telehealth or the occasional run back to their primary residence. But the mix of patients is different.

In Leadville, Colorado, a town nestled in the mountains at an altitude of 10,151 feet, summertime usually means an influx of mountain bikers and runners.

“Leadville has these crazy 100-mile races, where we have very elite athletes from all over the planet, and they have specific medical needs,” said Dr. Lisa Zwerdlinger, chief medical officer at the local St. Vincent Hospital. “But what we’re seeing now are these second-home owners, people who are coming from other places to spend extended periods of time in Leadville and who come with a whole host of other medical issues.”

Most of the races this summer were canceled. That meant fewer extreme athletes and more Texans; fewer broken bones and turned ankles, and more chronic conditions exacerbated by the high altitude. Nonetheless, August was the busiest month ever at Zwerdlinger’s family medicine practice.

Hospitals in vacation towns typically prepare for surges during holidays, said Jason Cleckler, CEO of Middle Park Health, with locations serving Colorado’s Winter Park and Granby Ranch ski resorts in Grand County. During Christmas week, the population of neighboring Summit County, which houses resorts like Breckenridge and Keystone, swells from 31,000 to 250,000. But Cleckler said the COVID surge in resort communities is drawn-out so hospitals may have to respond with more permanent increases in capacity.

In Big Sky, Montana, whose part-time residents include Bill Gates and Justin Timberlake, Big Sky Medical Center doubled its capacity to eight beds in anticipation of a surge in patients due to COVID-19. The center’s two primary care doctors are completely booked. With so many new people in town, the hospital has accelerated plans to shift a third full-time doctor into the clinic.

As the wily coronavirus works its way into all corners of America, though, patients may find that not all regions have the same capacity to deal with COVID or even other complex medical problems.

Visitors to the sole clinic in nearby West Yellowstone, a gateway to the namesake national park, expect to be able to get COVID tests even if they have no symptoms or a known connection to a case, said Community Health Partners spokesperson Buck Taylor.

“There seems to be a frustration that a rural Montana clinic doesn’t have the resources they expect at home,” Taylor said. “That’s nothing new. People come to Montana all the time and say, ‘But where can I get any good Thai food?’”

Planning for What’s Next

The year has been such an outlier for hospitals that it’s difficult for them to predict and plan for what will happen next. On Long Island, many locals typically leave the Hamptons for Florida during the winter. But it’s unclear whether those snowbirds will stay or go this year, given the high levels of COVID-19 in Florida now, said Robert Chaloner, CEO of Stony Brook Southampton. That could also change the demand for who needs medical care.

One indication that some visitors may be staying put? The jump in new students. The Big Sky school district expects a 20% increase in enrollment this fall. Leadville schools have at least 40 new students. Vail Mountain School’s waiting list is its longest ever.

Many have speculated that the pandemic lockdown might fundamentally change the way companies operate, allowing more people to work from distant locations for the foreseeable future.

“Every indicator that I see is pointing to the fact that this is a shift,” said Romer in Vail. “It has the potential to be permanent.”

Taylor Rose, Big Sky Medical Center’s director of operations and clinical services, said that, if that happens, the hospital will have to rebalance its services.

“I’d probably give it a year or two before I make any major changes,” Rose said. “People are going to start deciding, ‘This really isn’t for me. I’m not going to stay here and deal with 6 feet of snow in the winter.’”

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Public Health States

‘It Seems Systematic’: Doctors Cite 115 Cases of Head Injuries From Crowd Control Devices

At least 115 people were injured this summer when police shot them in the head or neck with so-called “less-lethal” projectiles at protests over racial injustice and police brutality, according to a report published Monday.

It’s the most comprehensive tally of such injuries to date, with about twice as many victims as KHN and USA Today cited in a July examination of how police across the U.S. wielded the weapons to control crowds.

But Physicians for Human Rights, the organization that compiled the incidents, believes even its figures are an undercount because its analysis is based on publicly available data and excluded some reports without adequate evidence.

The organization identified Austin, Texas; Portland, Oregon; and Los Angeles as hot spots during the period studied, May 26 to July 27.

Abigail Rodas, who was shot in the jaw with a rubber bullet on May 30, was one of the victims in Los Angeles, according to a lawsuit filed against the city and the police chief on behalf of Black Lives Matter Los Angeles, the Los Angeles Community Action Network and 14 people, including six who were struck with projectiles.

According to the suit, Rodas was leaving a protest when she “was struck in the face by a projectile and momentarily lost consciousness.”

A steel plate was used to repair her jawbone, the lawsuit says. She couldn’t talk for about 10 days and could drink only liquids for a week, it says.

“Nearly three weeks after the injury, she has screws in her gums and rubber bands to immobilize her jaw while the bones rejoin,” the suit says.

The city denied the allegations in a court filing, saying any use of force “was reasonable and necessary for self-defense.”

Protests Shine Light on Use of ‘Less-Lethal’ Weapons

The sheer number of incidents in those two months was shocking, said Dr. Rohini Haar, lead investigator for the analysis and an emergency physician in Oakland, California.

“It seems systematic,” Haar said. “It seems like there needs to be a reckoning with the use of force in protests.”

The projectiles in question are often called “rubber bullets,” but in law enforcement they’re known as “kinetic impact projectiles.”

They include plastic projectiles tipped with hard sponge or foam, “bean bag” rounds that consist of fabric socks containing metal shot, and “Sting-Balls” — grenades that spray hard rubber pellets. The report also cites incidents in which tear gas canisters were fired at people.

Though the weapons are referred to as “less lethal,” Haar said, there should be a shift to language that acknowledges how dangerous they can be. “Weapons are just as lethal as somebody wants them to be,” she said.

A study published in 2017 in the medical journal BMJ Open, which Haar co-authored, found that 3% of people hit by projectiles worldwide died. Fifteen percent of the 1,984 people studied were permanently injured.

In a letter to the editor of the New England Journal of Medicine, a group of Austin doctors said 19 patients were treated for bean bag-related wounds at the downtown hospital closest to the protests over two days in late May.

C.J. Montano, one week after attending a Los Angeles protest where the police shot a projectile at his head.(C.J. Montano)

For its analysis, Physicians for Human Rights searched social media, news accounts, lawsuits and other publicly available sources. They counted incidents on social media only if they were documented by photos or videos, and included news reports without visual evidence only from major newspapers or local affiliates of major outlets.

Physicians for Human Rights identified by name most of the people who were struck.

Among the group’s recommendations are banning weapons that release scattershot or multiple projectiles from a single canister because they can hit people indiscriminately, Haar said. Metal projectiles are particularly dangerous, she said.

She called for more training and adherence to departments’ rules on the use of such weapons.

“One of the findings of our study is police do not even appear to be following their own protocols for how to use these weapons or when,” Haar said.

There are no national standards for police use of less-lethal projectiles and no comprehensive data on their use, USA Today found.

Demonstrators in Los Angeles, Minneapolis, San Jose, Denver and Dallas told USA Today they were shot with less-lethal projectiles even though those departments don’t allow the weapons to be used against nonviolent people. Some witnesses said police aimed at faces or fired at close range.

Police have said they fired the weapons to protect themselves and property in chaotic, dangerous situations.

‘Protesters Feel Like They’re Being Attacked’

Haar, who has been studying these projectiles since 2014, said they have no place in crowd control. “Even before you get to the use of weapons, there needs to be a change in how we engage with protesters in terms of communication,” she said.

For example, police can get the phone number of a protest leader, opening the lines of communication. Police have other options besides firing projectiles, Haar said, such as “arresting the person that is actually violent, not just dispersing the entire crowd, or changing what you decide is an illegal assembly.”

Haar said the use of these projectiles tends to escalate tensions, “where the protesters feel like they’re being attacked.” Those who aren’t struck, she said, “are often incited. It’s not until that full crowd is dispersed that the anger goes away. The volatility has a cumulative impact that can last weeks or months.”

At least seven major U.S. cities and a few states have enacted or proposed limits on the use of less-lethal projectiles.

However, similar efforts have stalled in the face of opposition from police agencies or other critics. And as the summer stretched on, local and federal law enforcement agencies continued to use less-lethal weapons when confronting protesters.

Haar said city councils have reached out to her recently, showing they are “really trying to reckon with what they want in their communities.”

“I see more hope now than I have in all of my years of research,” she said. “I think the attention now is remarkable, and we actually have a really good chance of getting some actual, meaningful change.”

USA Today’s Kevin McCoy contributed to this report.

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Public Health Race and Health States

Readers and Tweeters Grapple With COVID Therapies and Forecasts

Letters to the Editor is a periodic feature. We welcome all comments and will publish a selection. We edit for length and clarity and require full names.


Giving Convalescent Plasma a Shot

Used to effectively treat mumps, measles, and even the so-called Spanish flu in 1918, convalescent plasma may not be a silver bullet, but it still has the potential to play an important role in helping some patients recover from COVID-19 (“5 Things to Know About Convalescent Blood Plasma,” Aug. 27).

To support its recent decision, the Food and Drug Administration used data from previous use cases of convalescent plasma for other respiratory coronaviruses, results of early safety and efficacy trials in animal models, and published studies on the safety and efficacy of convalescent plasma before issuing Emergency Use Authorization (EUA). The agency also pointed to a Mayo Clinic preliminary analysis of 56,000 patients who were given high or low titer units of blood plasma.

The EUA also specifies that donor blood can be released only to hospitals and patients after it is tested with a currently available antibody test that accurately detects the right type of antibodies to neutralize the virus and confirms that the blood contains sufficient levels of these antibodies for treatment purposes. This means that less accurate, less specific tests that are more susceptible to false positives will not be used to identify COVID-19 convalescent plasma — something that should give patients higher confidence that the plasma they receive meets scientific and quality standards.

Dr. Fernando Chaves, a board-certified hematopathologist who serves as Global Head of Medical and Scientific Affairs at Ortho Clinical Diagnostics, Raritan, New Jersey


— Dr. Andrew Gaffney, Boston


Vaccination and Prognostication

Both assertions that seniors will drive 800 miles or come home from an assisted living or skilled nursing facility to live with families are dubious (“What Seniors Can Expect as Their New Normal in a Post-Vaccine World,” Aug. 3). The latter are need-based moves (think dementia, wandering). The former makes sense for those who won’t tolerate the physical strain of long car rides — think Florida to D.C.

— Laurie Orlov, Aging and Health Technology Watch, Port St. Lucie, Florida


— Rosemary Wright, Wichita, Kansas


I don’t want these precautions to last forever. I want there to be a time where we can all give each other hugs and high fives again. We were built to be together and celebrations bring us so much joy. I want there to be a time when we can all be in fun crowds again. I want to be able to smile out in public again and not have to cover my face. What do you think about all of this?

— Christopher DeCarlo, Oyster Bay, New York


— Dr. Tony Slonim, Reno, Nevada


Humans as Guinea Pigs for the Sake of Corporate Piggy Banks?

We assume that this vaccine works, but how do we know (“They Pledged to Donate Rights to Their COVID Vaccine, Then Sold Them to Pharma,” Aug. 25)? The public is not some testing animal. I would not take this vaccine, especially since the back-and-forth is over money and not public health. No government should give any money to a business without a deal that protects the public as investors. We are not a source of free money; just as they make no concessions, we also should make no concessions without a deal. And the deal is public health.

There was no vaccine during the 1918-19 influenza, not until 1940. Our immune system needs to be considered as part of a cure. Is that not the theory behind flu shots? So, if we are exposed to the virus and allow our bodies to fight it off, that defense is greater than any vaccine. Those who cannot fight off the infection are the ones who need to be considered for medical attention — and not just some shot hopefully manufactured by a company that does not prioritize money over health.

There are times when profit is important, but since businesses are being subsidized, this is not one of those times. The world economy has been seriously affected, and printing money we do not have is not a sound idea. What good are medicine and doctors and medical research? Seems we should consider those old grandma medications, such as the hot toddy … whiskey and hot coffee and a good night to sweat it out under many covers. That cured my grandfather of influenza long before there was a vaccine.

Medical science doesn’t have all the answers. If soap can kill this coronavirus, then there must be a common household solution to eradicate it that is medically safe for humans. Perhaps technology students would do better to help the world instead of these money-hungry corporations.

— Tom Berger, Suffolk County, New York


— Amar Jesani, Mumbai, India


On COVID Tests and Risk

I have worked in a clean lab for many decades. I know how to behave and how to take advantage of and handle PPE, for the purpose of achieving very low contamination levels. The article “Analysis: When Is a Coronavirus Test Not a Coronavirus Test?” (July 29) presents a false option. It is not about accepting a level of risk, it is about doing everything possible to reduce the risk.

In my labs, I had the ability to require adherence to careful procedures and the option to fire anyone who would not follow approved procedures. I don’t have that option with those who refuse to follow the simple instructions for COVID-19, including the “religious” wearing of a mask, the same way that women cover their heads when entering a Catholic church and Jewish men wear a yarmulke in a temple.

And when the president irresponsibly and criminally refuses to follow and to mandate simple instructions by medical experts, then I am unable to calculate the risk. I don’t think Ms. Rosenthal can calculate the level of risk she suggests we accept.

— Dimitri Papanastassiou, Pasadena, California


I enjoyed your piece, but I regret that you said so little about therapies that may emerge to help us. Vaccines are not the only hope. I think a disservice is being done by indicating that our only options are to live with it or wait for a vaccine.

— John Van Drie, North Andover, Massachusetts


— Meghan McGinty, Brooklyn, New York


The Hydroxy Paradox

Wouldn’t it be refreshing, instead of slamming other doctors’ practical experience with hydroxychloroquine at low dosages and supplemented with zinc, etc. at the first sign of the infection, to at least let them make fools of themselves (“Don’t Fall for This Video: Hydroxychloroquine Is Not a COVID-19 Cure,” July 31)? What is the harm?

Aren’t “we all in this together”? Why are we afraid of a difference in opinion? What if it really works using the protocols as stated? Let it play out. Pretty sure no one has died when prescribed “hydroxy” in low dosages by doctors in actual practice, unlike the deaths that occurred when given in massive dosages late in the infection.

Why make fun of doctors who are trying their best to help us all? That seems narrow-minded to me.

— Larry Koch, Agoura Hills, California


— Tara Tisch, Peoria, Illinois


I know you disagree with Dr. Stella Immanuel, and that’s OK. The problem I have is that no one has done the clinical trials to prove that hydroxychloroquine doesn’t work. She said she has 350 patients who have had success with her prescriptions; the doctor from Dallas said she uses it with her own little concoction. If, in fact, what they are doing is working, then why don’t people visit these doctors to see if it is true — and, if it is, then try collaborating with them to keep people from dying, for crying out loud.

That is one of the problems here: Everyone is against one another instead of trying to support one another. We are Americans and, as in years past, we have stuck together for the betterment of the country. If we would stop trying to take care of America with money and start taking care of America with information, then America would live and thrive.

I am a first-year respiratory therapy student and spent 20 years in the Marine Corps, and back in the ’80s we took chloroquine, and I have no side effects and neither do the guys I stay in contact with. Keep in mind that the reports of the side effects are not in every patient and if hydroxychloroquine is offered to a patient and the patient is told, “This is going to make you better but there could be side effects later, but if you don’t take this you will get worse and we don’t know if you will die or not,” what do you think they will say? No one wants to die.

C’mon, let’s just be people trying to keep other people alive no matter the cost, no matter who is right or wrong — we can sort that out later.

— Jim Tumlinson, Canyon Lake, Texas

Editor’s note: A recent report from the Centers for Disease Control and Prevention expressed caution and concern that hydroxychloroquine was potentially being misused to treat COVID-19 and affecting supplies of the medication to treat rheumatoid arthritis, lupus and other conditions. “Current data on treatment and pre- or postexposure prophylaxis for COVID-19 indicate that the potential benefits of these drugs do not appear to outweigh their risks,” it said.


Yoga for All

I appreciate your article (“Namaste Noir: Yoga Co-Op Seeks to Diversify Yoga to Heal Racialized Trauma,” July 30) but have a hard time with “people of color” being repeated over and over. Yoga benefits all people, and until we start thinking as one and not labeling everything we will always have racial issues. We need to think all lives matter, not just a specific color. Thank you for your writings.

— Susan Ferguson, Cypress, California


— Eli Imadali, Denver


— Jimmy Etheredge, Atlanta


Words That Carry Weight

Thank you for calling attention to the challenges people with obesity face regarding risks of COVID-19 infections and the potential that vaccines may not be effective (“America’s Obesity Epidemic Threatens Effectiveness of Any COVID Vaccine,” Aug. 6). I would like to comment on how you refer to people with obesity. The Obesity Action Coalition, and other organizations focused on obesity, recommend using people-first language. An article about cancer does not refer to cancer people, nor does one on cardiovascular disease label individuals as heart disease people. The terms “obese people” and “morbid obesity” are stigmatizing. It is better to utilize people-first language as Dr. Timothy Garvey did at the end of the article. As a member of the Obesity Medicine Association as well as an obesity medicine specialist and educator, I work diligently with patients to overcome the bias and stigma that society imposes. Please be considerate of the use of language when referring to people with obesity.

— Dr. Nicholas Pennings, Raleigh, North Carolina


— John Ziegler, Los Angeles


As a sociologist researching weight stigma, I am appalled by the article by Sarah Varney suggesting obesity will undermine vaccine effectiveness. The article is full of stereotypes and misinformation. In the first place, it is Big Pharma’s fault vaccines aren’t made for fat people. It is beyond incompetence that any vaccine drugmakers come up with would be less effective for half the population. In the second place, many of the diseases fat folk allegedly have are caused by yoyo dieting and stigma. And there is no proof weight loss would make any vaccines more effective as most fat people are biochemically different than thin ones. This is a tone-deaf, fat-phobic article that serves only corporate interests.

— Sherie Sanders, Springfield, Illinois


Jail Outbreaks

My life and those of others are being put in danger by the San Bernardino County Sheriff’s Department (“COVID Runs Amok in 3 Detroit-Area Jails, Killing At Least 2 Doctors,” July 23). I’m in jail with health issues: asthma, prediabetes, vitamin D deficiency, high blood pressure, and may have a cancerous tumor and peripheral neuropathy. I’ve already been put on quarantine two times, once because a deputy who tested positive for COVID-19 had direct contact with me and the other because they put someone in the cell with me who was symptomatic for COVID-19. When being transported anywhere, they put chains on us that have been on many people and have not been cleaned. Then they chain multiple people together, not even knowing if a person has or is a carrier of the coronavirus. The social distancing was put in effect to protect the lives of people. The sheriff’s department is violating it, putting lives in danger and will continue to do so until they are stopped. To top it off, I am state property and not even supposed to be here. I don’t want to die or see anyone else die for being in jail and catching COVID-19. So can someone please help us all.

— LeAire Moore Sr., Adelanto, California


— Samuel Cook III, New Orleans


Correcting the Record on the Navajo Language

The article “Two Navajo Sisters Who Were Inseparable Died of COVID Just Weeks Apart” (Aug. 26) is incorrect. The Navajo language is most certainly “written down” and is taught in schools and universities.

— Randy Truman, Albuquerque

Editor’s note: Thanks for helping us clarify that point. The article has been updated.


Medicaid Expansion in the Age of COVID

The COVID-19 pandemic has shown us that Americans are in desperate need of health insurance, including publicly financed health insurance programs such as Medicaid. The time is now for some policymakers in America to reshape how they think of Medicaid as more than a government handout that makes us worse and not better.

Medicaid is a health insurance program that is jointly funded by the state and federal government. This program provides low-cost insurance to adults with low income, both young and elderly, pregnant women, the disabled and children through the Children’s Health Insurance Program, commonly known as the CHIP program.

The Affordable Care Act provided an opportunity for states to expand coverage to individuals at 138% of the federal poverty level. As an added incentive, the federal government pledged to pay 100% of the costs to expand, a share that would be reduced to 90% by 2020. In recent months, states such as Oklahoma and Missouri through the ballot box have expanded Medicaid. This leaves only 12 states to not expand, but millions more in need of affordable health insurance.

The argument by some policymakers against the Medicaid program is the fear of incentivizing Americans to not work. Contrary to this belief, in 2017, it was reported that more than 63% of Medicaid recipients are already in the workforce while only 7% were not working for various reasons.

Finally, since the beginning of the pandemic, one study estimated that nearly 27 million Americans could lose their employer-sponsored insurance this year. Of those 27 million, nearly 13 million would be eligible for Medicaid.

The American people deserve to have affordable health insurance. Therefore, policymakers have an obligation to expand it and not contract.

— Reginald Parson, Portland, Maine


— Stephen Ferrara, New York City

Related Topics

Aging Medicaid Public Health Race and Health States

With No Legal Guardrails for Patients, Ambulances Drive Surprise Medical Billing

School librarian Amanda Brasfield bent over to grab her lunch from a small refrigerator and felt her heart begin to race. Even after lying on her office floor and closing her eyes, her heart kept pounding and fluttering in her chest.

The school nurse checked Brasfield’s pulse, found it too fast to count and called 911 for an ambulance. Soon after the May 2018 incident, Brasfield, now 39, got a $1,206 bill for the 4-mile ambulance ride across the northwestern Ohio city of Findlay — more than $300 a mile. And she was on the hook for $859 of it because the only emergency medical service in the city has no contract with the insurance plan she has through her government job.

More than two years later, what was diagnosed as a relatively minor heart rhythm problem hasn’t caused any more health issues for Brasfield, but the bill caused her some heartburn.

“I felt like it was too much,” she said. “I wasn’t dying.”

Brasfield’s predicament is common in the U.S. health care market, where studies show the majority of ambulance rides leave patients saddled with hundreds of dollars in out-of-network medical bills. Yet ground ambulances have mostly been left out of federal legislation targeting “surprise” medical bills, which happen when out-of-network providers charge more than insurers are willing to pay, leaving patients with the balance.

However, the COVID-19 pandemic has prompted temporary changes that could help some patients. For instance, ambulance services that received federal money from the CARES Act Provider Relief Fund aren’t allowed to charge presumptive or confirmed coronavirus patients the balance remaining on bills after insurance coverage kicks in. Also during the pandemic, the Centers for Medicare & Medicaid Services is letting Medicare pay for ambulance trips to destinations besides hospitals, such as doctors’ offices or urgent care centers equipped to treat recipients’ illnesses or injuries.

But researchers and patient advocates said consumers need more, and lasting, protections.

“You call 911. You need an ambulance. You can’t really shop around for it,” said Christopher Garmon, an assistant professor at the University of Missouri-Kansas City who has studied the issue.

A Health Affairs study, published in April, found 71% of all ambulance rides in 2013-17 for members of one large, national insurance plan involved potential surprise bills. The median out-of-network surprise ground ambulance bill was $450, for a combined impact of $129 million a year.

And a study published last summer in JAMA Internal Medicine found 86% of ambulance rides to ERs — the vast majority by ground ambulances, not helicopters — resulted in out-of-network bills.

Caitlin Donovan, senior director of the National Patient Advocate Foundation in Washington, D.C., said she hears from consumers who get such bills and resolve to call Uber the next time they need to get to the ER. Although experts — and Uber — agree an ambulance is the safest option in an emergency, research out of the University of Kansas found that the Uber ride-sharing service has reduced per-person ambulance use by at least 7%.

Only Ambulance in Town

When Brasfield was rushed to the hospital, her employer, Findlay City Schools, offered insurance plans only from Anthem, and none included the Hanco EMS ambulance service in its network. School system treasurer Michael Barnhart said the district couldn’t insist that Hanco participate. Starting Sept. 1, Barnhart said the school system will have a different insurer, UMR/United Healthcare, but the same plans.

“There is no leverage when they are the only such service around. If it were a particular medical procedure, we could encourage employees to seek another doctor or hospital even if it was further away,” Barnhart said in an email. “But you can’t encourage anyone to use an ambulance service from 50 miles away.”

There is great disagreement about what an ambulance ride is worth.

Brasfield’s insurer paid $347 for her out-of-network ambulance ride. She said Anthem representatives told her that was consistent with in-network rates and Hanco’s $1,206 charge was simply too high.

Jeff Blunt, a spokesperson for Anthem, said that 90% of ambulance companies in Ohio agree to Anthem’s payment rates; Hanco is among the few medical transport providers that don’t participate in its network. He said Anthem reached out to Hanco twice to negotiate a contract but never heard back.

Brasfield sent three letters appealing Anthem’s decision and called Hanco to negotiate the bill down. The companies wouldn’t budge. Hanco sent her a collections notice.

An Ohio school librarian took a 4-mile ambulance ride across Findlay, Ohio, to nearby Blanchard Valley Hospital for what turned out to be a relatively minor heart rhythm problem. But the trip led to a $1,206 ambulance bill.(Amy E. Voigt for KHN)

Rob Lawrence of the American Ambulance Association pointed out that nearly three-quarters of the nation’s 14,000 ambulance providers have low transport volumes but need to staff up even when not needed, creating significant overhead. And because of the pandemic, ambulance providers have seen reduced revenue, higher costs and more uncompensated care, the association’s executive director, Maria Bianchi, said in an email.

Officials at Blanchard Valley Health System, which owns Hanco, said Brasfield’s ambulance charge was on par with the national average for this type of medical emergency, in which EMTs started an IV line and set up a heart monitor.

Fair Health, a nonprofit that analyzes billions of medical claims, estimates an ambulance ride costs $408 in-network and $750 out-of-network in Toledo, which is about 50 miles away from Findlay and has several ambulance companies. Even the higher of those two costs is $456 less than Brasfield’s bill.

Widespread Problem, No Action

Similar stories play out across the nation.

Ron Brooks, 72, received two bills of more than $690 each when his wife had to be rushed about 6 miles to a hospital in Inverness, Florida, after two strokes in November 2018. The only ambulance service in the county, Nature Coast EMS, was out-of-network for his insurer, Florida Blue. Neither had responded to requests for comment by publication time. Brooks’ wife died, and it took him months to pay off the bills.

“There should be an exception if there was no other option,” he said.

Sarah Goodwin of Shirley, Massachusetts, got a $3,161 bill after her now-14-year-old daughter was transported from a hospital to another facility about an hour away after a mental health crisis in November. That was the balance after her insurer, Tricare Prime, paid $491 to Vital EMS. Despite reaching out to the ambulance company and her insurer, she received a call from a collection agency.

“I feel bullied,” she said earlier this year. “I don’t plan to pay it.”

Since KHN asked the companies questions about the bill and the pandemic began, she said, she hadn’t gotten any more bills or calls as of late August.

In an emailed response to KHN, Vital EMS spokesperson Tawnya Silloway said the company wouldn’t discuss an individual bill, and added: “We make every effort to take patients out of the middle of billing matters by negotiating with insurance companies in good faith.”

Last year, an initial attempt at federal legislation to ban surprise billing left out ground ambulances. This February, a bill was introduced in the U.S. House that calls for an advisory committee of government officials, patient advocates and representatives of affected industries to study ground ambulance costs. The bill remains pending, without any action since the pandemic began.

In the meantime, consumer advocates suggest patients try to negotiate with their insurers and the ambulance providers.

Michelle Mello, a Stanford University professor who specializes in health law and co-authored the JAMA Internal Medicine study that examined surprise ambulance bills, was able to appeal to her insurer to pay 90% of such a bill she got after a bike accident last year.

That tactic, however, proved futile for Brasfield, the Ohio librarian. She set up a $100-a-month payment plan with Hanco and, eventually, paid off the bill.

From now on, she said, she’ll think twice about taking an ambulance unless she feels her life is in imminent danger. For anything less, she said, she’d ask a relative or friend to drive her to the hospital.

Related Topics

Health Care Costs Insurance States