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

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

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

Hell and back is more like it.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Biden’s Straight-Talking CDC Director Has Long Used Data to Save Lives

In early December, Dr. Katy Stephenson was watching TV with her family and scrolling through Twitter when she saw a tweet that made her shout.

“I said ‘Oh, my God!’” she recalled. “Super loud. My kids jumped up. My husband looked over. He said, ‘What’s wrong, what’s wrong, is everything OK?’ I was like, ‘No, no, it’s the opposite. It’s amazing. This is amazing!’”

Dr. Rochelle Walensky had just been tapped to lead the Centers for Disease Control and Prevention.

Stephenson is an infectious diseases specialist and vaccine scientist at Beth Israel Deaconess Medical Center in Boston. So the news had special meaning for her and the many jubilant colleagues tweeting their joy. They’d been helping one another through the brutal pandemic year, she said, while feeling they had little to no help from the federal government.

“It was so baffling,” she said. “It wasn’t even just that we didn’t know what the government was doing. It was that sometimes it felt like sabotage. Like the federal government was actively trying to mess things up.”

But through it all, as the long months became a year, Walensky had been out front, Stephenson said, sticking to the science and telling the truth.

When Walensky stepped up to lead the CDC, she promised to keep telling the truth — even when it’s bad news. She told a JAMA Network podcast last month that she’ll welcome straight talk from the scientists at the CDC as well.

“They have been diminished,” she said. “I think they’ve been muzzled — that science hasn’t been heard. This top-tier agency, world-renowned, hasn’t really been appreciated over the last four years and really markedly over the last year, so I have to fix that.”

Walensky, 51, has long been a doctor on a mission — first, to fight AIDS around the world, and now, to shore up the CDC and get the United States through the pandemic. Beyond unmuzzling her agency’s staff, she vows to tackle many other challenges, pushing particularly hard on vaccine distribution and rebuilding the public health system.

Walensky’s family has a tradition of service, including a grandfather who served in World War II and rose to be a brigadier general. And she likens the call she got from the Biden administration to a hospital alarm that goes off when a patient is in cardiac arrest.

“I got called during a code,” she told JAMA. “And when you get called during a code, your job is to be there to help.”

At Massachusetts General Hospital, where Walensky was the chief of infectious diseases, some of her many admirers now have T-shirts that read “Answer the Code” with her initials, RPW, beneath.

The shirts are part of an outpouring of affection in Boston biomedical circles and far beyond that greeted Walensky’s appointment — including a flood of floral bouquets that her husband and three sons helped accept after word of her new job got out.

“At one point, one of my sons said, ‘You know, Dad, we should just open a florist shop at this point,” said Dr. Loren Walensky, the CDC director’s husband.

He studies and treats children’s blood cancers at Boston Children’s Hospital and the Dana-Farber Cancer Institute. And now he could be called the “first gentleman” of the CDC.

He calls Rochelle his “Wonder Woman” and still remembers when he first saw her 30 years ago, in the cafeteria of the Johns Hopkins University School of Medicine, where they were both students.

“She stood out,” he said. “And one of the reasons why she stood out is because she stands tall. Rochelle is 6 feet tall.”

She also had extraordinary energy and discipline, even then, he remembered: “Most of us would roll out of bed and stumble into the lecture hall as our first activity of the day and, for Rochelle, she was already up and running and bright-eyed and bushy-tailed for hours before any of us ever saw the light of day.”

After medical school, Rochelle Walensky trained in a hospital medical unit so tough it was compared to the Marines. It was the mid-’90s, and the AIDS epidemic was raging. She saw many people die. And then, a few years later, she saw the advent of HIV treatments that could save patients — if those patients could get access to testing and care.

Loren Walensky recalls coming home one day to find her sitting at the kitchen table working on extremely complex math. She was starting to broaden her focus from patient care to bigger-picture questions about the increased equity in health care that more funding and optimal treatment choices could bring.

“And it was like a switch went off,” he said, “and she just had this natural gift for this style of testing — whether if you did X, would Y happen, and if you did X with a little more money, then how would that affect Y? And all of these if-thens.”

She started doing more research, including studies of ways to get more patients tested and treated for AIDS, even in the poorest countries. One of her most prominent papers calculated that HIV drugs had given American patients at least 3 million more years of life.

She worked with Dr. Ken Freedberg, a leading expert on how money is best spent in medicine.

“You can’t do everything,” Freedberg said, “and even if you could, you can’t do everything at once. So what Rochelle is particularly good at is understanding data about treatments and public health and costs, and putting those three sets of data together to understand, ‘Well, what do we do? And what do we do now?’”

So, if Walensky had a Wonder Woman superpower, it was using data to inform decisions and save lives. That analytic skill has come in handy over the past year, as she has helped lead the pandemic response for her Boston hospital and for the state of Massachusetts.

She has weighed in often — and publicly — about coronavirus policy and medicine, speaking to journalists with a seemingly natural candor that has contrasted with the stiffer style of some federal officials. In April, when a huge surge of covid cases hit, she acknowledged the pain.

“We are experiencing incredibly sad days,” she said in a spring interview. “But we sort of face every day with the hope and the vision that what we will be faced with, we can tackle.”

And in November, she offered a sobering reality check from the front lines about current covid medical treatments: “When I think about the armamentarium of true drugs that we have that benefit people with this disease, it’s pretty sparse,” she said.

Walensky published research on key pandemic topics, such as college testing and antibody treatments. And she weighed in often publicly — on Twitter, in newspapers and on radio and TV. Asked on CNN whether the President Joe Biden’s plan to get 100 million Americans vaccinated in 100 days could restore a sense of normalcy, she responded with characteristic bluntness — a quality that could cause trouble in these polarized times.

“I told you I’d tell you the truth,” she said. “I don’t think we’re going to feel it then. I think we’re still going to have, after we vaccinate 100 million Americans, we’re going to have 200 million more that we’re going to need to vaccinate.”

Walensky is facing a historic challenge and leading an agency for which she’s never worked.

Already, she’s fielded blowback for the new CDC guidance on when and how schools should reopen, and she’s openly worried about new, more transmissible variants spreading nationwide.

Still, Boston colleagues said they have no doubt she’ll succeed in making the transition from leading an infectious diseases division of 300 staffers to a public health agency of about 13,000.

“I would lie down in traffic for her,” said Elizabeth Barks, the infectious diseases division’s administrative director at Mass General. “And I think our entire division would lie down in traffic for her.”

Leading and rebuilding the CDC in the midst of a pandemic will be difficult. But Barks and others who know Walensky well said she’s clear-eyed and ready to dig in to meet the challenge; she’ll try a new approach if first attempts fall short.

Walensky brought a plaque from her desk in Boston to CDC headquarters in Atlanta. It reads: “Hard things are hard.”

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

Have a Case of a Covid Variant? No One Is Going to Tell You

Covid-19 infections from variant strains are quickly spreading across the U.S., but there’s one big problem: Lab officials say they can’t tell patients or their doctors whether someone has been infected by a variant.

Federal rules around who can be told about the variant cases are so confusing that public health officials may merely know the county where a case has emerged but can’t do the kind of investigation and deliver the notifications needed to slow the spread, according to Janet Hamilton, executive director of the Council of State and Territorial Epidemiologists.

“It could be associated with a person in a high-risk congregate setting or it might not be, but without patient information, we don’t know what we don’t know,” Hamilton said. The group has asked federal officials to waive the rules. “Time is ticking.”

The problem is that the tests in question for detecting variants have not been approved as a diagnostic tool either by the Food and Drug Administration or under federal rules governing university labs ― meaning that the testing being used right now for genomic sequencing is being done as high-level lab research with no communication back to patients and their doctors.

Amid limited testing to identify different strains, more than 1,900 cases of three key variants have been detected in 46 states, according to the Centers for Disease Control and Prevention. That’s worrisome because of early reports that some may spread faster, prove deadlier or potentially thwart existing treatments and vaccines.

Officials representing public health labs and epidemiologists have warned the federal government that limiting information about the variants ― in accordance with arcane regulations governing clinical labs ― could hamper efforts to investigate pressing questions about the variants.

The Association of Public Health Laboratories and the Council of State and Territorial Epidemiologists earlier this month jointly pressed federal officials to “urgently” relax certain rules that apply to clinical labs.

Washington state officials detected the first case of the variant discovered in South Africa this week, but the infected person didn’t provide a good phone number and could not be contacted about the positive result. Even if health officials do track down the patient, “legally we can’t” tell him or her about the variant because the test is not yet federally approved, Teresa McCallion, a spokesperson for the state department of health, said in an email.

“However, we are actively looking into what we can do,” she said.

Lab testing experts describe the situation as a Catch-22: Scientists need enough case data to make sure their genome-sequencing tests, which are used to detect variants, are accurate. But while they wait for results to come in and undergo thorough reviews, variant cases are surging. The lag reminds some of the situation a year ago. Amid regulatory missteps, approval for a covid-19 diagnostic test was delayed while the virus spread undetected.

The limitations also put lab professionals and epidemiologists in a bind as public health officials attempt to trace contacts of those infected with more contagious strains, said Scott Becker, CEO of the Association of Public Health Laboratories. “You want to be able to tell [patients] a variant was detected,” he said.

Complying with the lab rules “is not feasible in the timeline that a rapidly evolving virus and responsive public health system requires,” the organizations wrote.

Hamilton also said telling patients they have a novel strain could be another tool to encourage cooperation ― which is waning ― with efforts to trace and sample their contacts. She said notifications might also further encourage patients to take the advice to remain isolated seriously.

“Can our investigations be better if we can disclose that information to the patient?” she said. “I think the answer is yes.”

Public health experts have predicted that the B117 variant, first found in the United Kingdom, could be the predominant variant strain of the coronavirus in the U.S. by March.

As of Tuesday, the CDC had identified nearly 1,900 cases of the B117 variant in 45 states; 46 cases of B1351, which was first identified in South Africa, in 14 states; and five cases of the P.1 variant initially detected in Brazil in four states, Dr. Rochelle Walensky, the CDC director, told reporters Wednesday.

A Feb. 12 memo from North Carolina public health officials to clinicians stated that because genome sequencing at the CDC is done for surveillance purposes and is not an approved test under the Clinical Laboratory Improvement Amendments program ― which is overseen by the U.S. Centers for Medicare & Medicaid Services ― “results from sequencing will not be communicated back to the provider.”

Earlier this week, the topic came up in Illinois as well. Notifying patients that they are positive for a covid variant is “not allowed currently” because the test is not CLIA-approved, said Judy Kauerauf, section chief of the Illinois Department of Public Health communicable disease program, according to a record obtained by the Documenting COVID-19 project of Columbia University’s Brown Institute for Media Innovation.

The CDC has scaled up its genomic sequencing in recent weeks, with Walensky saying the agency was conducting it on only 400 samples weekly when she began as director compared with more than 9,000 samples the week of Feb. 20.

The Biden administration has committed nearly $200 million to expand the federal government’s genomic sequencing capacity in hopes it will be able to test 25,000 samples per week.

“We’ll identify covid variants sooner and better target our efforts to stop the spread. We’re quickly infusing targeted resources here because the time is critical when it comes to these fast-moving variants,” Carole Johnson, testing coordinator for President Joe Biden’s covid-19 response team, said on a call with reporters this month.

Hospitals get high-level information about whether a sample submitted for sequencing tested positive for a variant, said Dr. Nick Gilpin, director of infection prevention at Beaumont Health in Michigan, where 210 cases of the B117 variant have been detected. Yet patients and their doctors will remain in the dark about who exactly was infected.

“It’s relevant from a systems-based perspective,” Gilpin said. “If we have a bunch of B117 in my backyard, that’s going to make me think a little differently about how we do business.”

It’s the same in Washington state, McCallion said. Health officials may share general numbers, such as 14 out of 16 outbreak specimens at a facility were identified as B117 ― but not who those 14 patients were.

There are arguments for and against notifying patients. On one hand, being infected with a variant won’t affect patient care, public health officials and clinicians say. And individuals who test positive would still be advised to take the same precautions of isolation, mask-wearing and hand-washing regardless of which strain they carried.

“There wouldn’t be any difference in medical treatment whether they have the variant,” said Mark Pandori, director of the Nevada State Public Health Laboratory. However, he added that “in a public health emergency it’s really important for doctors to know this information.”

Pandori estimated there may be only 10 or 20 labs in the U.S. capable of validating their laboratory-based variant tests. One of them doing so is the lab at the University of Washington in Seattle.

Dr. Alex Greninger, assistant director of the clinical virology laboratories there, who co-created one of the first tests to detect SARS-CoV-2, said his lab began work to validate the sequencing tests last fall.

Within the next few weeks, he said, he anticipates having a federally authorized test for whole-genome sequencing of covid. “So all the issues you note on notifying patients and using [the] results will not be a problem,” he said in an email.

Companies including San Diego-based Illumina have approved covid-testing machines that can also detect a variant. However, since the add-on sequencing capability wasn’t specifically approved by the FDA, the results can be shared with public health officials ― but not patients and their doctors, said Dr. Phil Febbo, Illumina’s chief medical officer.

He said they haven’t asked the FDA for further approval but could if variants start to pose greater concern, like escaping vaccine protection.

“I think right now there’s no need for individuals to know their strains,” he said.

With GOP Back at Helm, Montana Renews Push to Sniff Out Welfare Fraud

Montana is considering becoming the latest state to intensify its hunt for welfare overpayments and fraud, a move expected to remove more than 1,500 enrollees from low-income health coverage at a time when the pandemic has left more people needing help.

With Republicans now controlling both chambers of the Montana legislature and the governor’s office, a lawmaker is reviving an effort to both broaden and increase the frequency of eligibility checks to search for welfare fraud, waste and abuse. Proponents say it’s about what’s fair — weeding out people who don’t qualify, protecting safety nets for those who do, and saving the state millions. But advocates for low-income people who rely on such services and some policy analysts say such changes would unfairly drop eligible people who need the aid.

“We’re not looking to do anything mean. We’re taking the emotion out of it,” state Sen. Cary Smith, a Republican, said during a Jan. 20 hearing on his bill, the Provide for the Welfare Fraud Prevention Act. “If you don’t qualify, then you shouldn’t be participating in that program.”

The Montana bill, and measures underway in Ohio and Utah, are similar to earlier efforts undertaken to cut costs in states such as Illinois and Michigan. But this year’s bills come even as Congress offers states more Medicaid dollars if they ensure people have continuous coverage through the pandemic because of its economic shock waves.

The Montana proposal would create a system potentially run by third-party vendors that would mine a large swath of data to see if someone, for example, has assets like a boat, has won the lottery or has filed for benefits in another state. The vendor could earn a bonus for flagging more cases than the state projected. State employees would have the final say in cutting someone from Medicaid, the Children’s Health Insurance Program, food stamps or other aid programs.

The state estimates the measure could save Montana’s treasury between $1.4 million and $2.3 million each year over the next four years by dropping more than 1,500 people on Medicaid and 277 children covered by CHIP.

This isn’t Smith’s first effort to create such a law. He sponsored a similar bill in 2015 that was vetoed by the state’s then-governor, Democrat Steve Bullock. In the veto letter, Bullock said the measure duplicated steps the state already took and unfairly stigmatized Montanans who are poor. Opponents of Smith’s latest proposal have repeated those concerns. Smith didn’t respond to several requests for an interview.

But this time, the potential legislation has a clearer path. The state has a new governor, Greg Gianforte, a Republican who called for heightened Medicaid eligibility checks throughout his 2020 campaign.

During Montana’s first hearing for the renewed effort, Scott Centorino of Opportunities Solutions Project was the sole person to testify in support of the bill.

“I’ve seen this play out in state after state,” Centorino said. “Turns out, the less you look for welfare, fraud and waste, the less you find.”

Opportunity Solutions Project, the lobbying wing of the Foundation for Government Accountability, a right-leaning think tank, has backed similar efforts elsewhere that followed FGA model legislation. The organizations have also been major forces in trying to link food assistance to work requirements and block states from expanding Medicaid.

Opportunity Solutions Project’s attempts to influence laws at the federal level, too, appear to be growing. The nonprofit spent $25,500 lobbying the federal government in 2017 and $420,000 last year, according to the Center for Responsive Politics.

Opponents of the Montana bill have said the focus on welfare recipients is misplaced. Nationally, most Medicaid payments deemed improper last year were tied to states not collecting information that federal standards already call for, not necessarily for covering ineligible enrollees, according to a U.S. Department of Health and Human Services financial report.

Michele Gilman, a University of Baltimore law professor, said the potential bonus Montana would pay a company finding more savings than expected is especially concerning.

“The goal should not be to create some bounty hunter system to find alleged cheats that don’t exist,” Gilman said. “This is built on an unfounded mistrust of poor people and undermines public support for social programs.”

If states do move to undertake broad data searches, she said, they need to start with a pilot program to test for errors in its design. Gilman called Michigan the ultimate cautionary tale. The state, which had used a new computer program to spot cheaters, ended up mired in lawsuits after it falsely charged thousands with unemployment fraud between 2013 and 2015.

The Trump administration and federal agencies encouraged states to increase eligibility checks. According to a KFF analysis, as of January 2019 more than half of states were conducting checks more often than during annual renewals, with some doing so quarterly. (KHN is an editorially independent program of KFF.)

Robin Rudowitz, co-director of KFF’s Program on Medicaid and the Uninsured, said Medicaid and CHIP enrollment dropped across the nation from late 2017 through 2019. Rudowitz said it’s hard to untangle all the reasons the enrollment declines occurred, but increased verification efforts that add to administrative hurdles create barriers to coverage.

Jennifer Wagner, with the left-leaning Center on Budget and Policy Priorities, said people may not realize they’re still eligible when notified that their benefits are in question or may not even receive the notice. She said a search for benefits filed in a separate state may flag aid that can cross states, such as food stamps, and such searches can pull up property someone no longer owns. Frequent wage checks may not take into account inconsistent jobs. The onus would fall to the aid recipient to prove they are still eligible in each scenario, she said.

One state that Opportunity Solutions Project points to as a success is Illinois, which in 2012 hired a company to identify Medicaid recipients who might not be eligible. Wagner, who was an associate director with the Illinois Department of Human Services at the time of the change, said Illinois is unique because the state knew it had a backlog of status checks. Within a year, Illinois had canceled benefits for nearly 150,000 people. But the state reported that more than 75% of cancellations were due to clients’ failure to respond to a state letter asking for more information. Wagner said similar issues have occurred in other states.

“In many cases, those individuals remain eligible, but they have a gap in coverage and they have to reapply and do what they can to get back on the program,” said Wagner. “There’s a large cohort of people who never get that done.”

Of all the people Illinois dropped, nearly 20% had reenrolled by the end of the year. That issue — people getting knocked off when they’re eligible — already happens in annual renewals. But Wagner said more checks means more people losing benefits, and more work for states to bring those people back onboard.

Centorino, with Opportunity Solutions Project, said systems that remove qualified people aren’t being implemented properly, but added it’s not too heavy of a lift to respond to an eligibility question.

“The alternative is not is not resolving the discrepancy at all and just assuming that there is no discrepancy and continuing to fund benefits for somebody who may be ineligible,” he said.

In Montana, even with the bill’s clearer shot at becoming law, some elements that opponents criticized were rolled back after the state estimated it would need to hire 42 employees to run the new system. Smith reduced how many programs would fall under its scrutiny and pulled back eligibility checks to twice a year instead of quarterly. He removed a rule that the system pay for itself, and he cut a section that would have disenrolled people who don’t respond to eligibility questions or notices within 10 business days.

Nonetheless, if a new system flags issues in people’s enrollment, the state will have to go out searching for why. The bill is under consideration in the Senate and must also pass the House before it goes to Gianforte for signing.

DeSantis Advances Questionable Link Between Lockdowns and Despair

The result of lockdowns “has been the destruction of millions of lives across America as well as increased deaths from suicide, substance abuse and despair without any corresponding benefit in covid mortality.”

Florida Gov. Ron DeSantis, Feb. 2, 2020

For months, Florida Gov. Ron DeSantis has boasted about his state’s “open for business” strategy in dealing with covid-19 and how it’s working better than so-called lockdown states.

Unlike in some other states, all Florida public schools are open for in-person learning, restaurants and bars have few restrictions, and the state has barred local governments from penalizing individuals for not wearing a mask in public.

In a recent rant against social network companies such as Facebook and Twitter, DeSantis suggested that states that had instituted heavy restrictions on residents experienced severe repercussions for residents without reducing the number of covid deaths.

“Lockdowns at the time of the pandemic were favored by the, quote, ‘narrative’ and so, in the name of, quote, ‘science,’ articles and posts warning against lockdowns were taken down and censored,” said DeSantis. “The result has been the destruction of millions of lives across America, as well as increased deaths from suicide, substance abuse and despair, without any corresponding benefit in covid mortality.”

We wondered whether that was true. Have state restrictions done such significant harm without providing any boost in the fight against covid deaths? So we dug in.

Locking In on Lockdowns

To reduce the spread of the coronavirus, states have enacted — and then sometimes relaxed or lifted — various restrictions, including mask mandates, limits on restaurant capacity, stay-at-home orders and bans on large gatherings.

DeSantis, a Republican, has bristled at such statewide orders, even resisting pleas from local officials in Florida and criticizing other jurisdictions for implementing them. He has consistently questioned their effectiveness. Late last year, for instance, he claimed that states with lockdowns had covid transmission rates twice as high as Florida’s. We rated that Half True.

We asked DeSantis’ office for any evidence supporting his more recent claim. The response reveals a mixed bag of information.

Check the Data: Did Florida’s Path Lead to Less ‘Despair’?

To support the governor’s claim that other states have seen higher numbers of deaths from suicide, substance abuse and despair than Florida has during the pandemic, DeSantis’ office sent information from the Centers for Disease Control and Prevention showing “all cause” mortality rates increased slower in Florida in 2020 — coinciding with the pandemic’s first months through June 3 — over 2019 rates than in California and New York — two states that have opted for more regulations on public gatherings and mask-wearing. DeSantis’ analysis showed Florida’s rate rose 15% compared with 16% in California and 29% in New York.

But the “all causes” category goes far beyond deaths associated with suicide and drug abuse. It includes deaths from cancer, heart disease, lung disease and dementia, for example.

DeSantis’ office did not provide any data showing how rates of suicide and drug abuse in Florida compared with those in so-called lockdown states. It sent us a Miami Herald article that said in Florida, according to preliminary medical examiners’ statistics, 2,975 people died by suicide in 2020, down 13% from the previous year. But the article did not have nationwide data or figures from California or New York.

Concerning overdose deaths, DeSantis’ office did not provide specific information. However, health experts said the pandemic likely did increase opioid overdoses. But the latest, provisional CDC data on drug overdose deaths shows Florida’s numbers rising faster than the national average.

Comparing the 12-month period ending in June 2020 to the prior 12 months, the period for which data is available, Florida had a 34% increase in the rate of overdose deaths compared with a 20% national average among states. California had a 23% increase and New York had an 18% increase.

Meanwhile, federal suicide data reflecting the months in which the pandemic has transpired will not likely be available until 2022. Experts say that anecdotal evidence suggests a possible uptick in suicide rates during the pandemic. In addition, an online tool offered by the nonprofit Mental Health America to help screen for mental health issues showed a slight increase last year in people having suicidal thoughts.

Nonetheless, Paul Gionfriddo, the group’s CEO, said he knows of no studies showing that so-called lockdown states have higher rates of suicide than those with fewer restrictions.

Gionfriddo said DeSantis may think he is mitigating the harmful effects of loneliness by not limiting public gatherings. But loneliness is not the only reason people cite in considering suicide, he said. Grief, financial insecurity and other factors also play a role, he said.

John Auerbach, president and CEO of Trust for America’s Health, a nonprofit think tank, said it’s difficult to pinpoint the psychological impact of restrictions to reduce infection because rules vary by state and within states, and such regulations have been imposed and lifted at different times.

Auerbach said he knows of no evidence that links states’ covid restrictions to suicides or drug overdose deaths.

“There are many contributing factors to suicide and drug overdoses,” he said. The pandemic itself is having the biggest effect on heightening people’s risk of dying from suicide and drug abuse — not the states’ different approaches to prevent the transmission of infection, he added.

“It is the underlying pandemic that is at the root of increased risks,” Auerbach said.

Factoring In Covid Mortality Rates

DeSantis also argued that statewide restrictions did not bring any corresponding benefit in limiting covid mortality.

We asked his office for evidence. They again pointed to the CDC increase in “all cause” mortality data that showed California’s rate was slightly higher than Florida’s. But those statistics cover all causes of death, and people are still dying of diseases and conditions besides covid.

We then consulted three epidemiologists to get their take. They all said the governor was playing loose with the facts. They stressed varying factors that affect states’ mortality rates — from the weather to socioeconomic indicators to access to health services.

The epidemiologists pointed to the latest CDC data, which indicated that Florida’s covid mortality rate is higher than California’s and seemed to undercut DeSantis’ position that lockdowns have only hurt states.

As of Feb. 22, Florida ranked 28th in covid death rates while California ranked 33rd, according to the latest CDC data, as compiled by Statista.

“That would bolster the argument that restrictions are one factor involved in lowering death rates,” said Nicole Gatto, an associate professor of public health at Claremont Graduate University in California.

Numerous others also have an effect, Gatto said, so it is impossible to compare states using current data based on their strategies.

“I do think it is an oversimplification to make the assertion that the governor did without further study of the numerous variables involved, characteristics of the population, timing of interventions and the limitations of the data,” she said.

Our Ruling

DeSantis said lockdown states have seen “increased deaths from suicide, substance abuse and despair without any corresponding benefit in covid mortality.”

The pandemic certainly has caused anxiety and distress across the country, and state and local restrictions designed to tamp down on the coronavirus’s spread have also affected people’s financial and emotional well-being. But currently, no clear data supports DeSantis’ strongly worded claim. Researchers agreed that more research is necessary before such broad conclusions could be drawn. In addition, experts said that covid death rates vary by state and numerous factors beyond state strategies to combat the virus affect this metric.

We rate the statement Mostly False.


Gov. Ron DeSantis news conference, Feb. 2, 2021

Telephone interview with Paul Gionfriddo, president and CEO of Mental Health America, Feb. 12, 2021

Mental Health America, Take a Mental Health Test, Mental Health America online screening tool, accessed Feb. 12, 2021

Centers for Disease Control and Prevention, Vital Statistics Rapid Release: Provisional Drug Overdose Death Counts — CDC data on overdose deaths, Feb. 7, 2021

Email correspondence with Meredith Beatrice, DeSantis spokesperson, Feb. 10 and 11, 2021

Telephone interview with John Auerbach, president and CEO of Trust for America’s Health, Feb. 12, 2021

Email interview with Nicole Gatto, MPH, Ph.D., associate professor of public health at Claremont Graduate University, Feb. 18, 2021

Email interview with William Miller, professor of epidemiology at the Ohio State University, Feb. 18, 2021

Telephone interview with Dr. Robert Murphy, professor of medicine and biomedical engineering and executive director, Northwestern University’s Institute for Global Health, Feb. 18, 2021

Statista, Death rates from coronavirus (COVID-19) in the United States as of Feb. 17, 2021, by state, accessed Feb. 22, 2021

Miami Herald, “One Pandemic Positive: Suicides in Florida Actually Plummeted. Experts Worry It Won’t Last,” Feb. 10, 2021

PolitiFact, “Is Florida Doing Better on COVID-19 than ‘Locked Down’ States? Dec. 2, 2020

‘It Doesn’t Feel Worth It’: Covid Is Pushing New York’s EMTs to the Brink

In his 17 years as an emergency medical provider, Anthony Almojera thought he had seen it all. “Shootings, stabbings, people on fire, you name it,” he said. Then came covid-19.

Before the pandemic, Almojera said it was normal to respond to one or two cardiac arrests calls a week; now he’s grown used to several each shift. One day last spring, responders took more than 6,500 calls — more than any day in his department’s history, including 9/11.

An emergency medical services lieutenant and union leader with the New York City Fire Department, Almojera said he has seen more death in the past year than in his previous decade of work. “We can’t possibly process the traumas, because we’re still in the trauma,” he said.

EMS work has long been grueling and poorly paid. New FDNY hires make just over $35,000 a year, or $200 more than what is considered the poverty threshold for a four-person household in New York City. (That figure is on par with national averages.) Employee turnover is high: In fiscal year 2019, more than 13% of EMTs and paramedics left their jobs.

But covid-19 has added a new layer of precarity to the work. According to Oren Barzilay, the Local 2507 union president, nearly half of its 4,400 emergency medical technicians and paramedics have tested positive for the covid virus. Five have died, though that figure doesn’t account for first responders who worked for private emergency response companies. Nationwide, at least 128 medical first responders have died of covid, according to Lost on the Frontline, an investigation by KHN and The Guardian.

The problem of EMS pay was in the spotlight in December, when the New York Post outed paramedic Lauren Caitlyn Kwei for relying on an OnlyFans page to make extra money. Kwei, who works for a private ambulance company, wrote on Twitter: “My First Responder sisters and brothers are suffering … exhausted for months, reusing months old PPE, being refused hazard pay, and watching our fellow healthcare workers dying in front of our eyes.” She added: “EMS are the lowest paid first responders in NYC which leads to 50+ hour weeks and sometimes three jobs.”

Almojera earns $70,000 annually as a lieutenant, but his paramedic colleagues’ salaries in non-leadership roles are capped at around $65,000 after five years on the job. He earns extra income as a paramedic at area racetracks and conducting defibrillator inspections. He has colleagues who drive for Uber, deliver for GrubHub and stock grocery shelves on the side. “There are certain jobs that deserve all your time and effort,” Almojera said. “This should be your only job.”

For Liana Espinal, a paramedic, union delegate and 13-year veteran of the FDNY, a sense of camaraderie and the opportunity to serve her fellow Brooklynites compensated for low pay and exhausting shifts. For years she was willing to take on overtime and even a second job with a private ambulance company to make ends meet.

But covid changed that. The department switched from eight- to 12-hour shifts last summer, leaving Espinal, a single mother of three, too exhausted to pick up overtime. Like many health care workers, she isolated from her children at the outset of the pandemic to avoid potentially exposing them to the coronavirus, leaving them in the care of her own mother; she described being separated from her 1-year-old son as “devastating.” Despite working round-the-clock to get the city through the early days of the pandemic, she often had to choose between paying rent on time or paying utility bills.

“After working this year, for me personally, it doesn’t feel worth it anymore,” she said. She is two exams shy of finishing a nursing degree she started studying for before the pandemic. She said the last year has only strengthened her resolve to shift careers.

The pandemic has disproportionately claimed Black and brown lives — Black and Hispanic people were significantly more likely than white people to die of covid — and those disparities extend to health care workers. Lost on the Frontline has found that nearly two-thirds of health care workers who have died of covid were non-white.

All five of the department’s EMS employees who died of covid were non-white.

They included Idris Bey, 60, a former Marine and 9/11 first responder who was known to stay cool under pressure. He was an avid reader who bought new books each time he got a paycheck.

Richard Seaberry, 63, was looking forward to retiring to the Atlanta area to be near his young granddaughter.

Evelyn Ford, 58, left behind four children when she died in December, just as the coronavirus vaccine became available to first responders in New York City. According to the City Council’s finance division, 59% of EMS workers are minorities.

Almojera and Espinal see a racial component to pay disparities within the FDNY. Firefighters with five years on the job can make more than $100,000, including overtime and holiday pay, whereas paramedics and EMTs cap out at $65,000 and $50,000, respectively. According to the City Council finance division, 77% of New York firefighters are white.

“My counterpart fire lieutenants make almost $40,000 more than me,” Almojera said. “I’ve delivered 15 babies. I’ve been covered head to toe in blood. I mean, what do you pay for that? You can at least pay us like the other 911 agencies.”

A spokesperson for the FDNY declined to comment on pay.

The last year has also exacted an emotional toll on an already stressed workforce. Three of the FDNY’s EMS workers died by suicide in 2020. John Mondello Jr, 23, a recent EMS academy graduate, died in April. Matthew Keene, 38, a nine-year veteran, died in June. Brandon Dorsa, 36, who had struggled with injuries from a 2015 workplace accident, died in July.

Family and colleagues told local news outlets that Mondello and Keene were struggling with trauma as a result of the pandemic. Last spring, New York Mayor Bill de Blasio and first lady Chirlane McCray announced a partnership between the U.S. Department of Defense and city agencies to help front-line health workers cope with the stress of working through the pandemic. But many EMS workers have said that the program has been difficult to access.

“There aren’t a lot of resources for people, so a lot of EMS internalize what they go through,” Almojera said. “It’s not normal to see the things that we see.”

Issues regarding pay and mental health challenges predate the pandemic: A national survey conducted in 2015 found EMS providers were much more likely than the general population to struggle with stress and contemplate suicide.

Almojera knew Keene and last spoke with him a week before his death. “You can’t say enough nice things about the guy,” he said. “I wish he had mentioned even a hint of [his struggles] on the phone. And I would have shared how I was feeling through all this.”

He said he has felt a mix of pride, exhaustion and resignation over the past year. “I’ve seen the magic that you can do on the job,” Almojera said. “And I’ve seen my brothers and sisters on this job cry after calls.”

Almojera is now representing his union in talks with the city to renegotiate EMS and paramedic contracts. He said he hopes that city officials will think of the hardships he and his fellow first responders endured over the past year when they come to the negotiating table to discuss pay raises. But early talks have not been encouraging.

“After all the sacrifices made by our members,” he said. “I don’t know whether to be angry, flip the table, or just shrug my shoulders and give up.”

This story is part of “Lost on the Frontline,” an ongoing project from The Guardian and Kaiser Health News that aims to document the lives of health care workers in the U.S. who die from COVID-19, and to investigate why so many are victims of the disease. If you have a colleague or loved one we should include, please share their story.

After Billions of Dollars and Dozens of Wartime Declarations, Why Are Vaccines Still in Short Supply?

The U.S. government has invested billions of dollars in manufacturing, used a wartime act dozens of times to boost supplies and yet there’s still not enough covid vaccine on the way to meet demand — or even the government’s own goals for national immunization.

President Joe Biden, in remarks at the National Institutes of Health this month, said the nation is “now on track to have enough supply for 300 million Americans by the end of July.” But at the current rate of production, Pfizer and Moderna will miss their targets of providing at least 100 million doses each by the end of March, let alone 200 million more doses each has promised by July.

Moderna would need to more than double its vaccine production rate from January — when it made roughly 19 million doses — to meet its contractual obligations. Pfizer supplied 40 million vaccine doses by Feb. 17. It has roughly six weeks left to deliver the first 120 million doses it has promised.

Biden and officials from the two companies say they are rapidly expanding production capacity. But critics are lining up. They want to know whether the government did enough, fast enough, to guarantee that companies would meet the urgent challenges of the pandemic. As for the manufacturers bolstered by extraordinary sums of taxpayer money, why did they not share technology and know-how sooner, or move more quickly into strategic production partnerships?

Experts say it’s complicated, noting that the output of raw materials and assembly lines can’t be ratcheted up 10,000-fold at the push of a button — and that the effort thus far has been close to miraculous. They cite bottlenecks in at least three areas: the production of specialty lipids, fatty materials that are a primary component of the Moderna and Pfizer-BioNTech vaccines; the hundreds of millions of glass vials that hold the vaccine; and the sterile automated assembly lines where vaccine moves from bulk containers into vials before shipment.

U.S. officials have run headlong into the limits of the Defense Production Act, a Korean War-era law that allows the federal government to ramp up supplies of critical materials in times of national emergency. The vaccine manufacturing process relies on a complex supply chain, from sourcing raw materials and equipment to designing chemical processes, building production lines and hiring and training workers.

Also, experts note, no one knew which vaccines would prove effective.

“A year ago there was no commercial market for mRNA product. There was scientific research and pharma making small-volume clinical lots. Now we need billions of doses, in the space of a year. That’s overloading the supply infrastructure,” said Kevin Gilligan, a senior consultant with Biologics Consulting and a former official with the Biomedical Advanced Research and Development Authority, or BARDA, a federal agency created in 2006 to deal with pandemics and bioterrorism.

As of December, the Trump administration through its Operation Warp Speed initiative had obligated nearly $14 billion for vaccine development and manufacturing, including investments to expand U.S. capacity, according to a Government Accountability Office report in January. The administration invoked the Defense Production Act on at least 23 vaccine-related contracts, in part to prioritize the government’s contracts over others, according to a KHN review of the federal contracts database, contracts obtained by the nonprofit group Knowledge Ecology International, GAO and government news releases.

They include the December contract that the Department of Health and Human Services signed with Pfizer for another 100 million doses, on top of the initial 100 million it committed to last summer. That contract, worth $1.95 billion, included DPA provisions to give the company priority access to raw materials and spare parts for factories, according to a former administration official.

The DPA has also been used in vaccine contracts with Moderna, Johnson & Johnson and other drug companies for hundreds of millions of doses. On top of that, the law has been invoked for at least 10 contracts with companies making needles or syringes. It’s been used to require glass makers Corning and SiO2 Materials Science to prioritize vial production for vaccine production, and in contracts for aspects of manufacturing with companies like Emergent BioSolutions, Fujifilm Diosynth Biotechnologies and Grand River Aseptic Manufacturing.

Operation Warp Speed awarded Emergent BioSolutions $648 million last year to boost the manufacturing capacity it needed to enter agreements with Johnson & Johnson and AstraZeneca — worth at least $615 million and $261 million, respectively — to help make their vaccines. Grand River Aseptic Manufacturing won a $160 million award from BARDA and has contracted with Johnson & Johnson to fill vials and finish packaging of its single-shot covid vaccine, which is expected to get emergency authorization from the Food and Drug Administration as soon as this month but will only have a few million doses available initially.

The Biden administration has expanded its use of the wartime act to prioritize equipment like filling pumps and filtration systems for Pfizer. “We told you that when we heard of a bottleneck on needed equipment, supplies or technology related to vaccine supply, that we would step in and help,” Tim Manning, the White House official leading the administration’s covid supply efforts, said during a February press briefing.

Yet it can do only so much, according to medical supply chain experts. Prashant Yadav, a senior fellow at the Center for Global Development at Harvard University, said it could take months for the impact of that DPA action to be felt because of the time it takes to procure equipment and get it installed, with each step tightly regulated.

The U.S. is unlikely to get a meaningful bump in capacity “unless we think about co-production deals,” in which a drug company agrees to manufacture a competitor’s vaccine, said Tinglong Dai, an associate professor at Johns Hopkins University’s Carey Business School.

So far, such arrangements have proliferated in Europe — which has less capacity to produce drugs than the United States does. Deals with other major vaccine manufacturers have been less common on the U.S. side of the pond.

“Though we have not partnered with, say, another large pharma for production, we have built strategic partnerships with a number of organizations that have been instrumental to our scaling up and meeting supply and commercialization plans,” Moderna spokesperson Ray Jordan said in an email.

Moderna this month said that its manufacturing process would scale up rapidly in the coming weeks, that it would provide the U.S. between 30 million and 35 million doses in February and March and between 40 million and 50 million doses monthly from April to July. The company declined to elaborate on what made the boost possible.

Vaccine manufacturers long ago should have been sharing technology and expertise to boost production in the U.S. and Europe, and especially in developing countries, said James Love, director of Knowledge Ecology International, a nonprofit focused on patent rights.

“We’ve wasted about a year by not doing some of the obvious things,” he said. “The rhetoric is that it’s an emergency. But on the scale-up of manufacturing, you just don’t see it.”

It’s not that simple, others say. “There wasn’t any excess capacity available in the United States a year ago. Zero,” Paul Mango, a former HHS official heavily involved in Operation Warp Speed, said regarding vaccines. “It’s getting the equipment. It’s quality control. It’s getting the employees. People make it sound like this is easy. You can’t just push 400 workers and say, go at it.”

Each Pfizer-BioNTech or Moderna shot contains billions of lipid nanoparticles, each particle containing four lipids and a strand of the nucleic acid RNA, the five pieces assembled in a way that allows the RNA to enter our cells and create a particle that stimulates the immune system to defend against the covid virus.

The lipids, which are made only in a handful of factories, have been a major supply problem. “No one has ever thought of a scenario where we would use lipid nanoparticle formulation for [billions of] doses,” Yadav said. “We have not invented a process for doing lipid nanoparticles at scale.”

Two of the lipids in the vaccine, cholesterol and DSCP, have long been used in industry to shape and buffer chemical formulations. A third lipid prevents the particles from clumping together. A fourth enables the lipid shell of the vaccine to fuse with human cells and, once inside the cell, to crack open so the RNA can move to a structure called a ribosome and make proteins that stimulate immunity.

All of these raw materials are produced under regulated conditions — in Massachusetts, Missouri, Colorado and Alabama by companies under license with Moderna, Pfizer or Acuitas Therapeutics, which was co-founded by Pieter Cullis, a University of British Columbia professor who is considered the grandfather of lipid nanoparticle technology.

Before the pandemic, these companies produced meager amounts for use in small clinical trials, laboratory experiments or in one licensed drug, patisiran, which is used to treat a rare genetic disease in about a thousand people worldwide. Now they are producing thousands of kilograms of the stuff, said Stefan Randl, a vice president at Evonik, a lipid maker. Evonik recently announced it would scale up production at two German sites, possibly in the second half of the year, to be used in the Pfizer-BioNTech vaccine. The company last year bought a U.S. lipid manufacturer in Alabama.

“All of a sudden the quantities had to be ramped up a thousand-fold or more,” Randl said. “This is the biggest bottleneck.”

Several elements of the vaccine, including lipids and enzymes used in making the mRNA, until recently were produced using animal products such as sheep’s wool, said Andrew Geall, chief scientific officer at Precision NanoSystems, which designs equipment for mixing the mRNA and lipids. Animal products could cause contamination or disease, even in minute quantities, so manufacturers now use synthetic chemicals.

Luckily, the cosmetic industry — a major user of some of the same lipids used in the vaccines — has been switching from animal products in recent decades, noted Julia Born, an Evonik spokesperson.

Still, only a limited number of companies globally have expertise and facilities to make the lipids, said Thomas Madden, CEO and a co-founder of Acuitas, and they’ve all struggled to move from quantities produced in a laboratory to industrial-scale production. For instance, he said, hazardous solvents and chemicals used in laboratory procedures need to be avoided in industrial processes, where they could give rise to workplace safety issues.

“This is a hugely complex supply chain,” Madden said. “Once you address a bottleneck at one point, you identify the next bottleneck in the process. It’s a bit of a game of whack-a-mole.”

Although it’s not particularly difficult to make the lipids used in vaccines, it takes time to get FDA authorization of a facility that can make them in high quantities, said Cullis, the UBC professor. It would take two to three years to start such a factory from scratch, so instead, Moderna and Pfizer-BioNTech have been hooking up with existing manufacturers and getting them to convert to lipid production, he said.

Another bottleneck is “fill/finish” — getting the finished vaccine into vials or syringes so the shots can be shipped to customers. Vaccine filling lines require extremely high levels of efficiency and sterility, and few companies in the world have this capacity, said Mike Watson, former president of Valera, a Moderna subsidiary. Moderna has hired Catalent, a contract manufacturer that recently experienced delays that slowed the release of some doses, to fill and finish U.S. doses at its facility in Bloomington, Indiana. At least two other companies will do the same for Moderna’s vaccine supply abroad.

In January, the French multinational Sanofi — whose own covid vaccine has been delayed by poor performance in producing immunity — agreed to offer its fill/finish line in Germany for the Pfizer-BioNTech vaccine. That line isn’t expected to be running until July.

In the U.S., the number of vaccine doses shipped to states has ticked up in recent weeks, partly because Pfizer said its five-dose vials actually provide six shots. Moderna is seeking FDA permission to add up to five doses to its 10-dose vials.

Pfizer has said it is manufacturing raw materials in St. Louis, the active ingredients for the vaccine in Andover, Massachusetts, and filling vials in Kalamazoo, Michigan.

CEO Albert Bourla, with Biden at his side in Kalamazoo on Friday, said the company added lipid production capabilities at plants in Michigan and Connecticut, as well as fill/finish lines in Kansas. He said it has significantly cut the average time it takes to make doses — from 110 days to 60 days.

“Today, during this meeting, the president challenged us to identify additional ways in which his administration could help us potentially accelerate even further the delivery of the full 300 million doses earlier than July,” Bourla said. “The challenge is accepted, and we will try to do our best.”

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

Paciente de transplante muere después de recibir pulmones infectados con covid

Médicos dicen que una mujer en Michigan desarrolló covid-19 y murió el otoño pasado, dos meses después de recibir un trasplante doble de pulmón de un donante que portaba el coronavirus que causa la enfermedad, a pesar de que no mostró signos de la enfermedad y que inicialmente dio negativo.

Autoridades de la Escuela de Medicina de la Universidad de Michigan sugirieron que podría ser el primer caso comprobado en el país de covid en el que el virus se transmitió a través de un trasplante de órganos. Un cirujano que manipuló los pulmones del donante también se infectó y se enfermó, pero luego se recuperó.

El incidente parece ser aislado, el único caso confirmado entre casi 40,000 trasplantes realizados en 2020. Pero ha generado el pedido de que se hagan pruebas más exhaustivas a los donantes, con muestras tomadas de las profundidades de los pulmones, así como de la nariz y la garganta, dijo el doctor Daniel Kaul, director del servicio de trasplantes de enfermedades infecciosas de Michigan Medicine.

“No hubiéramos usado los pulmones si hubiéramos tenido una prueba de covid positiva”, dijo Kaul, coautor de un informe sobre el caso en el American Journal of Transplantation.

El virus se transmitió cuando los pulmones de una mujer de la zona centrooeste del país, que murió después de sufrir una lesión cerebral grave en un accidente automovilístico, fueron implantados en una mujer con enfermedad pulmonar obstructiva crónica en el Hospital Universitario de Ann Arbor.

Las muestras de nariz y garganta recolectadas de forma rutinaria tanto de donantes como de receptores de órganos habían dado negativo para SARS-CoV-2, el virus que causa covid.

“Todos los exámenes que normalmente hacemos y podemos hacer, los hicimos”, dijo Kaul.

Sin embargo, tres días después de la operación, la receptora tuvo fiebre; su presión arterial bajó y su respiración se volvió dificultosa. Las radiografías mostraron signos de infección pulmonar.

A medida que su condición empeoraba, la paciente desarrolló un shock séptico y problemas de función cardíaca. Los médicos decidieron realizar la prueba para SARS-CoV-2, dijo Kaul. Las muestras de sus nuevos pulmones dieron positivo.

Sospechando el origen de la infección, los médicos regresaron a las muestras de la donante. Una prueba molecular de un hisopo de la nariz y la garganta de la donante, tomada 48 horas después de extraer los pulmones, resultó negativa para SARS-Cov-2. La familia de la donante les dijo a los médicos que no tenía antecedentes de viajes recientes o síntomas de covid, y que no había tenido una exposición conocida a nadie con la enfermedad.

Pero los médicos habían conservado una muestra de líquido tomada de lo más profundo de los pulmones de la donante. Cuando analizaron ese líquido, resultó positivo para el virus. Cuatro días después del trasplante, el cirujano que manipuló los pulmones y realizó la cirugía también dio positivo.

El examen genético reveló que la donante había infectado a la receptora del trasplante y al cirujano. Otros diez miembros del equipo de trasplantes dieron negativo para el virus.

La salud de la receptora del transplante se deterioró rápidamente y desarrolló una falla orgánica multisistémica. Los médicos probaron tratamientos conocidos para covid, incluido remdesivir, un medicamento recientemente aprobado, y plasma sanguíneo convaleciente de personas previamente infectadas.

Finalmente, tuvo respiración extracorpórea con la opción conocido como ECMO, un último recurso para mantener viva a una persona, sin éxito. Fue desconectada y falleció, 61 días después del trasplante.

Kaul calificó al incidente como “un caso trágico”.

Si bien el caso de Michigan marca el primer incidente confirmado en los Estados Unidos de transmisión a través de un transplante, se sospecha de otros.

Un informe reciente de los Centros para el Control y la Prevención de Enfermedades (CDC) revisó ocho posibles casos de lo que se conoce como infección derivada de donantes que ocurrieron la primavera pasada, pero concluyó que la fuente más probable de transmisión del virus en esos casos estaba en la comunidad o en el entorno de atención médica.

Antes de este incidente, no estaba claro si el coronavirus que causa covid podría transmitirse a través de trasplantes de órganos sólidos, aunque es algo que está bien documentado con otros virus respiratorios. La transmisión por donantes de la influenza pandémica H1N1 de 2009 se ha detectado casi exclusivamente en receptores de trasplantes de pulmón, apuntó Kaul.

Si bien no es sorprendente que el SARS-CoV-2 pueda transmitirse a través de los pulmones infectados, no se sabe todavía si otros órganos afectados por covid (corazones, hígados y riñones) también puedan transmitir el virus.

“Parece que para los donantes que no son de pulmón puede ser muy difícil transmitir covid, incluso si el donante tiene covid”, dijo Kaul.

Los donantes de órganos han sido analizados de forma rutinaria para SARS-CoV-2 durante la pandemia, aunque no es un requisito de la Organ Procurement and Transplantation Network (OPTN), que supervisa los trasplantes en todo el país. Pero el caso de Michigan subraya la necesidad de pruebas más extensas antes del trasplante, especialmente en áreas con altas tasas de transmisión de covid, dijo Kaul.

Cuando se trata de pulmones, eso significa asegurarse de analizar muestras del tracto respiratorio inferior del donante, así como de la nariz y la garganta. Obtener y analizar estas muestras de donantes puede ser difícil de realizar en una urgencia. También existe el riesgo de introducir una infección en los pulmones donados, explicó Kaul.

Debido a que no se utilizaron otros órganos además de los pulmones, el caso de Michigan no brinda información sobre los protocolos de prueba para otros órganos.

En general, las transmisiones virales de los donantes de órganos a los receptores siguen siendo raras y ocurren en menos del 1% de los receptores de trasplantes, según muestran investigaciones. Los riesgos médicos que enfrentan los pacientes enfermos que rechazan un órgano de un donante son generalmente mucho más altos, dijo el doctor David Klassen, director médico de United Network for Organ Sharing, el contratista federal que administra la OPTN.

“Los riesgos de frenar los trasplantes son catastróficos”, dijo. “No creo que los pacientes deban tener miedo al proceso de transplante”.

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Organ Transplant Patient Dies After Receiving Covid-Infected Lungs

Doctors say a woman in Michigan contracted covid-19 and died last fall two months after receiving a tainted double-lung transplant from a donor who turned out to harbor the virus that causes the disease — despite showing no signs of illness and initially testing negative.

Officials at the University of Michigan Medical School suggested it may be the first proven case of covid in the U.S. in which the virus was transmitted via an organ transplant. A surgeon who handled the donor lungs was also infected with the virus and fell ill but later recovered.

The incident appears to be isolated — the only confirmed case among nearly 40,000 transplants in 2020. But it has led to calls for more thorough testing of lung transplant donors, with samples taken from deep within the donor lungs as well as the nose and throat, said Dr. Daniel Kaul, director of Michigan Medicine’s transplant infectious disease service.

“We would absolutely not have used the lungs if we’d had a positive covid test,” said Kaul, who co-authored a report about the case in the American Journal of Transplantation.

The virus was transmitted when lungs from a woman from the Upper Midwest, who died after suffering a severe brain injury in a car accident, were transplanted into a woman with chronic obstructive lung disease at University Hospital in Ann Arbor. The nose and throat samples routinely collected from both organ donors and recipients tested negative for SARS-CoV-2, the virus that causes covid.

“All the screening that we normally do and are able to do, we did,” Kaul said.

Three days after the operation, however, the recipient spiked a fever; her blood pressure fell and her breathing became labored. Imaging showed signs of lung infection.

As her condition worsened, the patient developed septic shock and heart function problems. Doctors decided to test for SARS-CoV-2, Kaul said. Samples from her new lungs came back positive.

Suspicious about the origin of the infection, doctors returned to samples from the transplant donor. A molecular test of a swab from the donor’s nose and throat, taken 48 hours after her lungs were procured, had been negative for SARS-Cov-2. The donor’s family told doctors she had no history of recent travel or covid symptoms and no known exposure to anyone with the disease.

But doctors had kept a sample of fluid washed from deep within the donor lungs. When they tested that fluid, it was positive for the virus. Four days after the transplant, the surgeon who handled the donor lungs and performed the surgery tested positive, too. Genetic screening revealed that the transplant recipient and the surgeon had been infected by the donor. Ten other members of the transplant team tested negative for the virus.

The transplant recipient deteriorated rapidly, developing multisystem organ failure. Doctors tried known treatments for covid, including remdesivir, a newly approved drug, and convalescent blood plasma from people previously infected with the disease. Eventually, she was placed on the last-resort option of ECMO, or extracorporeal membrane oxygenation, to no avail. Life support was withdrawn, and she died 61 days after the transplant.

Kaul called the incident “a tragic case.”

While the Michigan case marks the first confirmed incident in the U.S. of transmission through a transplant, others have been suspected. A recent Centers for Disease Control and Prevention report reviewed eight possible cases of what’s known as donor-derived infection that occurred last spring, but concluded the most likely source of transmission of the covid virus in those cases was in a community or health care setting.

Before this incident, it was not clear whether the covid virus could be transmitted through solid organ transplants, though it’s well documented with other respiratory viruses. Donor transmission of H1N1 2009 pandemic influenza has been detected almost exclusively in lung transplant recipients, Kaul noted.

While it’s not surprising that SARS-CoV-2 can be transmitted through infected lungs, it remains uncertain whether other organs affected by covid — hearts, livers and kidneys, for instance — can transmit the virus, too.

“It seems for non-lung donors that it may be very difficult to transmit covid, even if the donor has covid,” Kaul said.

Organ donors have been tested routinely for SARS-CoV-2 during the pandemic, though it’s not required by the Organ Procurement and Transplantation Network, or OPTN, which oversees transplants in the U.S. But the Michigan case underscores the need for more extensive sampling before transplant, especially in areas with high rates of covid transmission, Kaul said.

When it comes to lungs, that means making sure to test samples from the donor’s lower respiratory tract, as well as from the nose and throat. Obtaining and testing such samples from donors can be difficult to carry out in a timely fashion. There’s also the risk of introducing infection into the donated lungs, Kaul said.

Because no organs other than lungs were used, the Michigan case doesn’t provide insight into testing protocols for other organs.

Overall, viral transmissions from organ donors to recipients remain rare, occurring in fewer than 1% of transplant recipients, research shows. The medical risks facing ailing patients who reject a donor organ are generally far higher, said Dr. David Klassen, chief medical officer with the United Network for Organ Sharing, the federal contractor that runs the OPTN.

“The risks of turning down transplants are catastrophic,” he said. “I don’t think patients should be afraid of the transplant process.”

New Single-Payer Bill Intensifies Newsom’s Political Peril

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

To Vaccinate Veterans, Health Care Workers Must Cross Mountains, Plains and Tundra

A Learjet 31 took off before daybreak from Helena Regional Airport in Montana, carrying six Veterans Affairs medical providers and 250 doses of historic cargo cradled in a plug-in cooler designed to minimize breakage.

Even in a state where 80-mph speed limits are normal, ground transportation across long distances is risky for the Moderna mRNA-1273 vaccine, which must be used within 12 hours of thawing.

The group’s destination was Havre, Montana, 30 miles from the Canadian border. About 500 military veterans live in and around this small town of roughly 9,800, and millions more reside in similarly rural, hard-to-reach areas across the United States.

About 2.7 million veterans who use the VA health system are classified as “rural” or “highly rural” patients, residing in communities or on land with fewer services and less access to health care than those in densely populated towns and cities. An additional 2 million veterans live in remote areas who do not receive their health care from VA, according to the department. To ensure these rural vets have access to the covid vaccines, the VA is relying on a mix of tools, like charter and commercial aircraft and partnerships with civilian health organizations.

The challenges of vaccinating veterans in rural areas — which the VA considers anything outside an urban population center — and “highly rural” areas — defined as having fewer than 10% of the workforce commuting to an urban hub and with a population no greater than 2,500 — extend beyond geography, as more than 55% of them are 65 or older and at risk for serious cases of covid and just 65% are reachable via the internet.

For the Havre event, VA clinic workers called each patient served by the Merril Lundman VA Outpatient Clinic in a vast region made up of small farming and ranching communities and two Native American reservations. And for those hesitant to get the vaccine, a nurse called them back to answer questions.

“At least 10 additional veterans elected to be vaccinated once we answered their questions,” said Judy Hayman, executive director of the Montana VA Health Care System, serving all 147,000 square miles of the state.

The Havre mission was a test flight for similar efforts in other rural locations. Thirteen days later, another aircraft took off for Kalispell, Montana, carrying vaccines for 400 veterans.

In Alaska, another rural state, Anchorage Veterans Affairs Medical Center administrators finalized plans for providers to hop a commercial Alaska Airlines flight on Thursday to Kodiak Island. There, VA workers expected to administer 100 to 150 doses at a vaccine clinic conducted in partnership with the Kodiak Area Native Association.

“Our goal is to vaccinate all veterans who have not been vaccinated in and around the Kodiak community,” said Tom Steinbrunner, acting director of the Alaska VA Healthcare System.

VA began its outreach to rural veterans for the vaccine program late last year, as the Food and Drug Administration approached the dates for issuing emergency use authorizations for the Pfizer-BioNTech and Moderna vaccines, according to Dr. Richard Stone, the Veterans Health Administration’s acting undersecretary. It made sense to look to aircraft to deliver vaccines. “It just seemed logical that we would reach into rural areas that, [like] up in Montana, we had a contract with, a company that had small propeller-driven aircraft and short runway capability,” said Stone, a retired Army Reserve major general.

Veterans have responded, Stone added, with more than 50% of veterans in rural areas making appointments.

As of Wednesday, the VA had tallied 220,992 confirmed cases of covid among veterans and VA employees and 10,065 known deaths, including 128 employees. VA had administered 1,344,210 doses of either the Pfizer or Moderna vaccine, including 329,685 second vaccines, to veterans as of Wednesday. According to the VA, roughly 25% of those veterans live in rural areas, 2.81% live in highly rural areas and 1.13% live on remote islands.

For rural areas, the VA has primarily relied on the Moderna vaccine, which requires cold storage between minus 25 degrees Centigrade (minus 13 degrees Fahrenheit) and minus 15 degrees C (5 degrees F) but not the deep freeze needed to store the Pfizer vaccine (minus 70 degrees C, or minus 94 degrees F). That, according to the VA, makes it more “transportable to rural locations.”

The VA anticipates that the one-dose Johnson & Johnson vaccine, if it receives an emergency use authorization from the FDA, will make it even easier to reach remote veterans. The vaccines from Moderna and Pfizer-BioNTech both require two shots, spaced a few weeks apart. “One dose will make it easier for veterans in rural locations, who often have to travel long distances, to get their full vaccination coverage,” said VA spokesperson Gina Jackson. The FDA’s vaccine advisory committee is set to meet on Feb. 26 to review J&J’s application for authorization.

Meanwhile, in places like Alaska, where hundreds of veterans live off the grid, VA officials have had to be creative. Flying out to serve individual veterans would be too costly, so the Anchorage VA Medical Center has partnered with tribal health care organizations to ensure veterans have access to a vaccine. Under these agreements, all veterans, including non-Native veterans, can be seen at tribal facilities.

“That is our primary outreach in much of Alaska because the tribal health system is the only health system in these communities,” Steinbrunner said.

In some rural areas, however, the process has proved frustrating. Army veteran John Hoefen, 73, served in Vietnam and has a 100% disability rating from the VA for Parkinson’s disease related to Agent Orange exposure. He gets his medical care from a VA location in Canandaigua, New York, 20 miles from his home, but the facility hasn’t made clear what phase of the vaccine rollout it’s in, Hoefen said.

The hospital’s website simply says a staff member will contact veterans when they become eligible — a “don’t call us, we’ll call you,” situation, he said. “I know a lot of veterans like me, 100% disabled and no word,” Hoefen said. “I went there for audiology a few weeks ago and my tech hadn’t even gotten her vaccine yet.”

VA Canandaigua referred questions about the facility’s current phase back to its website: “If you’re eligible to get a vaccine, your VA health care team will contact you by phone, text message or Secure Message (through MyHealtheVet) to schedule an appointment,” it states. A call to the special covid-19 phone number established for the Canandaigua VA, which falls under the department’s Finger Lakes Healthcare System, puts the caller into the main menu for hospital services, with no information specifically on vaccine distribution.

For the most part, the VA is using Centers for Disease Control and Prevention guidelines to determine priority groups for vaccines. Having vaccinated the bulk of its health care workers and first responders, as well as residents of VA nursing homes, it has been vaccinating those 75 and older, as well as those with chronic conditions that place them at risk for severe cases of covid. In some locations, like Anchorage and across Montana, clinics are vaccinating those 65 and older and walk-ins when extra doses are available.

According to Lori FitzGerald, chief of pharmacy at the VA hospital in Fort Harrison, Montana, providers have ended up with extra doses that went to hospitalized patients or veterans being seen at the facility. Only one dose has gone to waste in Montana, she said.

To determine eligibility for the vaccine, facilities are using the Veterans Health Administration Support Service Center databases and algorithms to help with the decision-making process. Facilities then notify veterans by mail, email or phone or through VA portals of their eligibility and when they can expect to get a shot, according to the department.

Air Force veteran Theresa Petersen, 83, was thrilled that she and her husband, an 89-year-old U.S. Navy veteran, were able to get vaccinated at the Kalispell event. She said they were notified by their primary care provider of the opportunity and jumped at the chance.

“I would do anything to give as many kudos as I can to the Veterans Affairs medical system,” Petersen said. “I’m so enamored with the concept that ‘Yes, there are people who live in rural America and they have health issues too.’”

The VA is allowed to provide vaccines only to veterans currently enrolled in VA health care. About 9 million U.S. veterans are not enrolled at the VA, including 2 million rural veterans.

After veterans were turned away from a VA clinic in West Palm Beach, Florida, in January, Rep. Debbie Wasserman Schultz (D-Fla.) wrote to Acting VA Secretary Dat Tran, urging him to include these veterans in their covid vaccination program.

Stone said the agency does not have the authorization to provide services to these veterans. “We have been talking to Capitol Hill about how to reconcile that,” he said. “Some of these are very elderly veterans and we don’t want to turn anybody away.”

Companies Pan for Marketing Gold in Vaccines

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Spurred by Pandemic, Little Shell Tribe Fast-Tracks Its Health Service Debut

Linda Watson draped a sweater with the words “Little Shell Chippewa Tribe” over her as she received the newly recognized tribal nation’s first dose of covid-19 vaccine.

“I wanted to show my pride in being a Little Shell member,” Watson, 72, said. “The Little Shell are doing very good things for the people.”

Watson has diabetes and a heart condition. The shot brought some peace of mind during a time when that isn’t fully possible. One of her sons is among those who have died of covid.

The Little Shell Tribe of Chippewa Indians of Montana is building its health services largely from scratch roughly a year after becoming the United States’ 574th federally recognized Indigenous tribe. Because of the pandemic, it’s doing it on hyperdrive.

The long-sought recognition came just months before the pandemic took hold, arriving in time to guarantee the right to crucial health care and a tribal supply of protective covid vaccines. Federal pandemic relief dollars are speeding up the Little Shell Tribe’s ability to build its own clinic.

Without the CARES Act funds, Indian Health Service and Little Shell officials said it would have likely taken years using only IHS resources to establish a clinic. The IHS already has a list of new and replacement health care facility projects nationwide estimated to cost more than $14.5 billion, yet it reported in 2019 it receives roughly $240 million each year to get that work done. At that pace, it would take 60 years to get through its current needs.

Now, in Great Falls, roughly 2 miles from where Watson got her shot, a brick building under renovation bears a banner announcing the Little Shell Tribal Health Clinic: “Coming 2021.” The former animal hospital site that the tribe purchased will provide medical, dental, vision and behavioral care, alongside traditional medicine, a pharmacy and a lab. The goal is to open the clinic by late summer.

When Watson drives by the future clinic’s site on her way to work as the tribal nation’s enrollment officer, she said, she feels proud.

“To have a Little Shell name on it, to see the results of what our ancestors had worked so hard for,” Watson said. “It’s their descendants that are now experiencing it.”

The Little Shell have advocated for their place as a sovereign nation for more than 150 years. Although Montana formally recognized the tribe in 2000, not having federal recognition until December 2019 kept it from accessing many vital services and programs.

And without a recognized homeland, the tribe’s more than 5,700 members had scattered across Northern Plains states and Canada. The vast majority live in Montana.

Because of the federal recognition, Little Shell tribal enrollment has surged and its Ojibwe language course has a lengthening waitlist.

But this newfound strength is tempered by the deep challenges of the pandemic. The coronavirus has stalled in-person celebrations and planning in the tribe’s first year of federal recognition.

Worst yet, covid has disproportionately infected and killed Indigenous people nationwide, exposing long-standing health inequities caused by a history of colonization and underinvestment in Indian Country. In Montana, Native Americans make up roughly 7% of the population yet account for 11% of the state’s covid cases and 17% of related deaths.

The Little Shell tribal health care system is so new, it doesn’t have electronic health records set up and hasn’t tracked the statistics.

With a sweater bearing the words “Little Shell Chippewa Tribe,” Linda Watson receives the first dose of the tribe’s covid-19 vaccine supply. (Desarae Baker)

In October, the tribal nation hired its first health director, who had to create a covid vaccination plan while juggling other immediate needs, such as helping establish a transportation service for members to get to doctor appointments. Setting up infrastructure for a sovereign nation without a reservation presents challenges. The tribe’s service area encompasses four counties — Blaine, Cascade, Glacier and Hill — that together would span an area larger than Maryland. Only two of those counties share a border, so the distances are even greater.

Little Shell members now have access to any IHS facility nationwide, but, until their clinic is ready, some services such as dental and vision care are far-flung even for those close to the nation’s Great Falls headquarters.

“Without our clinic, members would have to drive 118 miles one way to get some basic services — and try doing that in January and February in Montana,” Tribal Chairman Gerald Gray said.

In the meantime, the tribe is partnering with the Cascade City-County Health Department to administer about 100 vaccine doses each week, according to the tribal health department. The effort has attracted tribal members from out of state.

Many questions remain as to how the new clinic will operate. Gray said the tribe has been told IHS will operate the clinic for at least three years before the tribal nation has the chance to completely run its services. Bryce Redgrave, the Billings-area IHS director, said in a statement the agency is discussing the possibilities but “no plan has been finalized at this time.”

Little Shell leaders plan to model the clinic after an Alaska Native-owned nonprofit called Southcentral Foundation that has been emulated by other tribes, including the Eastern Cherokee in North Carolina.

“The model is about treating the whole person and prioritizing Indigenous interventions,” said Little Shell tribal council member Kim McKeehan.

What that looks like for the Little Shell is still being decided, said Molly Wendland, the Little Shell tribal health director. She said one idea is to grow plants for traditional medicines behind the clinic. The tribe also plans to have a smudge room, she said, in which members can burn sage and ask for healing.

Linda Wilmore, 51, a Little Shell member who lives in Great Falls, said the new clinic would mean she wouldn’t put off care such as going to the dentist anymore. Without an option close to home, she said, she has often waited until she’s in enough pain to warrant the three-hour round trip to an IHS health care facility that offers dental care, where her insurance won’t leave her with unwieldy out-of-pocket costs.

She is also excited about having a clinic designed for, and by, the Little Shell Tribe. Growing up, Wilmore remembers her family having to ask permission to use IHS facilities in Montana before state recognition in 2000 guaranteed it.

“You felt like the redheaded stepchild asking, ‘We’re Little Shell, can we use your clinic?’” Wilmore said.

The Great Falls clinic will also fill gaps in care for other Indigenous people in nearby rural communities and the city itself.

Little Shell member Jonni Kroll lives about 50 minutes from an Indian Health Service clinic. She says the Little Shell tribe spread out largely because they weren’t federally recognized ― and now they’re playing catch-up to understand how to access the services ensured by that recognition. (Jessica Gerlett)

Little Shell members who live far from Great Falls are sorting through how to tap into newly granted services or how to access specialty treatment they can’t get at an IHS clinic.

Little Shell member Jonni Kroll, 55, lives in Deer Park, Washington, some 380 miles from the tribe’s future clinic. Her closest IHS alternative is a roughly 50-minute drive. Her first call was to book an eye appointment, only to find the clinic doesn’t have an optometrist.

“So then I go to the next clinic on my list,” Kroll said. “That’s a problem across the board with IHS nationwide, and I think that will affect Little Shell people trying to figure out: How do we utilize this when we are scattered?”

Little Shell people are spread out largely because they weren’t recognized, she noted, and now they’re having to play catch-up to understand how to access the services that recognition ensures. She said members, some of whom have never met, are connecting by phone or online to work through those questions together.

“The Little Shell are so resilient,” Kroll said. “We’ve gotten to the point of federal recognition and so now we find a way to come past that. There are lots of doors that opened, but we have a lot to learn.”

Medicare Cuts Payment to 774 Hospitals Over Patient Complications

The federal government has penalized 774 hospitals for having the highest rates of patient infections or other potentially avoidable medical complications. Those hospitals, which include some of the nation’s marquee medical centers, will lose 1% of their Medicare payments over 12 months.

The penalties, based on patients who stayed in the hospitals anytime between mid-2017 and 2019, before the pandemic, are not related to covid-19. They were levied under a program created by the Affordable Care Act that uses the threat of losing Medicare money to motivate hospitals to protect patients from harm.

On any given day, one in every 31 hospital patients has an infection that was contracted during their stay, according to the Centers for Disease Control and Prevention. Infections and other complications can prolong hospital stays, complicate treatments and, in the worst instances, kill patients.

“Although significant progress has been made in preventing some healthcare-associated infection types, there is much more work to be done,” the CDC says.

Now in its seventh year, the Hospital-Acquired Condition Reduction Program has been greeted with disapproval and resignation by hospitals, which argue that penalties are meted out arbitrarily. Under the law, Medicare each year must punish the quarter of general care hospitals with the highest rates of patient safety issues. The government assesses the rates of infections, blood clots, sepsis cases, bedsores, hip fractures and other complications that occur in hospitals and might have been prevented. The total penalty amount is based on how much Medicare pays each hospital during the federal fiscal year — from last October through September.

Hospitals can be punished even if they have improved over past years — and some have. At times, the difference in infection and complication rates between the hospitals that get punished and those that escape punishment is negligible, but the requirement to penalize one-quarter of hospitals is unbending under the law. Akin Demehin, director of policy at the American Hospital Association, said the penalties were “a game of chance” based on “badly flawed” measures.

Some hospitals insist they received penalties because they were more thorough than others in finding and reporting infections and other complications to the federal Centers for Medicare & Medicaid Services and the CDC.

“The all-or-none penalty is unlike any other in Medicare’s programs,” said Dr. Karl Bilimoria, vice president for quality at Northwestern Medicine, whose flagship Northwestern Memorial Hospital in Chicago was penalized this year. He said Northwestern takes the penalty seriously because of the amount of money at stake, “but, at the same time, we know that we will have some trouble with some of the measures because we do a really good job identifying” complications.

Other renowned hospitals penalized this year include Ronald Reagan UCLA Medical Center and Cedars-Sinai Medical Center in Los Angeles; UCSF Medical Center in San Francisco; Beth Israel Deaconess Medical Center and Tufts Medical Center in Boston; NewYork-Presbyterian Hospital in New York; UPMC Presbyterian Shadyside in Pittsburgh; and Vanderbilt University Medical Center in Nashville, Tennessee.

There were 2,430 hospitals not penalized because their patient complication rates were not among the top quarter. An additional 2,057 hospitals were automatically excluded from the program, either because they solely served children, veterans or psychiatric patients, or because they have special status as a “critical access hospital” for lack of nearby alternatives for people needing inpatient care.

The penalties were not distributed evenly across states, according to a KHN analysis of Medicare data that included all categories of hospitals. Half of Rhode Island’s hospitals were penalized, as were 30% of Nevada’s.

All of Delaware’s hospitals escaped punishment. Medicare excludes all Maryland hospitals from the program because it pays them through a different arrangement than in other states.

Over the course of the program, 1,978 hospitals have been penalized at least once, KHN’s analysis found. Of those, 1,360 hospitals have been punished multiple times and 77 hospitals have been penalized in all seven years, including UPMC Presbyterian Shadyside.

The Medicare Payment Advisory Commission, which reports to Congress, said in a 2019 report that “it is important to drive quality improvement by tying infection rates to payment.” But the commission criticized the program’s use of a “tournament” model comparing hospitals to one another. Instead, it recommended fixed targets that let hospitals know what is expected of them and that don’t artificially limit how many hospitals can succeed.

Although federal officials have altered other ACA-created penalty programs in response to hospital complaints and independent critiques — such as one focused on patient readmissions — they have not made substantial changes to this program because the key elements are embedded in the statute and would require a change by Congress.

Boston’s Beth Israel Deaconess said in a statement that “we employ a broad range of patient care quality efforts and use reports such as those from the Centers for Medicare & Medicaid Services to identify and address opportunities for improvement.”

UCSF Health said its hospital has made “significant improvements” since the period Medicare measured in assessing the penalty.

“UCSF Health believes that many of the measures listed in the report are meaningful to patients, and are also valid standards for health systems to improve upon,” the hospital-health system said in a statement to KHN. “Some of the categories, however, are not risk-adjusted, which results in misleading and inaccurate comparisons.”

Cedars-Sinai said the penalty program disproportionally punishes academic medical centers due to the “high acuity and complexity” of their patients, details that aren’t captured in the Medicare billing data.

“These claims data were not designed for this purpose and are typically not specific enough to reflect the nuances of complex clinical care,” the hospital said. “Cedars-Sinai continually tracks and monitors rates of complications and infections, and updates processes to improve the care we deliver to our patients.”

KHN’s ‘What the Health?’: Open Enrollment, One More Time

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

An estimated 9 million Americans eligible for free or reduced premium health insurance under the Affordable Care Act have a second chance to sign up for 2021 coverage, since the Biden administration reopened enrollment on healthcare.gov and states that run their own marketplaces followed suit.

Meanwhile, Biden officials took the first steps to revoke the permission that states got from the Trump administration to require many adults on Medicaid to work or perform community service in exchange for their health coverage. The Supreme Court is scheduled to hear a case on the work requirements at the end of March.

This week’s panelists are Julie Rovner of Kaiser Health News, Alice Miranda Ollstein of Politico, Kimberly Leonard of Business Insider and Rachel Cohrs of Stat.

Among the takeaways from this week’s podcast:

  • The Biden administration said it will promote the special enrollment period, a stark change from the Trump administration, which dramatically limited funding for outreach. But navigator groups, whose workers help individuals find and sign up for coverage, say they haven’t yet heard whether the federal government will be offering to pay them to help people during this three-month sign-up period.
  • The House appears poised to pass a bill next week that would fund the covid relief measures President Joe Biden is seeking, as well as major changes to the ACA. Senate staffers are working with the House to align legislation from both chambers as much as possible. With little or no Republican support and only razor-thin majorities in both the House and Senate, Democrats will need to find common ground among their caucus to push the bill through.
  • Congress has a firm deadline on the covid relief bill since many current programs, such as the expanded unemployment funding, expire March 14.
  • CVS announced this week that its insurance subsidiary, Aetna, will be participating in the ACA marketplaces in the fall, another sign that those exchanges are growing in acceptance.
  • The Biden administration’s effort to walk back Medicaid work requirements appears to be an effort to head off the arguments at the Supreme Court. Democrats fear that even if they stop the program through administrative action now, a high-court ruling saying the effort was legal could open the door for future Republican administrations to restore work requirements.
  • The federal government is pushing hard to get more covid vaccine shots in arms around the country and last week reported that 1.7 million doses had been distributed. But it is a race against the emerging threat of covid virus variants, which are even more contagious than the original coronavirus.
  • Among hurdles in the vaccination effort is hesitancy among certain groups to get the shot. There have been reports that 30% of military personnel refused to accept the vaccine and some high-profile athletes in the NBA don’t want to be in public service announcements promoting it. Groups opposed to vaccines in general are posting misinformation online that may also be a source of concern.
  • The latest controversy over New York Gov. Andrew Cuomo’s policies on counting deaths among nursing home residents with covid-19 has consumed Albany and led to inquiries by legal authorities. It also raises questions about whether politics — Cuomo, a Democrat, and President Donald Trump regularly sparred about covid policies — influenced public health decisions.

Also this week, Rovner interviews medical student Inam Sakinah, president of the new group Future Doctors in Politics.

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

Julie Rovner: Stat’s “Hospitals’ Covid-19 Heroics Have Them Poised for Power in the New Washington,” by Rachel Cohrs

Rachel Cohrs: KHN’s “As Drug Prices Keep Rising, State Lawmakers Propose Tough New Bills to Curb Them,” by Harris Meyer; and Stat’s “States Still Can’t Import Drugs From Canada. Now, Many Are Seeking to Import Canadian Prices,” by Lev Facher

Alice Miranda Ollstein: Politico’s “How Covid-19 Could Make Americans Healthier,” by Joanne Kenen

Kimberly Leonard: The New Republic’s “The Darker Story Just Outside the Lens of Framing Britney Spears,” by Sara Luterman

To hear all our podcasts, click here.

And subscribe to What the Health? on iTunesStitcherGoogle PlaySpotify, or Pocket Casts.

Look Up Your Hospital: Is It Being Penalized By Medicare?

Under programs set up by the Affordable Care Act, the federal government cuts payments to hospitals that have high rates of readmissions and those with the highest numbers of infections and patient injuries. For the readmission penalties, Medicare cuts as much as 3 percent for each patient, although the average is generally much lower. The patient safety penalties cost hospitals 1 percent of Medicare payments over the federal fiscal year, which runs from October through September. Maryland hospitals are exempted from penalties because that state has a separate payment arrangement with Medicare.

Below are look-up tools for each type of penalty. You can search by hospital name or location, look at all hospitals in a particular state and sort penalties by year.

Related Topics

Cost and Quality Health Industry Medicare States The Health Law

Montana’s Health Policy MVP Takes Her Playbook on the Road

Marilyn Bartlett might be the closest thing health policy has to a folk hero. A certified public accountant who barely tops 5 feet, Bartlett bears zero resemblance to Paul Bunyan. But she did take an ax to Montana’s hospital prices in 2016, stopping the state’s employee health plan from bleeding money.

“Marilyn is not a physically imposing person,” said Montana Board of Investments Executive Director Dan Villa, who worked closely with Bartlett in state government. “She is a blend of your favorite aunt, an accounting savant and a little bit of July Fourth fireworks.”

Bartlett, whose faith in data borders on fervent, hauls binders full of numbers everywhere she goes. “My focus has always been following the dollars,” she said. “You’ve got to roll up your sleeves and get down to the nitty-gritty detail, especially in health care.”

Bartlett’s success in Montana saved the state more than $30 million in three years by pegging hospital prices to a multiple of what Medicare pays. Now, she is an in-demand adviser to states, counties and businesses all trying to control health care costs. But as she’s hit the road, binders in tow, she’s found it difficult to replicate the Montana solution.

A Montana Miracle

Bartlett earned her reputation as administrator of the Montana state employee health plan, a role she assumed in 2014 as the plan hurtled toward insolvency. As Bartlett dug into the data, she discovered hospitals were charging the state as much as five times what they charge Medicare, the federal insurance program — for exactly the same services.

Historically, the state had accepted the seemingly arbitrary prices set by hospitals. Bartlett, staring down a $9 million shortfall, knew that had to change. She wanted the state to start dictating the rates they were willing to pay, but she needed a benchmark first.

She turned to Medicare. Unlike most payers, who bury prices in secret contracts, Medicare makes its payments public. Bartlett borrowed those rates and then more than doubled them — to 234% — knowing that hospitals often complain Medicare pays too little. This new kind of contract, known as reference-based pricing, was among the first attempted at this scale.

Bartlett expected the hospitals to chafe at the offer, but with Montana’s plan insuring 30,000 people, more than any other employer in the state, she had the upper hand. Despite what Bartlett described as “very, very tense” negotiations, all the state’s hospitals signed on.

Five years later, the state health plan regularly runs in the black. Villa, who was former Gov. Steve Bullock’s budget director, said governors dip into the plan’s reserves to fill budget gaps. “I now refer to the state health plan as the ATM,” he said.

The Player Becomes the Coach

Montana’s success became a small sensation, at least in health policy circles. Now, one big question remains — the same one that has deflated the highest hopes of so many health care leaders. Can it be replicated?

Many of the country’s employers are desperate to find out. Their costs have risen 50% in just the past decade. Employee spending on health care is also on the rise, growing two times faster than wages. Leading economics researchers point to high hospital prices as a key culprit.

Since retiring from Montana state government in December 2019, Bartlett said she has spoken at numerous conferences, given hours of free advice, and answered a seemingly endless stream of calls.

One of the first calls came from Trish Riley, executive director of the National Academy for State Health Policy (NASHP). Riley hired Bartlett in 2019 to serve as “a coach, cheerleader and mentor” for officials from dozens of states trying to cut costs, including New Jersey, which passed a bill in 2020 overhauling the state’s health coverage for teachers and estimated to save the state $30 million annually.

Bartlett is also advising regional business coalitions stretching from Houston to Maine and seeing early signs of progress.

In Colorado, Bartlett is coaching a group of public employers, including city, county and state health plans, that have come together to negotiate with hospitals. The group recently notched its first win, signing one hospital to a Medicare-benchmarked contract.

In Indiana, Bartlett is advising the Employers’ Forum of Indiana, a coalition that recently pressured insurer Anthem to renegotiate its contract with a notoriously expensive health system.

Bartlett is even shaping legislation, including recent failed attempts in the Montana legislature to more broadly control hospital prices and in the U.S. Senate to increase transparency.

‘A Hard, Hard Thing to Tackle’

Bartlett has learned over the past five years just how difficult her model is to export. “It’s a hard, hard thing to tackle,” she said.

Opposition from hospitals is often fierce. In Montana, the deal Bartlett negotiated has actually boosted some hospitals’ bottom lines, but the Montana Hospital Association still criticizes it. MHA President Rich Rasmussen faults the contract for focusing on prices and largely neglecting issues of quality and access. “It doesn’t connect all the dots,” he said. Rasmussen also argued Medicare rates are an “inadequate” starting point for negotiations because they fall short of covering the full cost of care.

That opposition pales in comparison to what Bartlett has seen crisscrossing the country. “What I faced in Montana was nothing like North Carolina faced,” she said, her eyes widening as she described the sheer power of the “mega systems” she encountered while advising North Carolina officials.

North Carolina’s plan to pay hospitals roughly twice Medicare rates fell short in 2019 after just five hospitals agreed to the deal and several giant health systems refused to budge.

Bartlett understands that, as a result of decades of mergers, more states face hospital landscapes like North Carolina’s, with its immense consolidation, than Montana’s, with its more than 40 rural hospitals. And the insurance industry nationwide also is highly concentrated, leaving employers with fewer alternatives.

Saying No to Employees

For employers to have any chance at the negotiating table, Bartlett said, they must be willing to make tough calls. In practice, that might mean dropping a hospital that delivered an employee’s twins or a surgeon who cured a CEO’s cancer. “That’s pretty damn hard,” she acknowledged.

“Employers don’t want to disrupt their employees’ care,” said Elizabeth Mitchell, CEO of Purchaser Business Group on Health, which represents Fortune 500 companies like Walmart and Microsoft. “It takes a lot of fortitude to carve a marquee-brand hospital out of a network.”

A 2020 KFF survey found only 4% of employers had dropped a hospital from a network in order to cut costs. (KHN is an editorially independent program of KFF.)

Bartlett is quick to remind cold-footed employers that continuing to contract with expensive hospitals and doctors has a price, too. “You’re going to disrupt members when they get less and less benefits and pay more and more,” she said. High health care costs also eat up wage increases in the private sector and school funding in the public sector.

Will Covid-19 Be a Catalyst?

Bartlett’s work has hit a crossroads during the pandemic. It is harder to criticize hospitals and their business practices as they play such a vital role. Meanwhile, employers and workers are hurting financially.

“Many large employers are facing economic pressures they frankly haven’t had for a while. They’re laying off tens of thousands of employees,” said Mitchell. “There’s a new sensitivity to costs.”

Bartlett sees an opportunity and is hustling to help employers meet it. She has teamed up with researchers at Rice University on a NASHP project called the Hospital Cost Tool.

“It breaks open this black box and lets you ask where these dollars are going and why,” said Riley of NASHP. The tool aims to automate the kind of forensic accounting of hospitals’ finances that Bartlett had been doing on a one-off basis.

‘You’re Not Going to Be Liked’

There’s one final test Bartlett has tried to prepare employers for — one for which numbers won’t help. It’s the personal toll that comes with challenging the status quo.

While working for the state health plan and before her work delivered results, Bartlett lost close friends, was cut out of meetings and even discovered her co-workers had created a Facebook group to criticize her. “You’re not going to be liked. You’re going to be ridiculed.”

She reminds employers they have a moral and fiscal duty.

“The reality is this is hard work, and it became harder than I ever anticipated,” said Bartlett. “But employers have been given this money, by the taxpayer, by the member, for these benefits. They are responsible for every penny spent. You can’t turn your back on that.”

In Montana, the premiums and copays state workers pay have not increased a single cent since Bartlett and colleagues renegotiated with the hospitals. Over that same time, the average premium paid by American families with employer-based insurance rose 13%.

Dan Gorenstein is the creator and host of the Tradeoffs podcast and Leslie Walker is a senior producer on the show. Their Feb. 18 episode profiles employers’ efforts to purchase health care in new ways.

Rural Hospital Remains Entrenched in Covid ‘War’ Even Amid Vaccine Rollout

Editor’s note: KHN wrote about St. James Parish Hospital in April, when it was experiencing its first surge of covid-19 patients. Ten months later, we checked in to see how the hospital and its staff were faring.

The “heroes work here” sign in front of St. James Parish Hospital has been long gone, along with open intensive care unit beds in the state of Louisiana.

Staffers at the rural hospital spent hours each day in January calling larger hospitals in search of the elusive beds for covid-19 patients. They leveraged personal connections and begged nurses elsewhere to take patients they know are beyond their hospital’s care level.

But as patients have waited to be transferred out of the hospital, which is about 45 minutes outside New Orleans, doctors such as Landon Roussel are forced to make unthinkable choices. As recently as Jan. 29, he had to decide between two patients: Which one should get the sole available BiPAP machine to push oxygen into their lungs?

That’s like a “war situation, which is not a situation that I want to be in — in the United States,” he said.

As the nation’s attention shifts to the vaccine rollout, rural hospitals such as St. James Parish Hospital have struggled to handle their communities’ sick following the holiday surge of covid patients.

“We knew it was coming. We saw it coming,” Mary Ellen Pratt, St. James Parish Hospital’s CEO, said by phone. “It really has to happen to their family for them to really go, ‘OK, wow.’”

And even though the vaccines have arrived and caseloads continue to improve after the holiday surge, only about 30% of staffers have opted to get their shots. Disparities in the broader community persist: In the initial rollout, only 9% of those vaccinated were Black in a parish — the Louisiana equivalent of a county — that is nearly 49% Black.

Staff members are burned out from months of handling never-ending covid crises.

“They had been giving 150%, and they’re just getting really tired,” Pratt said. “It’s just exhausting.”

‘Sometimes, Your Best Isn’t Enough’

In mid-January, the closest intensive care bed the staff could find was some 600 miles away in Brownsville, Texas — so far that a plane would have been necessary to transport a patient. After three days, a closer bed was found at a Veterans Affairs hospital about 45 miles away.

Staffers have tried Mississippi and Alabama with mixed luck. One patient they tried to transfer four hours away couldn’t go because the ambulance didn’t have enough oxygen to make it that far. A hospital in Florida even called them looking for ICU beds at St. James Parish Hospital, which has never had any.

More than half of U.S. counties are like St. James Parish and have no intensive care beds, full or empty. Rural hospitals in those communities are designed for step-down care: They often serve as a stopping point to stabilize people before they can be sent to larger hospitals with more specialized staff and equipment.

Across the country, rural residents’ mortality rate from covid has been consistently higher than that of urban residents since August, according to the Rural Policy Research Institute Center for Rural Health Policy Analysis. That has occurred even though covid incidence has been lower among rural populations than urban ones since the middle of December, said Fred Ullrich, who runs the health policy department at the University of Iowa’s College of Public Health and co-authored the study.

But, he said, rural populations are typically older, sicker and poorer than urban populations. And the nation has lost at least 179 rural hospitals over the past 17 years.

“This crisis is just magnifying existing access issues in a rural context,” said Alan Morgan, the head of the National Rural Health Association. “If you don’t have a local hospital, that impacts the diagnosis, the initial treatment, the complex treatment. It has multiple impacts, all leading to what we’re seeing: higher mortality.”

And at the hospitals that remain, such as St. James Parish Hospital, the stress level is palpable, because the level of care needed for such sick patients is higher than what staffers normally handle, said Karley Babin, the hospital’s acute nurse manager.

“It’s just an uncomfortable spot,” she said. “You know you’re doing everything you can and that patient just needs more.”

That’s led to many sleepless nights for Pratt.

“Sometimes your best isn’t enough if you don’t have the right resources,” she said.

‘We Know All These People’

Radiology technologist Brooke Michel lives seven minutes from the hospital, where she works with her husband and five other relatives. Her grandfather, grandmother and aunt were hospitalized there in December with covid.

Her family brought folding chairs to sit outside her 83-year-old grandfather’s hospital window each day, keeping vigil through the glass on Christmas Eve. He died Jan. 3 while family members stood outside, taking turns looking in and praying.

“It gave us a sense of closure,” Michel said. “We were all together. We were with him. We would never have gotten that at a bigger hospital.”

Seeing multiple family members hospitalized at the same time is tough on the staff, said Scott Dantonio, the hospital’s pharmacy director. “We know all these people,” he said.

Dozens of hospital staffers also have battled covid, and three have been hospitalized. A nurse’s aide died last summer after contracting it. One staffer, who was particularly close to that aide, now has a hard time treating covid patients, said Rhonda Zeringue, chief nursing officer.

“It’s a reminder: ‘You took my person,’” she said.

Brooke Michel’s grandfather, grandmother and aunt were hospitalized with covid-19 at St. James Parish Hospital in December. Her grandfather, Richard Roussel, also had been hospitalized there in April when the family visited him outside his window amid covid-19 restrictions. When he returned there with covid, they also kept vigil outside his window. He died on Jan. 3. (Brooke Michel) Left to right: Tammy Hymel, Sandra Babin, Nadine Louviere, Brandi Zeringue, Caleb Zeringue. (Brooke Michel)

‘It’s Just Exhausting’

St. James Parish Hospital has been running short-staffed, because they haven’t been able to hire more nurses or pay traveling nurses — they’re just too expensive. Amid the pandemic, traveling nurses can command more than double what the staff nurses make.

So Babin’s kids ask often why she works all the time.

Community praise has died down, she said. People aren’t thanking them in grocery stores anymore. One upside? Pratt is happy to have finally lost the “covid 19” — the weight she put on from the community bringing food to the hospital back in the spring.

Pratt and Zeringue have offered staff members counseling, massage sessions, coffee and doughnuts. But it’s not enough.

Zeringue said the stress has gone through the staff in waves: First they were scared to death of being the front line in the spring. Now she sees burnout and sheer exhaustion.

The vaccines were supposed to offer hope. But when Pratt heard they would be distributed through CVS and Walgreens, she knew immediately the logistics of getting the ultra-cold Pfizer vaccine from its cooler into residents’ arms would fall to them. She said the community has no chain pharmacies nearby and the local health department is overloaded.

“We get an email at, like, 4:30 on Friday which says, ‘We’re going to send you another 350 vaccines on Wednesday and you have to respond in the next 10 minutes,’” Pratt said. “There’s not enough planning or time to do it.”

Staff members, who are juggling monoclonal antibody infusions and elective surgeries to deal with the backlog from the spring on top of the surge, must also call members of the community to let them know they have the vaccine available. And then the problems begin.

“People don’t answer the phone or they’re not available,” Dantonio said. “Or they can’t come at that time or they scheduled somewhere else.”

Most of the people coming in following the hospital’s advertising online and on Facebook have been white. So Pratt called on the people she had relied on during the rollout of the Affordable Care Act: Black preachers and well-respected Black local leaders such as Democratic state Rep. Kendricks Brass. After word from the pulpit spread and Brass’ team staffed a phone line, the vaccine distribution the next week jumped to 30% Black residents from the prior week’s 9%.

Even some among the St. James Parish Hospital staff have been reluctant. Many have told Zeringue they’re worried about their fertility. Others just don’t want to be first. So the hospital’s line of defense has many holes.

And the covid patients keep coming.

“This is a nightmare,” said Kassie Roussel, the hospital’s marketing director. “It’s crazy because it’s at the same time we marketed the beginning of the end.”

Why Biden Has a Chance to Cut Deals With Red State Holdouts on Medicaid

President Joe Biden has an unexpected opening to cut deals with red states to expand Medicaid, raising the prospect that the new administration could extend health protections to millions of uninsured Americans and reach a goal that has eluded Democrats for a decade.

The opportunity emerges as the covid-19 pandemic saps state budgets and strains safety nets. That may help break the Medicaid deadlock in some of the 12 states that have rejected federal funding made available by the Affordable Care Act, health officials, patient advocates and political observers say.

Any breakthrough will require a delicate political balancing act. New Medicaid compromises could leave some states with safety-net programs that, while covering more people, don’t insure as many as Democrats would like. Any expansion deals would also need to allow Republican state officials to tell their constituents they didn’t simply accept the 2010 health law, often called Obamacare.

“Getting all the remaining states to embrace the Medicaid expansion is not going to happen overnight,” said Matt Salo, executive director of the nonpartisan National Association of Medicaid Directors. “But there are significant opportunities for the Biden administration to meet many of them halfway.”

Key to these potential compromises will likely be federal signoff on conservative versions of Medicaid expansion, such as limits on who qualifies for the program or more federal funding, which congressional Democrats have proposed in the latest covid relief bill.

But any deals would bring the country closer to fulfilling the promise of the 2010 law, a pillar of Biden’s agenda, and begin to reverse Trump administration efforts to weaken public programs, which swelled the ranks of the uninsured.

“A new administration with a focus on coverage can make a difference in how these states proceed,” said Cindy Mann, who oversaw Medicaid in the Obama administration and now consults extensively with states at the law firm Manatt, Phelps & Phillips.

Medicaid, the half-century-old health insurance program for the poor and people with disabilities, and the related Children’s Health Insurance Program cover more than 70 million Americans, including nearly half the nation’s children.

Enrollment surged following enactment of the health law, which provides hundreds of billions of dollars to states to expand eligibility to low-income, working-age adults.

However, enlarging the government safety net has long been anathema to most Republicans, many of whom fear that federal programs will inevitably impose higher costs on states.

And although the GOP’s decadelong campaign to “repeal and replace” it has largely collapsed, hostility to the health law remains high among Republican voters.

That makes it perilous for politicians to embrace any part of it, said Republican pollster Bill McInturff, a partner at Public Opinion Strategies. “A lot of Republican state legislators are sitting in core red districts, looking over their shoulders at a primary challenge,” he said.

Many conservatives have called instead for federal Medicaid block grants that cap how much federal money goes to states in exchange for giving states more leeway to decide whom they cover and what benefits their programs offer.

Many Democrats and patient advocates fear block grants will restrict access to care. But just before leaving office, the Trump administration gave Tennessee permission to experiment with such an approach.

“It’s a frustrating place to be,” said Tom Banning, the longtime head of the Texas Academy of Family Physicians, which has labored to persuade the state’s Republican leaders to drop their opposition to expanding Medicaid. “Despite covid and despite all the attention on health and disparities, we see almost no movement on this issue.”

Some 1.5 million low-income Texans are shut out of Medicaid because the state has resisted expansion, according to estimates by KFF. (KHN is an editorially independent program of KFF.)

An additional 800,000 people are locked out in Florida, which has also blocked expansion.

Two million more are caught in the 10 remaining holdouts: Alabama, Georgia, Kansas, Mississippi, North Carolina, South Carolina, South Dakota, Tennessee, Wisconsin and Wyoming.

Advocates of Medicaid expansion, which is broadly popular with voters, believe they may be able to break through in a handful of these states that allow ballot initiatives, including Mississippi and South Dakota.

Since 2018, voters in Idaho, Nebraska, Utah, Oklahoma and Missouri have backed initiatives to expand Medicaid eligibility, effectively circumventing Republican political leaders.

“The work that we’ve done around the country shows that no matter where people live — red state or blue state — there is overwhelming support for expanding access to health care,” said Kelly Hall, policy director of the Fairness Project, a nonprofit advocacy group that has helped organize the Medicaid measures.

But most of the holdout states, including Texas, don’t allow citizens to put initiatives on the ballot without legislative approval.

And although Florida has an initiative process, mounting a ballot campaign there is challenging, as political advertising is expensive. Unlike in many states, Florida’s leading hospital association hasn’t backed expansion.

Another route for expansion: compromises that could win over skeptical Republican state leaders and still get the green light from the Biden administration.

The Obama administration approved conservative Medicaid expansion in Arkansas, which funneled enrollees into the commercial insurance market, and in Indiana, which forced enrollees to pay more for their medical care.

Money is a major focus of current talks in several states, according to health officials, advocates and others involved in efforts across the country.

The health law at first fully funded Medicaid expansion with federal money, but after the first three years, states had to begin paying part of the tab. Now, states must come up with 10% of the cost of expansion.

Even that small share is a challenge for states, many of which are reeling from the economic downturn caused by the pandemic, said David Becker, a health economist at the University of Alabama-Birmingham who has assisted efforts to expand Medicaid in that state.

“The question is: Where do we get the money?” Becker said, noting that some Republicans may be open to expanding Medicaid if the federal government pays the full cost of the expansion, at least for a year or two.

Other efforts to find ways to offset state costs are underway in Kansas and North Carolina, which have Democratic governors whose expansion plans have been blocked by Republican state legislators. Kansas Gov. Laura Kelly this month proposed using money from the sale and taxation of medical marijuana.

Some Democrats in Congress are pushing to revise the health law to provide full federal funding to states that expand Medicaid now. Separately, in the stimulus bill unveiled last week, House Democrats proposed an additional boost in total Medicaid aid to states that expand.

Other Republicans have signaled interest in partly expanding Medicaid, opening the program to people making up to 100% of the federal poverty level, or about $12,900, rather than 138%, or $17,800, as the law stipulated.

The Obama administration rejected this approach, but the idea has gained traction in several states, including Georgia.

It’s unclear what kind of compromises the new administration may consider, as Biden has yet to even nominate someone to oversee the Medicaid program.

Some Democrats say it’s time to give up the search for middle ground with Republicans on Medicaid.

A better strategy, they say, is a new government insurance plan, or public option, for people in non-expansion states, a strategy Biden endorsed on the campaign trail.

“Democrats can no longer countenance millions of Americans living in poverty without insurance,” said Chris Jennings, a Democratic health care strategist who worked in the White House under Presidents Bill Clinton and Barack Obama and served on Biden’s transition team.

“This is why the Biden public option or other new ways to secure affordable, meaningful care should become the order of the day for people living in states like Florida and Texas.”

El discurso anti inmigrante complica la vacunación contra covid en estados del sur

En el este de Tennessee, los médicos han visto de primera mano cómo una política de inmigración dura puede afectar la salud y el bienestar de una comunidad.

En 2018, agentes federales allanaron una planta empacadora de carne en Morristown, en el Valle de Tennessee, y detuvieron a unos 100 trabajadores sospechosos de ser indocumentados.

En las semanas siguientes, decenas de familias inmigrantes que habían encontrado trabajo en esas plantas buscaron santuario en las iglesias y dejaron de ir a las citas médicas.

¿La razón? Los agentes de inmigración estaban vigilando las clínicas.

“No queríamos que la gente viniera a recibir atención porque había oficiales de ICE en nuestro estacionamiento”, dijo Parinda Khatri, directora clínica de Cherokee Health Systems, un proveedor sin fines de lucro en el condado de Hamblen.

Mientras Tennessee, al igual que otros estados, se embarca en la abrumadora tarea de vacunar a millones de residentes contra covid-19, a muchos funcionarios de salud se les dificulta la tarea, por una desconfianza generalizada en el gobierno y las fuerzas del orden entre los inmigrantes sin papeles, una población estimada en 11 millones en todo el país.

Los desafíos son particularmente críticos en el sur, donde grandes poblaciones de inmigrantes indocumentados ayudan a mantener las prósperas industrias agrícola y de procesamiento de alimentos, incluso cuando muchos líderes republicanos estatales y locales, empoderados por la retórica antiinmigrante de la administración Trump, los denuncian como criminales y piden limitar su camino a la ciudadanía.

La confluencia de esas actitudes agresivas y un virus altamente contagioso ha generado preocupación en algunos estados: temen que la baja vacunación de indocumentados ponga en riesgo los esfuerzos para lograr la inmunidad colectiva.

“Nunca podremos superar esta pandemia si los indocumentados se quedan fuera”, dijo la doctora Sharon Davis, directora médica de la clínica comunitaria Los Barrios Unidos en Dallas, que atiende a 28,000 pacientes, la mayoría sin papeles.

Davis reconoció el desafío que plantea esto en un estado como Texas, donde la plataforma estatal del Partido Republicano pide la expulsión inmediata de todos los “extranjeros ilegales”. Como otros directores de clínicas en muchos estados del sur, Davis dijo que implementar planes de vacunación en las comunidades inmigrantes es una política de “don’t ask, don’t tell (“no preguntar, no decir”).

“Vivimos en Texas, así que ni lo mencionas”, agregó. “Hablamos de los que no tienen seguro, y hablamos de la población latina con la mayor morbilidad y mortalidad, es a quien estamos tratando de atender”.

En el área de Dallas-Fort Worth, hogar de una de las poblaciones más grandes de inmigrantes sin papeles de la nación, la tasa de muerte de los hombres latinos de mediana edad es ocho veces mayor que la de sus homólogos blancos no latinos.

Los epidemiólogos dicen que la disparidad no es sorprendente, dado que un gran número de trabajadores centro y sudamericanos indocumentados están en empleos considerados esenciales en la pandemia, incluido el trabajo agrícola, procesamiento de carne y servicio de alimentos, y la mayoría no tiene seguro médico.

Para agravar los riesgos, muchos trabajan en condiciones propicias para la propagación viral, parados hombro con hombro a lo largo de las cintas transportadoras en las empacadoras de verduras, lavando platos en las cocinas de los restaurantes, abasteciendo los estantes de los supermercados y limpiando habitaciones de hoteles.

Al final del día, muchos regresan a barracas o casas pequeñas que albergan a varias generaciones de familias.

“Si no trabajan, no comen”, dijo Davis. “Hemos tenido pacientes que nos suplican que no les hagamos la prueba, porque entonces no pueden ir a trabajar”.

Davis fue uno de los directores médicos que dijo que los sitios de vacunación masiva que muchos estados están usando (carpas gigantes con personal uniformado de la Guardia Nacional y personal médico con iPads) asustan a las familias inmigrantes.

“Preguntan ‘¿qué documentos tenemos que mostrar?’”, dijo Davis. “El miedo a la deportación es enorme y muy real”.

Y no es infundado, señalaron defensores, después de cuatro años en los que el ex presidente Donald Trump redujo drásticamente la inmigración legal e ilegal a través de detenciones y deportaciones masivas, prohibiciones de viaje y restricciones severas de asilo.

El presidente Joe Biden se ha comprometido a anular muchas de esas normas, pero defensores dicen que el apoyo a medidas más drásticas es fuerte entre algunos agentes de inmigración y agentes locales, lo que podría complicar la vida de muchos inmigrantes.

Davis agregó que, más allá del miedo al hostigamiento o al arresto, los funcionarios de salud pública están lidiando con información errónea. “Están escuchando historias horribles en las redes sociales”, dijo. “Creen que hay un microchip en la vacuna y que serán rastreados”.

Incluso algunos inmigrantes con papeles tienen reservas sobre recibir una vacuna proporcionada por el gobierno. La administración Trump presionó para descarrilar la ciudadanía de cualquier inmigrante que usara servicios públicos financiados por los contribuyentes, incluida la atención médica.

En diciembre, el Departamento de Justicia retiró la regla, pero hay confusión y los directores de las clínicas dicen que los pacientes darán prioridad a sus tarjetas de residencia por encima de casi todo.

Las bajas tasas de vacunación entre las poblaciones inmigrantes ya son evidentes. En Mississippi, por ejemplo, el Departamento de Salud informó que la semana del 8 de febrero se habían vacunado menos de 2,800 latinos, aproximadamente el 1% de todas las vacunas administradas hasta ahora.

Tennessee ofrece un excelente ejemplo de las tensiones que subyacen al lanzamiento de la vacuna.

El gobernador republicano, Bill Lee, fue noticia en mayo cuando permitió que el Departamento de Salud estatal compartiera con la policía los nombres y direcciones de quienes daban positivo para covid.

Por separado, el departamento de salud de la ciudad de Nashville proporcionó a la policía local las direcciones de las personas que daban positivo o que estaban en cuarentena.

Ambas acciones fueron criticadas y finalmente terminaron, pero Lee las defendió, diciendo que las eran apropiadas “para proteger las vidas de las fuerzas del orden” y que cumplían con las reglas federales de privacidad de la salud. Posteriormente, la ciudad buscó tranquilizar a sus “comunidades de inmigrantes diversas” diciendo que la información no se compartiría con las autoridades federales de inmigración.

Alabama, como Tennessee, tiene un historial de reglas estrictas con respecto a la inmigración, como una ley de 2011 que prohíbe que los inmigrantes sin papeles reciban casi todos los beneficios públicos, incluida la mayoría de la atención médica que no es de emergencia.

Velvet Luna, enfermera registrada de 26 años, ha construido su vida en Ozark, Alabama, una pequeña ciudad en Wiregrass, una región conocida por sus instalaciones de procesamiento de aves de corral y grandes poblaciones de inmigrantes hispanos y vietnamitas.

Luna se inscribió en el programa de Acción Diferida para los Llegados en la Infancia (DACA) una iniciativa de la era Obama que otorga estatus temporal a jóvenes indocumentados a los que trajeron al país de niños. Según el Centro Nacional de Leyes de Inmigración, casi 500,000 inmigrantes elegibles para DACA son trabajadores esenciales.

Luna, que habla con un suave acento sureño, solía hablar de su estatus migratorio, pero dijo que, en los últimos años, hombres que coqueteaban con ella cambiaban inmediatamente de actitud si sabían su estatus migratorio. “Decían cosas feas, hirientes, ‘Ustedes son la razón por la que nuestro país está en declive. Tienes que irte’”.

Como enfermera en un hospital del área que se ofreció como voluntaria para la unidad de covid, Luna ha recibido las dos dosis de la vacuna, pero entiende los riesgos que sopesan las familias indocumentadas; ninguno de sus padres, que vive cerca, tiene papeles. “Está bien tener miedo, y es una decisión valiente ir a vacunarse y proteger a tu familia”, dijo.

Incluso los opositores a la inmigración reconocen que la pandemia ha unido el destino de todos los que viven en el país, independientemente de cómo hayan llegado.

“Lo principal es vacunar a tantas personas como sea posible”, dijo Mark Krikorian, director ejecutivo del Centro de Estudios de Inmigración, un grupo conservador que aboga enérgicamente por restringir la inmigración. “Tu inmigración puede alcanzarte algún día, pero no será hoy”.

La administración Biden ha dicho que ICE no realizará operaciones en o cerca de los sitios de vacunación. “ICE no realiza ni llevará a cabo operaciones en o cerca de las instalaciones de atención médica, como hospitales, consultorios médicos, clínicas de salud acreditadas e instalaciones de atención de emergencia o urgencias, excepto en las circunstancias más extraordinarias”, según una declaración del Departamento de Seguridad Nacional del 1 de febrero.

Los comisionados estatales de salud también han tratado de calmar los nervios. “No le negamos la vacuna a nadie que se presente en nuestros sitios y esté en la fase que se está vacunando”, dijo la doctora Lisa Piercey, comisionada del Departamento de Salud de Tennessee. “Este es un recurso federal, y si estás en este país, tienes una vacuna”.

Los defensores, sin embargo, dijeron que persisten obstáculos para convencer a los inmigrantes de que la información no se utilizará en su contra. Los Centros para el Control y la Prevención de Enfermedades (CDC) esperan que los proveedores que administran las vacunas carguen la información del paciente en los registros estatales, incluido TennISS en Tennessee o ImmTrac2 en Texas.

Los sistemas de seguimiento permiten a los proveedores asegurarse de que los pacientes regresen para su segunda dosis e identificar cualquier reacción adversa.

Los proveedores tratan de explicar que esta información se usa para iniciativas de salud, no para inmigración.

“Los pacientes, en particular los de origen inmigrante, son muy sensibles a compartir detalles familiares”, escribió Brian Haile, director ejecutivo de Neighborhood Health, una clínica comunitaria en Nashville, a funcionarios de salud de Tennessee en diciembre. “Si les pedimos que proporcionen esta información a proveedores que no conocen, serán aún más reticentes a vacunar a sus familias”.

En el condado de Hamblen, Khatri dijo que está tratando de persuadir a trabajadores en granjas de tomate y tabaco, y en plantas procesadoras de carne, zonas calientes de brotes de coronavirus, de que confíen en su clínica no solo para administrar la vacuna sino también para manejar datos confidenciales.

“Quieren acudir a un grupo de confianza”, dijo Khatri, cuyas clínicas tienen la aprobación para distribuir la vacuna, pero aún no han recibido ninguna dosis.

Helena Lobo, quien coordina el alcance hispano en Cherokee Health, dijo que, para algunos inmigrantes, la elección puede estar entre su salud o permanecer ocultos.

“Si tienen que arriesgar su estatus migratorio para recibir la vacuna contra covid, no la tendrán. No los culpo”, dijo Lobo. “Se preguntan: ‘¿Cuál es mi mayor riesgo? ¿Ser deportado o tener covid?’”.

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Noticias En Español Public Health Race and Health States

Anti-Immigrant Vitriol Complicates Vaccine Rollout in Southern States

In eastern Tennessee, doctors have seen firsthand how a hard-line immigration policy can affect the health and well-being of a community.

In 2018, federal agents raided a meatpacking plant in Morristown, a manufacturing hub in the Tennessee Valley, and detained nearly 100 workers they suspected of being in the country illegally. In the weeks that followed, scores of immigrant families who had found work in the meat-processing plants dotting broader Hamblen County scrambled to find sanctuary in churches — and scrupulously avoided seeking medical care.

The reason? Immigration agents were staking out clinics.

“We did not want people to come in for care because there were ICE officers in our parking lot,” said Parinda Khatri, chief clinical officer at Cherokee Health Systems, a nonprofit provider in Hamblen County.

As Tennessee, like other states, embarks on the daunting task of inoculating millions of residents against covid-19, many health officials find their mission complicated by a pervasive mistrust of government and law enforcement among unauthorized immigrants, a population estimated at 11 million across the U.S.

The challenges are particularly acute in the South, where large populations of immigrants living there illegally help maintain the region’s thriving agricultural and food-processing industries even as many state and local Republican leaders, emboldened by the Trump administration’s four years of anti-immigrant vitriol, denounce unauthorized residents as criminals and call for more limited paths to citizenship.

The confluence of those aggressive attitudes and a highly contagious virus has prompted concerns in some states that lackluster vaccination of people in the country without legal permission will short-circuit efforts to achieve herd immunity for the broader community.

“We will never get on top of this pandemic if the undocumented are left out,” said Dr. Sharon Davis, chief medical officer at Los Barrios Unidos Community Clinic in Dallas, which serves 28,000 patients, the majority of them in the country without authorization.

She acknowledged the challenge that poses in a state such as Texas, where the state Republican Party platform calls for the immediate expulsion of all “illegal aliens.” Echoing clinic directors in many Southern states, Davis said rolling out vaccination plans in immigrant communities is a “don’t ask, don’t tell” policy.

“We live in Texas, so you don’t bring it up. You don’t mention it,” she said. “We talk about the uninsured, and we talk about the Latinx population with the highest morbidity and mortality — that’s who we’re trying to serve.”

In the Dallas-Fort Worth area, home to one of the nation’s largest populations of unauthorized immigrants, the covid death rate for middle-aged Latino men is eight times higher than for their non-Latino white counterparts.

Epidemiologists say the disparity is not surprising, given vast numbers of Central and South American workers in the country illegally are doing jobs deemed essential in the pandemic, including farm labor, meat-processing and food service, and most have no health insurance.

Compounding the risks, many of these workers labor in conditions ripe for viral spread, standing shoulder to shoulder along conveyor belts in vegetable-packing houses, washing dishes in restaurant kitchens, stocking grocery shelves and cleaning hotel rooms. At day’s end, many return to bunkhouses or cramped homes housing multiple generations of family.

“It’s going through the whole house, and if the whole house doesn’t work, they don’t eat,” Davis said. “We’ve had patients begging us not to test them, because then they can’t go to work.”

Davis was among the medical directors who said the mass vaccination sites many states are using in the rollout — giant tents staffed by uniformed National Guard troops and iPad-toting medical personnel — have spooked immigrant families.

“They are asking, ‘What documentation do we have to show at the mass vaccination sites?’” said Davis. “Fear of deportation is just huge, and very real.”

And not unfounded, advocates noted, coming off four years in which former President Donald Trump sharply curtailed both legal and illegal immigration through mass detention and deportation, travel bans and severely restricting asylum. President Joe Biden has pledged to undo many of Trump’s policies, but immigrant advocates say support for more drastic measures runs strong among some immigration agents and local law enforcement officers, who could make life difficult for immigrants they suspect are in the country illegally.

Beyond fear of harassment or arrest, Davis said, public health officials are dealing with misinformation, including widespread rumors about government surveillance efforts secreted in the vaccine. “They are hearing horrible stories on social media,” she said. “They believed there was a microchip in the vaccine and they would be tracked.”

Even some immigrants living in the U.S. legally have reservations about receiving a government-provided vaccine. The Trump administration pushed to derail citizenship for any immigrant who used taxpayer-funded public services, including health care. In December, the Department of Justice withdrew the rule, but confusion abounds, and clinic directors say patients will prioritize their green cards above almost all else.

Sluggish vaccination rates among immigrant populations are already apparent. In Mississippi, for example, the Department of Health reported last week that fewer than 2,800 Latinos have been vaccinated — about 1% of all vaccinations administered so far.

Tennessee offers a prime example of the tensions underlying the vaccine rollout.

The Republican governor, Bill Lee, made headlines in May when he allowed the state Department of Health to share the names and addresses of those who tested positive for the virus with police. The city of Nashville’s health department separately provided local police with the addresses of people who tested positive or were quarantining.

Both efforts came under criticism and eventually ended, but Lee defended the effort, saying the information was “appropriate to protect the lives of law enforcement” and permitted by federal health privacy laws. The city later sought to reassure its “diverse immigrant communities” that the information would not be shared with federal immigration authorities.

Alabama, like Tennessee, has a history of tough rules regarding immigration, including a sweeping 2011 law that bars unauthorized immigrants from receiving nearly all public benefits, including most nonemergency medical care.

Velvet Luna, a 26-year-old registered nurse, has built her life in Ozark, Alabama, a small city in the Wiregrass, a region known for its poultry-processing facilities and large populations of Hispanic and Vietnamese immigrants. Luna enrolled in Deferred Action for Childhood Arrivals, or DACA, an Obama-era program that granted temporary status to unauthorized immigrants brought across the border as children. According to the National Immigration Law Center, nearly 500,000 DACA-eligible immigrants are essential workers.

Luna, who speaks with a soft Southern accent, once freely shared her immigration status, she said, but in recent years men who flirted with her “would find out my status and they would immediately change their attitude toward me. They would say ugly, ugly, hurtful things. ‘You are the reason our country is declining. You need to get out of here.’”

As a nurse at an area hospital who volunteered in the covid unit, she has received both doses of vaccine, but she understands the risks undocumented families weigh; neither of her parents, who live close by, are authorized to be in the U.S. “It’s OK to be scared, and it’s a courageous move to go get the vaccine and protect your family,” she said.

Even hard-line immigration opponents acknowledge the pandemic has tied together the fates of everyone living in the U.S., regardless of how they arrived.

“The main thing is to get shots into as many people’s arms as possible,” said Mark Krikorian, executive director of the Center for Immigration Studies, a conservative think tank that strenuously advocates for restricting immigration. “Your immigration may catch up with you someday, but that’s not today.”

The Biden administration has said U.S. Immigration and Customs Enforcement will not conduct enforcement operations at or near vaccine distribution sites. “ICE does not and will not carry out enforcement operations at or near health care facilities, such as hospitals, doctors’ offices, accredited health clinics, and emergent or urgent care facilities, except in the most extraordinary of circumstances,” according to a Feb. 1 statement issued by the Department of Homeland Security.

State health commissioners also have tried to calm rattled nerves. “We are not denying vaccine to anyone who shows up at our sites and is in a phase,” said Dr. Lisa Piercey, commissioner of the Tennessee Department of Health. “This is a federal resource, and if you’re in this country, then you get a vaccine.”

Advocates, however, said hurdles remain in convincing wary emigres that the personnel information collected as part of the vaccination process will not be used against them. The Centers for Disease Control and Prevention expects providers administering covid vaccines to upload patient information to state registries, including TennISS in Tennessee or ImmTrac2 in Texas. The tracking systems allow providers to ensure patients return for their second dose, and to identify any adverse reactions.

The use of such information for health initiatives, not immigration crackdowns, is a nuance that providers struggle to explain.

“Patients, particularly those of immigrant origin, are highly sensitive to sharing family details,” Brian Haile, executive director of Neighborhood Health, a community clinic in Nashville, wrote to Tennessee health officials in December. “If we ask them to provide this information to providers they do not know, they will be even more reticent to have their families get vaccinated.”

In Hamblen County, Khatri said she’s trying to persuade those laboring on tomato and tobacco farms and in meat-processing plants — hot zones of coronavirus outbreaks — to trust her clinic not only to administer the vaccine but also to handle sensitive data.

“They want to go to a trusted group,” said Khatri, whose clinics have received approval to distribute the vaccine but have not yet received any doses.

Helena Lobo, who coordinates Hispanic outreach at Cherokee Health, echoed that, saying, for some immigrants, the choice may come down to choosing their health or choosing to remain hidden.

“If they have to risk their immigration status to have the covid vaccine, they will not have it. I don’t blame them,” said Lobo. “They go by risk: ‘What is my biggest risk? Being deported or to have covid?’”

Vaccines Go Mobile to Keep Seniors From Slipping Through the Cracks

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

California Healthline correspondent Angela Hart contributed to this report.

In Search of the Shot

Too little covid vaccine and too great a demand: That’s what KHN readers from around the country detail in their often exasperating quest to snag a shot, although they are often clearly eligible under their local guidelines and priority system. Public health officials say the supply is growing and will meet demand in several months, but, for now, readers’ experiences show how access is limited. Some savvy readers report no problem getting in line for the vaccine, but others say that balky application processes and lack of information have stymied their efforts. Their unedited reports are a good snapshot of the mixed situation around the country.

— Feb. 12 —

I’m 65 and eligible for the vaccine. But I belong to an independent medical group, and many of the big vaccinators here are big medical groups. When I call my doctor, he tells me that they are waiting for a clinic, that he has no vaccine. The touted “mass vaccination site” at Cal Expo is barely used. When I hear there’s vaccine available at various hospitals, pharmacies and clinics, when I log on there are no appointments available. It’s vaccine for the privileged and members of the big medical groups. Everyone else loses out.

— 65-Year-Old
Sacramento, California

— Feb. 12 —

I am trying to get my 86-year-old mother vaccinated in Manhattan, NYC. Aside from the shortage, I am very angry at the hospitals and other vaccination sites for their horrible, inconsiderate websites, which are making the anxiety worse. Very simple things could be done to make them kinder. At present, you end up going in circles. For example: NorthwellHealth’s facilities are near her apartment. After going to the NYC covid page, I select one of their hospitals and click to their site. When they do not have any vaccine, they have no information on their covid page about 1st vaccine appointments. None. There is a button for making appointments, which leads you to making regular appointments with doctors. There should be a big button on the page you land on from the NYS listing that says MAKE A VACCINATION APPOINTMENT, even if there are no appointments. Some of the other sites make you fill out the forms before telling you that there are no vaccines. And you can’t just do it once. You have to do it over and over again. 

My sister and I are trying to do this for her. The fact that you MUST go thru the internet is pushing the elderly, those who need the vaccine the most, to periphery. But, at least, they could make the websites friendly and helpful. We’re a country where we spend more money and time making sure people know how to drink coke than they do helping people understand healthcare. This is a systematic problem that should be improved. There are marketing people out there who know how to interact with the public, but the healthcare system chooses not to use them.

— New York

Yesterday I experienced the good and the bad of the vaccine rollout.  My 95-year-old mother endured a one hour, twenty minute ordeal mostly standing outside 380 W MacArthur Kaiser in Oakland, thankfully a wheelchair was offered and very much appreciated.

We were there 15 minutes early for the 10:15 appt. and finished at 11:20. The whole operation seemed clunky and bureaucratic, think of standing in a long line at a rental car company.

Now to my almost dreamlike experience gliding through the Moscone Center in SF, arriving about 25 minutes early for my 5:45 appt. I was immediately checked in and escorted to the vaccination booth, the nurse checked me out on her screen asked me the routine questions jabbed my arm gave me my 5:45 sticker and sent me to observation area.  After my morning in Oakland I’d love to take my mom to Moscone for her second shot but as far as I can tell Kaiser doesn’t seem to allow that.

— Oakland, California

I’m a stage 4 cancer survivor and may have long-term heart and lung effects from the treatments I went through. I’m 44 and live in Denver. It’s unclear which vaccine group I fall into. Some states, such as New York, prioritize any cancer survivor, but Colorado only considers people who have been in treatment for the past month. Also, they want you to have two high-risk conditions — how are those defined? Do I qualify? Do my doctors have any input on that?

My oncologist and my primary care doctor have no word on when I might get vaccinated. My health system’s website says if you have an online account, you’re already in their system and they will inform you when you’re eligible. I do not know if that takes into account my medical history.

I’ve been to four pharmacies so far in my area; only one has had vaccines, and they did have a list on paper to call if they wound up with extras. I also signed up online with a couple of health care systems (Centura, National Jewish) for notifications; only one asked about medical conditions upon sign-up.

So, at this rate, I’m guessing: spring? Summer? Will I be treated as a healthy adult and be the last vaccinated?

— 44-Year-Old

Checked the Sacramento County website on Feb. 3. Found a link to a vaccination clinic at our neighborhood Safeway. Made an appointment for Feb. 6, at which time I received my first dose. Within minutes of being vaccinated, I received an email confirming an appointment for the second dose in 28 days.

— Sacramento, California

We heard the local center would allow people to sign up at 3 p.m. on a Sunday. My husband and I were refreshing our respective computers every five seconds waiting for the portal to open. We snagged appointments via EventBrite on the same day, same hour. When my husband and I went for our first shot, we stood in line for roughly 1½ hours outside, in the sun and heat, before we got inside the county health office, which administered the shot. Most of the other people in line were older and/or frail, with walkers and in wheelchairs. The county staff did their best to make them comfortable, which wasn’t much due to the logistics of the operation. The second shot was a breeze — in and out in about 25 minutes, including the mandatory 15-minute wait after the inoculation. I have a friend who is 80 years old, a three-time cancer survivor, and still can’t get an appointment and has tried numerous times.

— Lakewood Ranch, Florida

I signed up with the Kalamazoo County Health Department in Michigan. It was just a couple of weeks, I think, before they sent the application to sign up for the appointment. I had a choice of two days and three time spans with first, second and third choice and was asked if I needed any assistance. I then was emailed an appointment. When I got there, a policeman was directing traffic and giving instructions to stay in the car until five minutes before my appointment. It seemed less. I went through several stops very fast. The parking lot had so many cars and I had to wait 30 minutes after my injection. And, still, in 45 minutes I was driving down the street and also had my second appointment made. 

They reminded me days before my appointment, the day before my appointment and the morning of my appointment. So fast, so efficient and so many people there that there was no time to do anything but get done what had to be done. AMAZING planning and amazing workers and volunteers.

— 77-Year-Old
Kalamazoo, Michigan

Maryland covid distribution is a true mess. There is no central registration site. The state has a site that lists many providers, most of which do not have the vaccine. One of the large statewide vaccine sites, Six Flags America, does not allow you to sign up for the vaccine. Almost all the sites listed on the state’s website indicated they do not have the vaccine.

— 68-Year-Old
Ellicott City, Maryland

It’s terrible here in the county for Tier 2. That includes all the educators and everyone over 70. The appointment software company they chose to use did nothing to change their program to account for thousands daily and hourly trying to get an appointment.

I eventually was able to get my first shot. I still was not able to use the information that the Carson City Health and Human Services was putting in the news. I noodled around on the internet and discovered a notice that a drugstore (Walgreens) and a drugstore within a supermarket (Smith’s Food and Drug) were being sent the Moderna vaccine and were taking appointments starting the next day. I tried Walgreens but I don’t shop there and could not enter its system. I tried Smith’s, and it was so simple anyone could get on it. I made an appointment so easily for the next morning. Four days ago, I received an email from Kroger, the parent company of Smith’s, telling me the day and time for my second dose. 

Each city, county and state seem to have surprisingly different ways of putting out information, where and how the vaccine is delivered and administered. I do think it is still a logistics issue that was not anticipated by our former government officials.

— 78-Year-Old
Carson City, Nevada

I signed up for a vaccine several weeks ago with the county health department. I’m 78, living in Albuquerque. My registration was acknowledged but nothing further. The county program appears to be in chaos.

— 78-Year-Old
Albuquerque, New Mexico