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Dentistas eliminan los problemas de las personas sin seguro ofreciéndoles ellos mismos planes

Mon, 09/20/2021 - 3:22pm

David White, dentista de Nevada, ha visto dientes enfermos y podridos en la boca de pacientes que habitualmente posponen sus chequeos y evitan procedimientos menores como empastes. Si bien la fobia dental es un factor, White dijo que la razón principal por la que las personas no se tratan es el costo.

Para ayudar a los pacientes que no tienen seguro dental, en 2019 White comenzó a ofrecer un plan de membresía que se parece mucho a una póliza, excepto que solo se puede usar en sus oficinas en Reno y Elko. Los adultos pagan $29 al mes, o $348 al año, y reciben dos exámenes gratuitos, dos limpiezas, radiografías y un examen de emergencia, servicios valorados en $492. También tienen un 20% de descuento en procedimientos como empastes y extracciones.

Aproximadamente 250 de los pacientes de White se han inscrito, lo que ha llevado a muchos a hacer citas con más frecuencia para exámenes de rutina y tratamientos, dijo. “Impulsa a los pacientes a tener una mejor salud bucal”, dijo White.

White está entre una cuarta parte de los dentistas en todo el país que ofrecen membresías, según una encuesta de 2021 a 70,000 dentistas realizada por la Asociación Dental Estadounidense.

Estos planes limitados a una práctica están dirigidos principalmente a los 65 millones de estadounidenses que no tienen cobertura dental, y tienen que pagar de su bolsillo toda su atención. A los dentistas también les gusta más esta alternativa que manejar los planes de seguro porque no tienen que lidiar con las tasas de reembolso con grandes descuentos de las aseguradoras, esperar por aprobaciones previas para brindar servicios y retrasos en el pago de sus reclamos.

La falta de cobertura dental contribuye a retrasar o renunciar a la atención dental en 1 de cada 4 adultos, según un análisis de KFF de una encuesta nacional de 2019.

Kleer, una empresa de Wayne, Pennsylvania, fundada en 2018, ha ayudado a más de 5,000 dentistas a configurar estas ofertas. “Los pacientes con planes de membresía actúan como pacientes asegurados y hacen citas tanto como pacientes asegurados, pero pagan menos por la cobertura mientras que a los dentistas se les paga más”, dijo su director ejecutivo Dave Monahan. “Todo lo que estamos haciendo es eliminar al intermediario”, explicó.

Monahan dijo que el negocio se ha disparado durante la pandemia de covid-19, a medida que más dentistas vieron a estos planes como una alternativa frente a mayores costos por los equipos de protección, y más pacientes sin cobertura laboral.

Anthony Wright, director ejecutivo del grupo de defensa de la salud del consumidor Access California, dijo que es escéptico sobre el valor del seguro dental individual, pero dijo que los pacientes también deben tener cuidado con un plan de membresía dental porque generalmente no son supervisados ​​por los estados. “La gente debe ser consciente de que este es un campo generalmente no regulado, por lo que el comprador debe tener cuidado”, dijo.

Antes de unirse a un plan de membresía, los consumidores deben preguntar cuánto cobra el dentista por los procedimientos para saber no solo el descuento, sino también el costo real de su bolsillo. En algunos casos, es una opción viable.

“Si va a una práctica establecida y si los costos son razonables y están dentro de su presupuesto, puede tener algún sentido” inscribirse, dijo.

Vanessa Bernal, gerente de la oficina de Winter Garden Smiles en el centro de Florida, dijo que muchos pacientes que trabajan por cuenta propia o para pequeñas empresas se han unido al plan de membresía de su consultorio.

“No tienen cobertura de empleador y si fueran a comprarla por su cuenta se enfrentarían a un período de espera, mientras que nuestros descuentos comienzan de inmediato”, dijo.

Winter Garden Smiles ha inscrito a más de 370 pacientes en su plan, que cuesta $245 al año para niños y $285 para adultos. La oficina se retire de tres pequeñas redes de seguros desde que comenzó con su propio plan.

Muchos de los planes que se ofrecen en todo el país se parecen mucho a un seguro dental. Los pacientes pagan al consultorio dental por lo general entre $300 y $400 al año. A cambio, reciben ciertos servicios preventivos sin cargo y otros procedimientos con descuento.

Pero los planes de membresía no tienen los deducibles anuales o los períodos de espera que pueden hacer que el seguro dental comprado individualmente sea poco atractivo. Otro factor poco atractivo de los planes tradicionales son sus límites máximos de beneficios, generalmente de $1,200 a $1,500 al año. En comparación, los pacientes con membresías pueden usar los descuentos para un tratamiento ilimitado.

Aproximadamente la mitad de los estadounidenses obtienen cobertura dental a través de sus empleos. Por lo general, esas pólizas son la mejor opción. Pero Medicare no ofrece cobertura dental y la mayoría de los programas estatales de Medicaid no cubren el tratamiento dental para adultos.

Pero para los pacientes sin un plan basado en el trabajo, comprar una póliza dental independiente es costoso y, a diferencia de un seguro médico, no está claro si el beneficio supera los costos. Eso se debe a que los costos dentales no son tan catastróficos financieramente como las facturas del hospital, que pueden ascender a decenas de miles de dólares.

Las primas anuales del seguro dental suelen oscilar entre $400 y $700. La mayoría de los planes cubren todos los costos de los servicios preventivos, como limpiezas. Para procedimientos menores, como empastes, los planes generalmente pagan del 70% al 80%. Para procedimientos importantes, como coronas, los planes a menudo pagan alrededor del 50% del costo, que aún es más de lo que cubren los planes de membresía. Sin embargo, los planes de seguro a menudo negocian precios con los dentistas, por lo que también se reduce la responsabilidad de los miembros del plan.

Melissa Burroughs, quien lidera una campaña de “salud bucal para todos” para el grupo de defensa Families USA, dijo que los planes de membresía dental pueden ayudar a algunas personas, pero no resuelven los problemas de los altos costos dentales y la forma diferente en que las aseguradoras tratan la cobertura de los dientes comparado con el resto del cuerpo.

“No creo que estos planes sean la respuesta, y definitivamente no cumplen con el estándar para hacer que la atención sea realmente asequible para muchas personas”, dijo.

Megan Lohman, directora ejecutiva de Plan Forward, una empresa de Indianapolis que ayuda a establecer planes de membresía, dijo que muchas aseguradoras no han aumentado las tasas de reembolso en años, lo que impulsa a los dentistas a ofrecer sus propios planes. “No vemos que el seguro dental desaparezca, pero los pacientes y los dentistas solo necesitaban una alternativa”, dijo.

Los pacientes dicen que aprecian que los servicios de las membresías son menos costosos que cuando pagan exclusivamente de su bolsillo, y el prepago de los servicios los motiva a buscar servicios preventivos.

“El plan de membresía me mantiene encaminada, ya que es casi como si tuviera un pago inicial por mi atención”, dijo Christina Campbell, de 29 años, de Hamden, Connecticut. Tuvo un plan dental bajo la póliza de su madre hasta los 26 años y luego comenzó a buscar su propia cobertura.

Cuando su dentista, Kevin D’Andrea, le mencionó su plan, pareció demasiado bueno para dejarlo pasar. Con la membresía, dijo, ha vuelto a hacerse chequeos y limpiezas dos veces al año, y ya no duda cuando llega el momento de las radiografías. Campbell, quien administra una bodega, paga $38 al mes.

Holly Wyss, enfermera de 59 años, de Greenwood, Indiana, dijo que el seguro dental era demasiado caro, por lo que se unió a un plan de membresía de $300 al año a través de su dentista, David Wolf. Los descuentos le ahorraron varios cientos de dólares en dos coronas, dijo.

Entre los grupos que carecen de seguro dental y que recientemente han llamado la atención se encuentran las personas cubiertas por el Medicare tradicional. Sin embargo, muchos planes privados de Medicare Advantage ofrecen algunos beneficios dentales.

Estos planes brindan cobertura solo en ciertos consultorios dentales, tienen una prima y, a menudo, cubren solo una pequeña parte de los costos de los pacientes. El límite promedio de cobertura es de $1,300, y más de la mitad de los beneficiarios tienen planes con un límite de $1,000 en beneficios, según un informe de KFF.

El presidente Joe Biden y los demócratas del Congreso han propuesto agregar un beneficio dental a Medicare, junto con otras iniciativas de atención médica, como parte de un plan de $3.5 mil millones que los legisladores están tratando de impulsar este otoño.

El proyecto de ley publicado por el Comité de Medios y Arbitrios de la Cámara de Representantes este mes todavía haría recaer en los beneficiarios el pago del 20% de los costos de los servicios preventivos como los chequeos y entre el 50% y el 90% de los costos de ciertos procedimientos. Y la ley, si se aprueba, podría tardar cinco años o más en implementarse.

La necesidad entre los estadounidenses mayores es enorme.

Casi la mitad de los beneficiarios de Medicare (unas 24 millones de personas) no tenían cobertura dental en 2019, según KFF. En 2018, casi la mitad de todos los beneficiarios de Medicare no habían visitado a un dentista en el último año (47%), con tasas más altas entre afroamericanos (68%) e hispanos (61%).

D’Andrea, el dentista de Hamden, Connecticut, dijo que el plan de membresía que comenzó en 2020 genera la lealtad de los pacientes. “Los pacientes saben de antemano cuáles son sus gastos de bolsillo y no tienen que esperar a ver qué cubre su seguro”, dijo. “Es como un juego que juegan las aseguradoras, manteniéndonos en espera durante una hora para obtener aprobaciones previas. Sacamos suficientes dientes en la oficina, y es lo mismo sacar información de ellos”.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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Ask KHN-PolitiFact: Is My Cloth Mask Good Enough to Face the Delta Variant?

Mon, 09/20/2021 - 5:00am

In recent months, some European airlines have banned the use of cloth face coverings to control the spread of the coronavirus during air travel, instead favoring surgical masks — sometimes referred to as medical or disposable — and N95 respirators.

It’s another salvo in the debate over the effectiveness of the ubiquitous cloth mask, which sprang into fashion when surgical masks and N95s were harder to find in the pandemic’s early days. The Centers for Disease Control and Prevention still promotes cloth face coverings in its guidance about masks.

And masks remain a critical mitigation tool because people primarily become infected with SARS-CoV-2, the virus that causes covid-19, by inhaling small aerosol particles that linger in the air or large respiratory droplets produced in coughs and sneezes.

But the science is changing. Delta, currently the primary variant in the United States, is far more contagious than the original coronavirus, so the density of virus in the air is greater.

Some experts have adjusted their advice proportionally. “Given the delta variant that’s out there, you probably need to upgrade your mask,” Dr. Ashish Jha, a leading covid expert and dean of the Brown University School of Public Health, said on “Fox News Sunday” earlier this month.

What Type of Mask Should You Wear?

Don’t worry if you are confused. Mask guidance has been mixed since the dawn of the pandemic, and new research has altered conventional thinking. We decided to dig in and sort out the latest developments.

First, people were told masking wasn’t necessary. Soon after, this recommendation changed, but the public was advised against purchasing surgical-style masks used by health professionals because of dire shortages of such protective gear. Americans instead were told to spring for cloth masks or make do-it-yourself versions. Shortages do not appear to be as big a problem now, though the CDC still advises against choosing N95 respirators.

As recently as late August, the nation’s top infectious-disease doctor, Dr. Anthony Fauci, declined to recommend higher-quality masks. “Instead of worrying about what kind of mask, just wear a mask,” he told “The Mehdi Hasan Show” on MSNBC.

So, what gives? Dr. Peter Chin-Hong, an expert on infectious diseases at the University of California-San Francisco, said Fauci was taking a harm-reduction approach. “It probably is more important to wear something that you feel comfortable with, and you can wear for long periods of time if you’re going into a particular environment … rather than saying you need to wear the gold standard thing at all times,” he said.

“A baseline should be a surgical mask,” added Chin-Hong. “It’s easier to implement. It’s cheap, albeit not always environmentally friendly.” Personally, he wears only N95s when wildfires are blazing. “Even in the hospital, I’m mainly wearing a surgical mask,” he said.

While he thinks government and public health officials should emphasize wearing surgical masks, Chin-Hong said cloth masks can offer enough protection in certain circumstances. For example, a fully vaccinated person, he said, would likely get adequate protection by wearing a cloth face covering for brief periods indoors when the venue is not at capacity. A lot depends on the context, so he provided these questions to help the decision-making process: If you are going indoors, will the building be especially crowded? How long will you be inside? Will everyone most likely be masked? Are you and others around you fully vaccinated? Are you immunocompromised?

The riskier the situation, the more likely the higher-quality mask is the best option. “Nothing is zero risk, so it’s just a matter of risk reduction,” Chin-Hong said.

“So definitely, masks need to be stepped up to fight delta, but it does not mean those who cannot afford N95s have no options,” said Raina MacIntyre, head of the biosecurity research program at the University of New South Wales in Sydney, Australia, who has conducted many studies on masks.

MacIntyre said it is “possible to design a high-performing cloth mask.” An experimental lab study she co-authored found a layered cloth mask can effectively block droplets. The study, published in May in the journal ACS Biomaterials Science & Engineering, recommends using a minimum of three layers — a combination of cotton/linen and polyester/nylon — to resemble the droplet-blocking performance of surgical masks.

Not only is layering important to improve filtration but so is fit. A CDC-recommended technique for improving the fit of either a cloth or surgical mask is knotting the straps and tucking the sides. A mask is generally a good fit if you feel warm air coming through the front of the mask as you inhale and exhale.

What Does the Research Say?

A large-scale, real-world study published this month found surgical masks especially effective at reducing symptomatic infections. These types of masks prevented 1 in 3 infections among people 60 and older.

Researchers from Yale, Stanford and the nonprofit GreenVoice monitored more than 340,000 adults in rural Bangladesh for at least eight weeks. Roughly half the Bangladeshis received interventions like free mask distribution and promotion. Villages that received interventions saw mask use jump from 13% to 42%. The same villages reported fewer confirmed covid infections and a lower incidence of related symptoms.

Villages where cloth masks were given out reported an 8.5% reduction in symptoms, while villages that received surgical masks reported a 13.6% reduction. When a third of adults with symptoms commonly associated with covid agreed to get their blood tested for the virus, researchers discovered an 11% reduction among those who wore surgical masks. Researchers observed a 5% reduction in infections among those who wore cloth masks. This study was conducted before the delta variant was circulating widely in the country. The study has not yet undergone peer review, but some experts have already heralded its methodology and results.

“When I saw those results, I threw away my cloth mask,” said Stephen Luby, a co-author of the study and professor of infectious disease at Stanford University. “If delta is circulating and if you’re going to wear a mask, why don’t you wear one that the data tell you is good?”

“We find very strong evidence that surgical masks are effective,” added Jason Abaluck, an economist at Yale who helped lead the study. “My read of that is that cloth masks are probably somewhat effective. They are probably better than nothing.”

Abaluck suspects his study offers mixed evidence for cloth masks because only about a third of those who reported symptoms consented to blood testing for covid. In other words, the sample size was too small to observe anything significant. “The most likely interpretation of this whole constellation of results is that [cloth masks] actually do help. They actually do make you less likely to get covid. That’s why we saw fewer symptoms,” he said. A second possibility is that cloth masks prevent other respiratory diseases that have similar symptoms, he said.

Multiple observational studies and trend analyses found community masking, which includes the use of cloth masks, reduces the spread of covid. The researchers of the Bangladesh study said those studies had drawbacks, which is why they conducted a randomized clinical trial. For example, some of those studies could not observe the independent effect of masks in real-world settings because they looked at the aftermath of mask mandates, which were often coupled with other covid mitigation steps such as physical distancing. However, they agreed with those studies’ overall assessment: People who wear masks are less likely to get infected than people who don’t.

“This is the nature of science. Science evolves,” Luby said. “We had evidence that we get some protection from cloth masks, and we now have newer evidence that we get better protection from surgical masks.”

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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I Got a ‘Mild’ Breakthrough Case. Here’s What I Wish I’d Known.

Mon, 09/20/2021 - 5:00am

The test results that hot day in early August shouldn’t have surprised me — all the symptoms were there. A few days earlier, fatigue had enveloped me like a weighted blanket. I chalked it up to my weekend of travel. Next, a headache clamped down on the back of my skull. Then my eyeballs started to ache. And soon enough, everything tasted like nothing.

As a reporter who’s covered the coronavirus since the first confirmed U.S. case landed in Seattle, where I live, I should have known what was coming, but there was some part of me that couldn’t quite believe it. I had a breakthrough case of covid-19 — despite my two shots of the Pfizer-BioNTech vaccine, the second one in April.

I was just one more example of our country’s tug and pull between fantasies of a post-covid summer and the realities of our still-raging pandemic, in which even the vaccinated can get sick.

Not only was I sick, but I’d exposed my 67-year-old father and extended family during my first trip back to the East Coast since the start of the pandemic. It was just the scenario I had tried to avoid for a year and a half.

Where did I get it? Who knows. Like so many Americans, I had loosened up on wearing masks all the time and physical distancing after getting fully vaccinated. We had flown across the country, seen friends, stayed at a hotel, eaten indoors and, yes, even gone to a long-delayed wedding with other vaccinated people.

I ended up in quarantine at my father’s house. Two rapid antigen tests (taken a day apart) came back negative, but I could tell I was starting to feel sick. After my second negative test, the nurse leveled with me. “Don’t hang your hat on this,” she said of the results. Sure enough, a few days later the results of a PCR test for the coronavirus (this one sent to a lab) confirmed what had become obvious by then.

It was a miserable five days. My legs and arms ached, my fever crept up to 103 and every few hours of sleep would leave my sheets drenched in sweat. I’d drop into bed exhausted after a quick trip to the kitchen. To sum it up, I’d put my breakthrough case of covid right up there with my worst bouts of flu. Even after my fever broke, I spent the next few weeks feeling low.

Of course, I am very lucky. I didn’t go up against the virus with a naive immune system, like millions of Americans did before vaccines were widely available. And, in much of the world, vaccines are still a distant promise.

“You probably would have gotten much sicker if you had not been vaccinated,” Dr. Francesca Torriani, an infectious-disease physician at the University of California-San Diego, explained to me recently.

As I shuffled around my room checking my fever, it was also reassuring to know that my chances of ending up in the hospital were slim, even with the delta variant. And now, about a month later, I’ve made a full recovery.

The reality is breakthrough cases are becoming more common. Here’s what I wish I’d known when those first symptoms laid me low.

1. Is it time for a reality check about what the vaccines can — and can’t do?

The vaccines aren’t a force field that wards off all things covid. They were given the green light because they greatly lower your chance of getting seriously ill or dying.

But it was easy for me — and I’m not the only one — to grab onto the idea that, after so many months of trying not to get covid, the vaccine was, more or less, the finish line. And that made getting sick from the virus unnerving.

After all, there were reassuring findings earlier this year that the vaccine was remarkably good at stopping any infection, even mild ones.

“There was so much initial euphoria about how well these vaccines work,” said Dr. Jeff Duchin, an infectious-disease physician and the public health officer for Seattle and King County. “I think we — in the public health community, in the medical community — facilitated the impression that these vaccines are bulletproof.”

It’s hard to keep adjusting your risk calculations. So if you’d hoped to avoid getting sick at all, even slightly, it may be time for a “reset,” Duchin said. This isn’t to be alarmist but a reminder to clear away expectations that covid is out of your life, and stay vigilant about commonsense precautions.

2. How high are my chances of getting a breakthrough case these days?

It used to be quite rare, but the rise of delta has changed the odds.

“It’s a totally different ballgame with this delta phase,” said Dr. Eric Topol, a professor of molecular medicine and director of the Scripps Research Translational Institute in San Diego. “I think the chance of having a symptomatic infection has gone up substantially.”

But “quantifying that in the U.S. is very challenging” because our “data is so shoddy,” he said.

The vaccinated still have a considerably lower chance of getting infected than those who aren’t protected that way. Los Angeles County collected data over the summer as the delta variant started to surge: Unvaccinated people were five times more likely to test positive than those who were vaccinated.

3. How careful do I need to be if I want to avoid a breakthrough?

Looking back, I wish I’d taken more precautions.

And my advice to friends and family now is: Wear masks, stay away from big gatherings with unvaccinated people and cut down on travel, at least until things calm down.

The U.S. is averaging more than 150,000 coronavirus infections a day (about twice what it was when I fell sick), hospitals are overwhelmed, and the White House has proposed booster shots. Scientists are still making sense of what’s happening with breakthrough cases.

In many parts of the U.S., we’re all more likely to run into the virus than we were in the spring. “Your risk is going to be different if you are in a place that’s very highly vaccinated, with very low level of community spread,” said Dr. Preeti Malani, a specialist in infectious diseases at the University of Michigan. “The piece that’s important is what’s happening in your community.”

4. What does a “mild” case of covid feel like?

In my case, it was worse than I expected, but in the parlance of public health, it was “mild,” meaning I didn’t end up in the hospital or require oxygen.

This mild category is essentially a catchall, said Dr. Robert Wachter, who chairs the Department of Medicine at the University of California-San Francisco. “Mild” can range from “a day of feeling crummy to being completely laid up in bed for a week, all of your bones hurt and your brain isn’t working well.”

There’s not great data on the details of these mild breakthrough infections, but so far it appears that “you do way better than those who are not vaccinated,” said Dr. Sarang Yoon, an occupational medicine specialist at the University of Utah who was part of a nationwide study by the Centers for Disease Control and Prevention on breakthrough infections.

Yoon’s study, published in June with data collected before the delta surge, found that the presence of fever was cut in half, and the days spent in bed reduced by 60% among people with breakthrough infections, compared with unvaccinated people who got sick.

If you’re vaccinated, the risk of being hospitalized is 10 times lower than if you weren’t vaccinated, according to the latest data from the CDC. Those who get severely and critically ill with a breakthrough case tend to be older — in one study done before delta, the median age was 80.5 — with underlying medical conditions such as cardiovascular disease.

5. Can I spread it to others, and do I need to isolate?

Unfortunately, you still have covid and need to act like it.

Even though my first two tests were negative, I started wearing a mask at my house and keeping my distance from my vaccinated family members. I’m glad I did: No one else got sick.

The delta variant is more than twice as contagious as the original strain of the virus and can build up quickly in your upper respiratory tract, as was shown in a cluster of breakthrough infections linked to Provincetown, Massachusetts, over the summer.

“Even in fully vaccinated, asymptomatic individuals, they can have enough virus to transmit it,” said Dr. Robert Darnell, a physician-scientist at The Rockefeller University.

The science isn’t settled about just how likely vaccinated people are to spread the virus, and it does appear that the amount of virus in the nose decreases faster in people who are vaccinated.

Still, wearing masks and staying isolated from others if you test positive or have symptoms is absolutely critical, Darnell said.

6. Could I get long covid after a breakthrough infection?

While there’s not a lot of data yet, research does show that breakthrough infections can lead to the kind of persistent symptoms that characterize long covid, including brain fog, fatigue and headaches. “Hopefully that number is low. Hopefully it doesn’t last as long and it’s not as severe, but it’s just too early to know these things,” Topol said.

Recent research from the United Kingdom suggests that vaccinated people are about 50% less likely to develop long covid than those who are unvaccinated.

This story is from a reporting partnership that includes NPR and KHN.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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Científicos analizan los sistemas inmunes únicos de los niños mientras más son víctimas de covid

Fri, 09/17/2021 - 3:52pm

A un año y medio del comienzo de la pandemia de covid-19, con la variante delta impulsando un resurgimiento masivo de casos, muchos hospitales están alcanzando un triste récord. Ahora están perdiendo bebés por el coronavirus.

La primera muerte reportada de un recién nacido relacionada con covid fue en el condado de Orange, Florida, y un bebé murió en Mississippi. El condado de Merced en California vio morir a un niño de menos de un año a fines de agosto.

“Es muy difícil ver sufrir a los niños”, dijo el doctor Paul Offit, experto en enfermedades infecciosas del Hospital Infantil de Philadelphia, que, al igual que otros hospitales pediátricos del país, se ha visto colmado de pacientes con covid.

Hasta que la variante delta comenzará a acechar este verano, casi todos los niños parecían estar a salvo de los peores estragos de covid, por razones que los científicos no comprendían del todo.

Aunque no hay evidencia de que la variante delta cause una enfermedad más grave, el virus es tan infeccioso que los niños están siendo hospitalizados en gran número, principalmente en estados con bajas tasas de vacunación. Casi el 30% de las infecciones por covid informadas durante la semana que terminó el 9 de septiembre fueron en niños, según la Academia Americana de Pediatría.

Los médicos diagnosticaron más de 243,000 casos en niños esa semana, lo que elevó el número total de infecciones por covid en menores de 18 años desde el inicio de la pandemia a 5,3 millones, con al menos 534 muertes.

Expertos dicen que es una cuestión de matemática básica. “Si 10 veces más niños están infectados con delta que con las variantes anteriores, entonces veremos 10 veces más niños hospitalizados”, dijo el doctor Dimitri Christakis, director del Center for Child Health, Behavior and Development en el Seattle Children’s Research Institute.

Pero el aumento más reciente pone de nuevo sobre la mesa la pregunta que ha desconcertado a los científicos durante toda la pandemia: ¿Qué protege a la mayoría de los niños de enfermarse gravemente? ¿Y por qué a veces esa protección falla?

“Esta es una pregunta urgente y compleja”, dijo el doctor Bill Kapogiannis, oficial médico senior y experto en enfermedades infecciosas del Instituto Nacional de Salud Infantil y Desarrollo Humano Eunice Kennedy Shriver. “Estamos haciendo todo lo posible para abordarla, utilizando todas las herramientas que tenemos disponibles”, dijo Kapogiannis.

Durante gran parte de la pandemia, los médicos solo supusieron por qué el sistema inmune de los niños tenía mucho más éxito en rechazar al coronavirus.

A pesar del alarmante número de niños hospitalizados ahora, sigue siendo mucho menos probable que los jóvenes se enfermen gravemente. Menos del 1% de los niños diagnosticados con covid son hospitalizados y aproximadamente el 0,01% muere, tasas que no han cambiado en los últimos meses, según la Academia Americana de Pediatría.

Más evidencia sugiere que el sistema inmune innato de los niños generalmente corta la infección de raíz desde el principio, evitando que el virus se “instale” y multiplique sin control, dijo el doctor Lael Yonker, profesor asistente de pediatría en el Hospital General de Massachusetts.

En una serie de estudios publicados el año pasado, el matrimonio de doctores Betsy y Kevan Herold descubrió que los niños tienen una inmunidad mucosa particularmente fuerte, llamada así porque los actores clave en este sistema no están en la sangre, sino en las membranas mucosas que recubren la nariz, la garganta y otras partes del cuerpo que frecuentemente se encuentran con los gérmenes.

Estas membranas actúan como los muros de piedra que protegían a las ciudades medievales de los invasores. Están hechos de células epiteliales, que también recubren muchos órganos internos, que se encuentran al lado de soldados clave del sistema inmunológico llamados células dendríticas y macrófagos, explicó Betsy Herold, jefa de la división de enfermedades infecciosas pediátricas del Albert Einstein College of Medicine.

Significativamente, estas células están cubiertas de proteínas, denominadas receptores de reconocimiento de patrones, que actúan como centinelas, explorando continuamente el paisaje en busca de algo inusual. Cuando los centinelas notan algo extraño, como un virus nuevo, alertan a las células para que comiencen a liberar proteínas llamadas interferones, que ayudan a coordinar la respuesta inmunitaria del organismo.

En un estudio de agosto en Nature Biotechnology, Roland Eils y sus colegas del Instituto de Salud de Berlín, en Alemania, encontraron que las vías respiratorias superiores de los niños están "preactivadas" para combatir al nuevo coronavirus. Sus vías respiratorias están repletas de estos centinelas, incluidos algunos que se destacan por reconocer al coronavirus.

Esto permite que activen inmediatamente su sistema inmunológico innato, liberando interferones que ayudan a apagar el virus antes de que pueda establecerse, explicó Eils.

En comparación, los adultos tienen muchos menos centinelas al acecho y tardan unos dos días en responder al virus, agregó Eils. Para ese momento, el virus puede haberse multiplicado exponencialmente y la batalla se vuelve mucho más difícil.

Cuando la inmunidad innata no logra controlar un virus, el cuerpo puede recurrir al sistema inmunológico adaptativo, una segunda línea de defensa que se adapta a cada amenaza única. El sistema adaptativo crea anticuerpos adaptados a cada virus o bacteria que encuentra el cuerpo.

Si bien los anticuerpos son algunas de las partes de la respuesta inmune más fáciles de medir y, por lo tanto, a menudo se citan como sustitutos de la protección, los niños no parecen necesitar tantos para combatir al covid, dijo Betsy Herold. De hecho, su investigación muestra que los niños con covid tienen menos anticuerpos neutralizantes que los adultos. (Tanto los niños como los adultos suelen producir suficientes anticuerpos para frustrar futuras infecciones por coronavirus después de una infección natural o de la vacunación).

Si bien el sistema inmune adaptativo puede ser eficaz, a veces puede causar más daño que bien. Un sistema inmunológico hiperactivo puede causar daños colaterales, desencadenando una cascada inflamatoria que no solo destruye los virus, sino también las células sanas de todo el cuerpo.

En algunos pacientes con covid, la inflamación incontrolada puede provocar coágulos sanguíneos potencialmente mortales y síndrome de dificultad respiratoria aguda, que ocurre cuando el líquido se acumula en los sacos de aire del pulmón y dificulta la respiración, dijo Betsy Herold. Ambas son causas comunes de muerte en pacientes adultos con covid.

Debido a que los niños generalmente eliminan el coronavirus tan rápido, suelen evitar este tipo de inflamación peligrosa, dijo.

Investigaciones muestran que los niños sanos tienen grandes cantidades de un tipo de célula pacificadora, llamadas células linfoides innatas, que ayudan a apaciguar a un sistema inmunológico hiperactivo y reparar el daño a los pulmones, dijo el doctor Jeremy Luban, profesor de la Escuela de Medicina de la Universidad de Massachusetts.

Los niños nacen con muchas de estas células, pero su número va disminuyendo con la edad. Y tanto los niños como los adultos que están enfermos de covid tienden a tener menos de estas células reparadoras, apuntó Luban.

Los hombres también tienen menos células reparadoras que las mujeres, lo que podría ayudar a explicar por qué tienen un mayor riesgo de morir de covid que las mujeres.

Tanto los niños como los adultos pueden desarrollar "covid prolongado", los problemas de salud persistentes que experimentan alrededor del 10% de los adultos más jóvenes y hasta el 22% de los mayores de 70 años. Estudios sugieren que entre el 4% y el 11% de los niños tienen síntomas persistentes.

Los científicos tienen menos pistas sobre lo que resulta mal en ciertos niños con covid, dijo Kevan Herold, quien enseña inmunobiología en la Escuela de Medicina de Yale.

Investigaciones sugieren que los niños tienen un sistema inmunológico innato más robusto que los adultos porque han experimentado muchas infecciones respiratorias recientes, durante sus primeros años, que pueden preparar su sistema inmunológico para ataques posteriores.

Pero no todos los niños ignoran el covid tan fácilmente, dijo Eils. Los recién nacidos no han vivido lo suficiente como para preparar su sistema inmunológico para la batalla. Incluso los niños pequeños pueden no lograr una respuesta contundente, remarcó.

En el Hospital de Niños de Nueva Orleans, la mitad de los pacientes con covid son menores de 4 años, dijo el doctor Mark Kline, especialista en enfermedades infecciosas y médico jefe.

"Hemos tenido bebés de tan solo 7 semanas, 9 semanas, en terapia intensiva infantil, con ventiladores", dijo Kline. “Tuvimos un bebé de 3 meses que requirió ECMO”, oxigenación por membrana extracorpórea, en la que el paciente está conectado a una máquina similar a la máquina de bypass corazón-pulmón que se usa en la cirugía a corazón abierto.

Incluso los niños previamente sanos a veces mueren de infecciones respiratorias, desde covid hasta influenza o virus respiratorio sincitial.

Pero estudios han encontrado que del 30% al 70% de los niños hospitalizados con covid tenían afecciones subyacentes que aumentaron su riesgo, como síndrome de Down, obesidad, enfermedades pulmonares, diabetes o inmunodeficiencias. Los bebés prematuros también corren un mayor riesgo, al igual que los niños que han recibido tratamiento contra el cáncer.

Una cosa que los niños hospitalizados tienen en común es que casi ninguno está vacunado, dijo la doctora Mary Taylor, presidenta de pediatría del Centro Médico de la Universidad de Mississippi.

"Realmente no hay forma de saber qué niño con covid tendrá un resfriado y estará bien y qué niño estará gravemente enfermo", dijo Taylor. "Es una sensación muy impotente para las familias sentir que no hay nada que puedan hacer por sus hijos".

Aunque los científicos han identificado mutaciones genéticas asociadas con el covid grave, estas variantes son extremadamente raras.

Los científicos han tenido más éxito al esclarecer por qué ciertos adultos sucumben al covid.

Por ejemplo, algunos casos de covid grave en adultos, se han relacionado con anticuerpos equivocados que se dirigen a los interferones, en lugar de al coronavirus. Un estudio de agosto en ScienceImmunology informó que tales "autoanticuerpos" contribuyen al 20% de las muertes por covid.

Sin embargo, los autoanticuerpos son muy raros en niños y adultos jóvenes, y es poco probable que expliquen por qué algunos jóvenes sucumben a la enfermedad, dijo la coautora del estudio, la doctora Isabelle Meyts, inmunóloga pediátrica de la Universidad Católica de Lovaina en Bélgica.

Aunque las hospitalizaciones están disminuyendo en todo el país, recién ahora están surgiendo algunas de las consecuencias más graves de la infección.

Dos meses después de aumento de la variante delta, los hospitales de todo el sur están viendo una segunda ola de niños con una afección poco común pero potencialmente mortal llamada síndrome inflamatorio multisistémico o MIS-C.

A diferencia de los niños que desarrollan neumonía por covid, la principal causa de hospitalizaciones entre los niños, los que tienen MIS-C suelen tener infecciones leves o asintomáticas, pero se enferman mucho aproximadamente un mes después y desarrollan síntomas como náuseas, vómitos, sarpullido, fiebre y diarrea.

Algunos desarrollan coágulos de sangre y una presión arterial peligrosamente baja. Más de 4,661 niños han sido diagnosticados con MIS-C y 41 han muerto, según los Centros para el Control y la Prevención de Enfermedades (CDC).

Aunque los científicos aún no conocen la causa exacta de MIS-C, la investigación de Yonker del hospital de Massachusetts y otros sugieren que las partículas virales pueden filtrarse desde el intestino al torrente sanguíneo, provocando una reacción del sistema en todo el cuerpo.

Es demasiado pronto para saber si los niños que sobreviven al MIS-C sufrirán problemas de salud duraderos, dijo la doctora Leigh Howard, especialista en enfermedades infecciosas pediátricas del Centro Médico de la Universidad de Vanderbilt.

Aunque un estudio de agosto en The Lancet muestra que delta duplica el riesgo de hospitalización en adultos, los científicos no saben si esta afirmación es igual en el caso de los niños, dijo el doctor Anthony Fauci, el principal funcionario de enfermedades infecciosas del país.

"Ciertamente no sabemos en este momento si los niños tienen una enfermedad más grave, pero lo estamos monitoreando", dijo.

Para proteger a los niños, Fauci instó a los padres a vacunarse ellos mismos y a los niños de 12 años en adelante. En cuanto a los niños demasiado pequeños para las vacunas contra covid, "la mejor manera de mantenerlos a salvo es rodearlos de personas vacunadas".

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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Scientists Examine Kids’ Unique Immune Systems as More Fall Victim to Covid

Fri, 09/17/2021 - 5:00am

Eighteen months into the covid-19 pandemic, with the delta variant fueling a massive resurgence of disease, many hospitals are hitting a heartbreaking new low. They’re now losing babies to the coronavirus.

The first reported covid-related death of a newborn occurred in Orange County, Florida, and an infant has died in Mississippi. Merced County in California lost a child under a year old in late August.

“It’s so hard to see kids suffer,” said Dr. Paul Offit, an expert on infectious diseases at Children’s Hospital of Philadelphia, which — like other pediatric hospitals around the country — has been inundated with covid patients.

Until the delta variant laid siege this summer, nearly all children seemed to be spared from the worst ravages of covid, for reasons scientists didn’t totally understand.

Although there’s no evidence the delta variant causes more severe disease, the virus is so infectious that children are being hospitalized in large numbers — mostly in states with low vaccination rates. Nearly 30% of covid infections reported for the week that ended Sept. 9 were in children, according to the American Academy of Pediatrics.

Doctors diagnosed more than 243,000 cases in children in the same week, bringing the total number of covid infections in kids under 18 since the onset of the pandemic to 5.3 million, with at least 534 deaths.

Experts say it’s a question of basic math. “If 10 times as many kids are infected with delta than previous variants, then, of course, we’re going to see 10 times as many kids hospitalized,” said Dr. Dimitri Christakis, director of the Center for Child Health, Behavior and Development at the Seattle Children’s Research Institute.

But the latest surge gives new urgency to a question that has mystified scientists throughout the pandemic: What protects most children from becoming seriously ill? And why does that protection sometimes fail?

“This is an urgent and complex question,” said Dr. Bill Kapogiannis, senior medical officer and infectious-disease expert at the Eunice Kennedy Shriver National Institute of Child Health and Human Development.

“We are doing everything we can to address it, using all the tools we have available,” Kapogiannis said. “Answers can’t come soon enough.”

Investigating Immune Systems

For much of the pandemic, doctors could only guess why children’s immune systems were so much more successful at rebuffing the coronavirus.

Despite the alarming number of hospitalized children in the recent surge, young people are much less likely to become critically ill. Fewer than 1% of children diagnosed with covid are hospitalized and about 0.01% die — rates that haven’t changed in recent months, according to the American Academy of Pediatrics. Most children shrug off the virus with little more than a sniffle.

A growing body of evidence suggests that kids’ innate immune systems usually nip the infection early on, preventing the virus from gaining a foothold and multiplying unchecked, said Dr. Lael Yonker, an assistant professor of pediatrics at Massachusetts General Hospital.

In a series of studies published in the past year, the husband-and-wife team of Drs. Betsy and Kevan Herold found that children have particularly strong mucosal immunity, so called because the key players in this system are not in the blood but in the mucous membranes that line the nose, throat and other parts of the body that frequently encounter germs.

These membranes act like the layered stone walls that protected medieval cities from invaders. They’re made of epithelial cells — these also line many internal organs — which sit side by side with key soldiers in the immune system called dendritic cells and macrophages, said Betsy Herold, chief of the division of pediatric infectious diseases at the Albert Einstein College of Medicine.

Significantly, these cells are covered in proteins — called pattern recognition receptors — that act like sentries, continuously scanning the landscape for anything unusual. When the sentries notice something foreign — like a new virus — they alert cells to begin releasing proteins called interferons, which help coordinate the body’s immune response.

In an August study in Nature Biotechnology, Roland Eils and his colleagues at Germany’s Berlin Institute of Health found that kids’ upper airways are “pre-activated” to fight the novel coronavirus. Their airways are teeming with these sentries, including ones that excel at recognizing the coronavirus.

That allows kids to immediately activate their innate immune system, releasing interferons that help shut down the virus before it can establish a foothold, Eils said.

In comparison, adults have far fewer sentinels on the lookout and take about two days to respond to the virus, Eils said. By that time, the virus may have multiplied exponentially, and the battle becomes much more difficult.

When innate immunity fails to control a virus, the body can fall back on the adaptive immune system, a second line of defense that adapts to each unique threat. The adaptive system creates antibodies, for example, tailored to each virus or bacterium the body encounters.

While antibodies are some of the easiest pieces of the immune response to measure, and therefore often cited as proxies for protection, kids don’t seem to need as many to fight covid, Betsy Herold said. In fact, the Herolds’ research shows that children with covid have fewer neutralizing antibodies than adults. (Both kids and adults usually make enough antibodies to thwart future coronavirus infections after natural infection or vaccination.)

While the adaptive immune system can be effective, it can sometimes cause more harm than good.

Like soldiers who kill their comrades with friendly fire, a hyperactive immune system can cause collateral damage, triggering an inflammatory cascade that tramples not just viruses, but also healthy cells throughout the body.

In some covid patients, uncontrolled inflammation can lead to life-threatening blood clots and acute respiratory distress syndrome, which occurs when fluid builds up in the air sacs of the lung and makes it difficult to breathe, Betsy Herold said. Both are common causes of death in adult covid patients.

Because kids typically clear the coronavirus so quickly, they usually avoid this sort of dangerous inflammation, she said.

Research shows that healthy children have large supplies of a type of peacekeeper cell, called innate lymphoid cells, that help calm an overactive immune system and repair damage to the lungs, said Dr. Jeremy Luban, a professor at the University of Massachusetts Medical School.

Kids are born with lots of these cells, but their numbers decline with age. And both children and adults who are sick with covid tend to have fewer of these repair cells, Luban said.

Men also have fewer repair cells than women, which could help explain why males have a higher risk of dying from covid than females.

Both children and adults can develop “long covid,” the lingering health issues experienced by about 10% of younger adults and up to 22% of those 70 and older. Studies suggest that 4% to 11% of kids have persistent symptoms.

Unanswered Questions

Scientists have fewer clues about what goes wrong in certain children with covid, said Kevan Herold, who teaches immunobiology at the Yale School of Medicine.

Research suggests that children have more robust innate immune systems than adults because they have experienced so many recent respiratory infections, within their first few years, which may prime their immune systems for subsequent attacks.

But not all children shrug off covid so easily, Eils said. Newborns haven’t been alive long enough to prime their immune systems for battle. Even toddlers may fail to mount a strong response, he said.

At Children’s Hospital New Orleans, half of covid patients are under 4, said Dr. Mark Kline, a specialist in infectious diseases and physician-in-chief.

“We’ve had babies as young as 7 weeks, 9 weeks old in the ICU on ventilators,” Kline said. “We had a 3-month-old who required ECMO,” or extracorporeal membrane oxygenation, in which the patient is connected to a machine similar to the heart-lung bypass machine used in open-heart surgery.

Even previously healthy children sometimes die from respiratory infections, from covid to influenza or respiratory syncytial virus.

But studies have found that 30% to 70% of children hospitalized with covid had underlying conditions that increase their risk, such as Down syndrome, obesity, lung disease, diabetes or immune deficiencies. Premature babies are also at higher risk, as are children who’ve undergone cancer treatment.

One thing hospitalized kids have in common is that almost none are vaccinated, said Dr. Mary Taylor, chair of pediatrics at the University of Mississippi Medical Center.

“There’s really no way to know which child with covid will get a cold and be just fine and which child will be critically ill,” Taylor said. “It’s just a very helpless sensation for families to feel like there is nothing they can do for their child.”

Although scientists have identified genetic mutations associated with severe covid, these variants are extremely rare.

Scientists have had more success illuminating why certain adults succumb to covid.

Some cases of severe covid in adults, for example, have been tied to misguided antibodies that target interferons, rather than the coronavirus. An August study in ScienceImmunology reported that such “autoantibodies” contribute to 20% of covid deaths.

Autoantibodies are very rare in children and young adults, however, and unlikely to explain why some youngsters succumb to the disease, said study co-author Dr. Isabelle Meyts, a pediatric immunologist at the Catholic University of Leuven in Belgium.

Although hospitalizations are declining nationwide, some of the most serious consequences of infection are only now emerging.

Two months into the delta surge, hospitals throughout the South are seeing a second wave of children with a rare but life-threatening condition called multisystem inflammatory syndrome, or MIS-C.

Unlike kids who develop covid pneumonia — the major cause of hospitalizations among children — those with MIS-C typically have mild or asymptomatic infections but become very ill about a month later, developing symptoms such as nausea, vomiting, a rash, fever and diarrhea. Some develop blood clots and dangerously low blood pressure. More than 4,661 children have been diagnosed with MIS-C and 41 have died, according to the Centers for Disease Control and Prevention.

Although scientists still don’t know the exact cause of MIS-C, research by Yonker of Massachusetts General and others suggests that viral particles may leak from the gut into the bloodstream, causing a system reaction throughout the body.

It’s too soon to tell whether children who survive MIS-C will suffer lasting health problems, said Dr. Leigh Howard, a specialist in pediatric infectious diseases at Vanderbilt University Medical Center.

Although an August study in The Lancet shows that delta doubles the risk of hospitalization in adults, scientists don’t know whether that’s true for kids, said Dr. Anthony Fauci, the country’s top infectious-disease official.

“We certainly don’t know at this point whether children have more severe disease, but we’re keeping our eye on it,” he said.

To protect children, Fauci urged parents to vaccinate themselves and children age 12 and up. As for children too young for covid shots, “the best way to keep them safe is to surround them by people who are vaccinated.”

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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Covid-Overwhelmed Hospitals Postpone Cancer Care and Other Treatment

Fri, 09/17/2021 - 5:00am

It’s a bad time to get sick in Oregon. That’s the message from some doctors, as hospitals fill up with covid-19 patients and other medical conditions go untreated.

Charlie Callagan looked perfectly healthy sitting outside recently on his deck in the smoky summer air in the small Rogue Valley town of Merlin, in southern Oregon. But Callagan, 72, has a condition called multiple myeloma, a blood cancer of the bone marrow.

“It affects the immune system; it affects the bones,” he said. “I had a PET scan that described my bones as looking ‘kind of Swiss cheese-like.’”

Callagan is a retired National Park Service ranger. Fifty years ago, he served in Vietnam. This spring, doctors identified his cancer as one of those linked to exposure to Agent Orange, the defoliant used during the war.

In recent years, Callagan has consulted maps showing hot spots where Agent Orange was sprayed in Vietnam.

“It turns out the airbase I was in was surrounded,” he said. “They sprayed all over.”

A few weeks ago, Callagan was driving the nearly four-hour trek to Oregon Health & Science University in Portland for a bone marrow transplant, a major procedure that would have required him to stay in the hospital for a week and remain in the Portland area for tests for an additional two weeks. On the way, he got a call from his doctor.

“They’re like, ‘We were told this morning that we have to cancel the surgeries we had planned,’” he said.

Callagan’s surgery was canceled because the hospital was full. That’s the story at many hospitals in Oregon and in other states where they’ve been flooded with covid patients.

OHSU spokesperson Erik Robinson said the hospital, which is the state’s only public academic medical center and serves patients from across the region, has had to postpone numerous surgeries and procedures in the wake of the delta surge of the pandemic. “Surgical postponements initially impacted patients who needed an overnight hospital stay, but more recently has impacted all outpatient surgeries and procedures,” Robinson wrote.

Callagan said his bone marrow transplant has not yet been rescheduled. 

Such delays can have consequences, according to Dr. Mujahid Rizvi, who leads the oncology clinic handling Callagan’s care.

“With cancer treatment, sometimes there’s a window of opportunity where you can go in and potentially cure the patient,” Rizvi said. “If you wait too long, the cancer can spread. And that can affect prognosis and can make a potentially curable disease incurable.”

Such high stakes for delaying treatment at hospitals right now extends beyond cancer care.

“I’ve seen patients get ready to have their open-heart surgery that day. I’ve seen patients have brain tumor with visual changes, or someone with lung cancer, and their procedures are canceled that day and they have to come back another day,” said Dr. Kent Dauterman, a cardiologist and co-director of the regional cardiac center in Medford, Oregon. “You always hope they come back.”

In early September, Dauterman said, the local hospital had 28 patients who were waiting for open-heart surgery, 24 who needed pacemakers, and 22 who were awaiting lung surgeries. During normal times, he said, there is no wait.

“I don’t want to be dramatic — it’s just there’s plenty of other things killing Oregonians before this,” Dauterman said.

Right now, the vast majority of patients in Oregon hospitals with covid are unvaccinated, about five times as many as those who got the vaccine, according to the Oregon Health Authority. Covid infections are starting to decline from the peak of the delta wave. But even in non-pandemic times, there’s not a lot of extra room in Oregon’s health care system.

“If you look at the number of hospital beds per capita, Oregon has 1.7 hospital beds per thousand population. That’s the lowest in the country,” said Becky Hultberg, CEO of the Oregon Association of Hospitals and Health Systems.

A new study focused on curtailing nonemergency procedures looked back at how Veterans Health Administration hospitals did during the first pandemic wave. It found that the VA health system was able to reduce elective treatments by 91%.

It showed that stopping elective procedures was an effective tool to free up beds in intensive care units to care for covid patients. But the study didn’t look at the consequences for those patients who had to wait.

“We clearly, even in hindsight, made the right decision of curtailing elective surgery,” said Dr. Brajesh Lal, a professor of surgery at the University of Maryland School of Medicine and the study’s lead author. “But we as a society have not really emphatically asked the question ‘At what price in the long term?’”

He said they won’t know that without more long-term research.

At his home in southern Oregon, Charlie Callagan said he doesn’t consider his bone-marrow transplant as urgent as what some people are facing right now.

“There’s so many other people who are being affected,” he said. “People are dying waiting for a hospital bed. That just angers me. It’s hard to stay quiet now.”

He said it’s hard to be sympathetic for the covid patients filling up hospitals, when a simple vaccine could have prevented most of those hospitalizations.

This story is from a reporting partnership that includes Jefferson Public Radio, NPR and Kaiser Health News. 

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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Dentists Chip Away at Uninsured Problem by Offering Patients Membership Plans

Fri, 09/17/2021 - 5:00am

Nevada dentist David White has seen diseased and rotted teeth in the mouths of patients who routinely put off checkups and avoided minor procedures such as fillings. While dental phobia is a factor, White said, the overriding reason people avoid treatment is cost.

To help patients lacking dental insurance, White in 2019 started offering a membership plan that looks much like an insurance policy — except it’s good only at his offices in Reno and Elko. Adults pay $29 a month — or $348 a year — and receive two free exams, two cleanings, X-rays and an emergency exam, services valued at $492. They also get a 20% discount on office procedures such as fillings and extractions.

About 250 of White’s patients have signed up, and it’s led many to visit more frequently for routine exams and get necessary treatment, he said. “It’s pushing patients toward better oral health,” White said.

He’s among a quarter of dentists nationwide offering memberships, according to a 2021 survey of 70,000 dentists by the American Dental Association.

These in-office plans are largely targeted to the 65 million Americans who lack dental insurance and have to pay out-of-pocket for all their care. Dentists also like the plans better than handling insurance plans because they don’t have to deal with insurers’ heavily discounted reimbursement rates, waits to get preapprovals to provide services and delays in getting their claims paid.

Lack of dental coverage contributes to the delaying or forgoing of dental care by 1 in 4 adults, according to a KFF analysis of a 2019 national survey.

Kleer, a Wayne, Pennsylvania, company started in 2018, has helped more than 5,000 dentists set up the offerings. “Patients on membership plans act like insured patients and come in as much as insured patients, but they pay less for coverage while dentists get paid more,” said CEO Dave Monahan. “All we are doing is cutting out the middleman,” he said.

Monahan said business has soared during the covid-19 pandemic as more dentists, confronted with higher costs for personal protective equipment and more patients without job-based coverage, saw the need for such plans.

Anthony Wright, executive director of consumer health advocacy group Access California, said he’s skeptical about the value of individual dental insurance but said patients also should be cautious about a dental membership plan because they are generally not overseen by states. “People should be aware that this is a generally unregulated field, so it’s buyer beware,” he said.

Before joining a membership plan, consumers should ask what the dentist charges for procedures so they know not just the discount but their actual out-of-pocket cost. In some cases, the membership plans are a viable option.

“If you are going to an established practice and if the costs are reasonable and within your budget, it may make some sense” to enroll, he said.

Vanessa Bernal, office manager at Winter Garden Smiles in central Florida, said many patients who are self-employed or work for small businesses have joined the practice’s membership plan.

“They don’t have employer coverage, and if they went to buy it on their own they would face a waiting period, whereas our discounts start immediately,” she said.

Winter Garden Smiles has enrolled more than 370 patients in its plan, which costs $245 a year for children and $285 for adults. The office has dropped out of three small insurance networks since starting its own plan.

Many of the plans being offered around the country look much like dental insurance. Patients pay the dental office typically $300 to $400 a year. In return, they receive certain preventive services at no charge and other procedures at a discount.

But the membership plans don’t have the annual deductibles or waiting periods that can make individually purchased dental insurance unattractive. Another deterrent to traditional insurance plans is their maximum benefit limits, usually $1,200 to $1,500 a year. In comparison, patients with memberships can use the discounts for unlimited treatment.

About half of Americans get dental coverage through their workplace. Those policies are generally the best buy for those with the benefit. But Medicare doesn’t offer dental coverage, and most state Medicaid programs don’t cover dental treatment for adults.

But for patients without a job-based plan, purchasing an independent dental policy is expensive and, unlike buying health insurance, it’s unclear whether the benefit outweighs the costs. That’s because dental costs are not as financially catastrophic as hospital bills, which can run into tens of thousands of dollars.

Annual dental insurance premiums typically range from $400 to $700. Most plans cover all the cost of preventive services, like cleanings. For minor procedures, like fillings, the plans generally pay 70% to 80%. For major procedures, such as crowns, the plans often pay about 50% of the cost, which is still more than what the membership plans cover. The insurance plans, however, often have negotiated prices with dentists, so plan members’ responsibility is reduced by that also.

Melissa Burroughs, who leads an oral-health-for-all campaign for the advocacy group Families USA, said the dental membership plans may help some people, but they don’t solve the problems of high dental costs and insurers treating coverage for teeth differently than for the rest of the body. “I don’t think these plans are the answer, and they definitely don’t meet the standard to make care truly affordable for many people,” she said.

Megan Lohman, CEO of Plan Forward, an Indianapolis company that helps set up membership plans, said many insurers haven’t raised reimbursement rates in years, encouraging dentists to offer their own plans. “We do not see dental insurance going away, but patients and dentists just needed an alternative,” she said.

Patients say they appreciate that services under the memberships are less expensive than when paying strictly out-of-pocket, and prepaying for services motivates them to seek preventive services.

“The membership plan keeps me on track, as it’s almost like I have a down payment on my care,” said Christina Campbell, 29, of Hamden, Connecticut. She had dental coverage under her mother’s policy until she was 26 and then started shopping for her own coverage.

When her dentist, Kevin D’Andrea, mentioned his plan, she decided it looked too good to pass up. With the membership, she said, she is back to getting twice-annual checkups and cleanings, and she no longer hesitates when it’s time for X-rays. Campbell, who manages a winery, pays $38 a month.

Holly Wyss, 59, of Greenwood, Indiana, found dental insurance too expensive, so she joined a $300-a-year membership plan through her dentist, David Wolf. The discounts saved her several hundred dollars on two crowns, she said. “For me, it’s a no-brainer,” said Wyss, a nurse practitioner. “It’s been a godsend to me, since everything I pay is out-of-pocket.”

Among the groups lacking dental insurance that have recently attracted attention are people covered by traditional Medicare. Many private Medicare Advantage plans, however, offer some dental benefits. These plans provide coverage only at certain dental offices, have a premium and often cover just a small portion of patients’ costs. The average limit on coverage is $1,300, and more than half of enrollees are in plans with a $1,000 cap on benefits, according to a report from KFF.

President Joe Biden and congressional Democrats have proposed adding a dental benefit to Medicare, along with other health care initiatives, as part of a $3.5 trillion human infrastructure plan those lawmakers are seeking to push through this fall. The bill released by the House Ways and Means Committee this month would still leave beneficiaries paying 20% of costs for preventive services such as checkups and between 50% to 90% of costs for certain procedures. And the law, if passed, could take five years or more to implement.

The need among older Americans is great.

Nearly half of Medicare beneficiaries, or 24 million people, had no dental coverage in 2019, according to KFF. In 2018, almost half of all Medicare beneficiaries had not visited a dentist within the past year (47%), with higher rates among African Americans (68%) and Hispanics (61%).

D’Andrea, the Hamden, Connecticut, dentist, said the membership plan he started in 2020 builds patient loyalty. “Patients know upfront what their out-of-pocket expenses are, and they don’t have to wait and see what their insurance will cover,” he said. “It’s like a game the insurers play, keeping us on hold for an hour to get preapprovals. We pull enough teeth in the office, and it’s the same getting information out of them.”

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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Leader of California’s Muscular Obamacare Exchange to Step Down

Thu, 09/16/2021 - 4:03pm

Peter Lee, who has steered California’s Affordable Care Act marketplace since late 2011 and helped mold it into a model of what the federal health care law could achieve, announced Thursday he will leave his post in March.

As executive director of Covered California, Lee has worked closely with the administrations of Democratic presidents Barack Obama and Joe Biden to expand health coverage to millions of people who don’t get it through an employer or government program, most of them aided by income-based financial assistance from the state or federal government. Over 1.6 million people are now enrolled in plans through the exchange, which has covered 5.3 million Californians since it started selling health plans.

Lee lobbied fiercely to fight efforts by the Trump administration and Republicans to repeal the ACA, known popularly as Obamacare. Those efforts appear dead following the U.S. Supreme Court’s decision in June to uphold the law for the third time.

“The really terrific thing, and you can’t say this of every leader, is that Peter is leaving the organization in a position where it is still poised to have the success it has had recently,” said Dr. Mark Ghaly, who chairs the Covered California board and is secretary of the California Health and Human Services Agency.

The board will launch a national search for Lee’s successor. The long runway to his departure “gives us time to cast a wide net and find a leader who understands the history of this organization but also has the vision of where we can go,” Ghaly said.

Lee said he was leaving largely for personal reasons, including the deaths of his mother, Sharon Girdner, and his uncle, Dr. Philip R. Lee. The latter was part of the original Medicare brain trust under President Lyndon Johnson, and the younger Lee described him as a health policy mentor. Lee’s father and grandfather were also deeply involved in health care policy.

The past two years have prodded him to reflect, he said. “Covid reminds you that life’s too short. It’s a good time to say, ‘What else do I want to do?’”

But, at 62, he has no intention of retiring. In his next job, Lee said, he wants to tackle what he believes are flaws in employer-based health insurance that leave many workers, especially low-wage earners, at financial risk if they get sick.

He said he has no idea whether he’ll land in the private sector, a nonprofit or government. First, he plans to take time off to travel and think about his next move.

Covered California’s enrollment is at its highest level since the exchange opened for business — credited partly to longer enrollment periods due to covid and the expansion of federal premium assistance, at least through 2022, under the American Rescue Plan Act.

The expanded federal subsidies were based on California’s first-in-the-nation state-funded financial aid, which — with Lee’s ardent support and implementation — extended subsidized coverage well into the middle class.

The percentage of Californians who don’t have insurance has dropped sharply, from 17% before the ACA began expanding coverage in 2014 to 7% now — mostly due to the expansion of Medicaid rather than the Covered California marketplace.

Those who have worked with Lee credit him for innovations that transcend the provisions of Obamacare and have either set California apart or served as templates for other states.

Covered California, unlike many state exchanges, has standardized health plan designs, so that plans within each coverage level offer the same services with the same deductibles and other out-of-pocket costs.

“Instead of insurers submitting and selling dozens and dozens of plans with differences that just cause consumer confusion, he established standardized benefit packages so you could make apples-to-apples comparisons,” said Anthony Wright, executive director of Health Access California, a consumer advocacy group. Consumers need only compare provider networks and price, Wright said, “but you don’t have to worry that, ‘Oh, in this plan the deductible is $50 less but the copays are $30 more.’ That stuff is crazy-making.”

Paul Markovich, CEO of Blue Shield of California, Covered California’s second-largest insurer, said the health plans didn’t want to standardize benefits at first, but “Peter stuck to his guns.”

As a result, Markovich said, “there was no way to game the system. The only way to compete was to work on your costs and your quality and the access that the members had.”

Another Covered California initiative that was unpopular at first with health plans “but very effective,” Markovich said, is its ambitious advertising and marketing strategy — across racial, ethnic and linguistic communities — which is financed by a surcharge on plans.

Because many people don’t know they are eligible for subsidies, Lee believed no amount of outreach was too much, Markovich said. “And again, he was right.”

Lee has frequently expressed pride in his ability to negotiate relatively low premium increases, noting that over the past three years rate hikes for exchange-based health plans have averaged only about 1%.

Some analysts believe premiums could have been even lower, and that Lee hasn’t pushed the health plans hard enough.

“I think that Covered California has been too eager to see health plans as partners,” said Michael Johnson, a former Blue Shield of California executive turned industry critic.

Lee said he and his team strive to ensure that insurers don’t make excessive profits in the exchange. “Every year we sit down with health plans and look at their books to ask, ‘What profit are you making this year? And what profit are you making next year?’” he said.

Lee has seen health care from the business, consumer and regulatory sides. He held two health care-related jobs in the Obama administration and previously served as CEO of the Pacific Business Group on Health (since renamed the Purchaser Business Group on Health), which represents large employers, and as executive director of the Center for Health Care Rights, a consumer advocacy group.

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

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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KHN’s ‘What the Health?’: Much Ado About Drug Prices

Thu, 09/16/2021 - 1:36pm

Can’t see the audio player? Click here to listen on SoundCloud. You can also listen on SpotifyApple PodcastsStitcherPocket Casts or wherever you listen to podcasts.

Congressional Democrats are finding it harder to actually write legislation to lower drug prices than it is to make promises about it. But the drug price provisions of the $3.5 trillion social-spending bill are critical — not only to keep that promise to voters but to produce savings that will pay for many of the other promised improvements, like new dental and other benefits for Medicare patients.

Meanwhile, the abortion debate has been jolted by the Supreme Court’s decision to allow a highly restrictive law to take effect in Texas. And the Biden administration unveils a “Covid Control 2.0” strategy that includes more sticks and fewer carrots.

This week’s panelists are Julie Rovner of KHN, Alice Miranda Ollstein of Politico, Rachel Cohrs of Stat and Shefali Luthra of The 19th.

Among the takeaways from this week’s episode:

  • The budget reconciliation process has claimed considerable congressional attention this week. Different committees have been writing and voting on their parts of this detailed and complex budget and savings measure. There have been marathon markup sessions and a degree of drama.
  • What could become a major sticking point is the reconciliation bill’s prescription drug provisions, which by reining in drug costs provide a lion’s share of the savings set to pay for Medicare, Medicaid and ACA expansions. The drug proposal would tie the prices Medicare pays for drugs to those of other nations — something the drug industry strongly opposes.
  • Democratic leaders continue to project confidence that drug price restraints will make it into the final bill. Bringing down drug costs was a big campaign issue for Democrats. Also, the funding it would provide pays the tab for a number of progressive priorities. However, the margins in the House are very slim and committee action has already spotlighted caucus members who voted against it.
  • It also appears that leaders are leaning toward scaling back some investments — doing a little for everyone rather than going big on certain initiatives. For instance, Medicare’s expansion of dental and vision coverage is not as robust as many progressives wanted. Home health investments have also been scaled back and a new cancer research institute will receive significantly less funding. However, the reconciliation measure currently does appear to make funding for Medicaid expansion and ACA subsidies permanent.
  • In the wake of the recent Supreme Court decision, abortion is effectively unavailable in Texas. Though the new Texas law the court allowed to take effect does not make getting abortion a crime, it allows private citizens to bring lawsuits against a person who may have aided or abetted a woman in getting an abortion. It’s already had an intense chilling effect. Health professionals who previously performed abortions are stopping, even though the law technically allows abortions during the first six weeks of pregnancy.
  • The Supreme Court’s take on this measure will likely open the door to other such state laws. The reach could also go beyond abortion to other issues, such as voting rights. Politically, the Supreme Court’s decision to allow the Texas law to go forward plays into the angst and debate surrounding the court itself. Chief Justice Roberts, for instance, who worries about the court’s credibility, voted with the minority to block the law.
  • Meanwhile, President Joe Biden, who has been criticized for not talking about the issue, has become more vocal and forward about his position. And Congress is planning a vote to write the protections of Roe v. Wade into federal law. However, such a bill likely would not gain Senate approval, since it would need 60 votes to overcome a filibuster by abortion opponents.
  • Medicare trustees finally released their delayed annual report, which found the program’s Hospital Insurance Trust Fund will likely remain solvent until 2026 — the same estimate floated last year. Meanwhile, the Census Bureau released its annual statistics on health insurance, which also stuck mostly to the status quo — although many people who lost private health coverage in 2020 apparently picked up public coverage instead.

Also this week, Rovner interviews KHN senior correspondent Phil Galewitz, who reported the latest KHN-NPR “Bill of the Month” feature about two similar jaw surgeries with two very different price tags. If you have an outrageous medical bill you’d like to send us, you can do that here.

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

Julie Rovner: The New York Times’ “A Medical Career, at a Cost: Infertility,” by Jacqueline Mroz

Alice Miranda Ollstein: The New York Times’ “Phony Diagnoses Hide High Rates of Drugging at Nursing Homes,” by Katie Thomas, Robert Gebeloff and Jessica Silver-Greenberg

Rachel Cohrs: KHN’s “Over Half of States Have Rolled Back Public Health Powers in Pandemic,” by Lauren Weber and Anna Maria Barry-Jester

Shefali Luthra: The 19th’s “’No One Wants to Get Sued’: Some Abortion Providers Have Stopped Working in Texas,” by Jennifer Gerson

To hear all our podcasts, click here.

And subscribe to KHN’s What the Health? on Spotify, Apple Podcasts, Stitcher, Pocket Casts or wherever you listen to podcasts.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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Sin papeles, sin atención: migrantes con discapacidades buscan ayuda a través de demandas y activismo

Thu, 09/16/2021 - 7:52am

Hace 13 años, la desesperación llevó a José Luis Hernández a subirse a un tren que iba a alta velocidad en el norte de México con la esperanza de llegar a los Estados Unidos. Pero no lo logró. Resbaló y cayó bajo las ruedas de acero: perdió el brazo y la pierna derechas, y cuatro dedos de la mano izquierda.

Había dejado su pueblo natal en Honduras rumbo a los Estados Unidos “para ayudar a mi familia, porque no había trabajos, no había oportunidades”, dijo. En cambio, terminó teniendo que someterse a una serie de cirugías en México antes de regresar a casa “a las mismas condiciones miserables en mi país, pero peor”.

Pasarían años antes de que finalmente llegara a los Estados Unidos. Ahora, a los 35 años y viviendo en Los Ángeles, Hernández ha comenzado a organizar a otros inmigrantes con discapacidades para luchar por el derecho a la atención médica y a otros servicios.

No hay estadísticas disponibles sobre el número de inmigrantes indocumentados con dispacadidades en los Estados Unidos. Pero ya sea que estén detenidos, trabajando sin papeles o esperando audiencias de asilo en el lado mexicano de la frontera, no tienen “ningún derecho a los servicios”, dijo Mónica Espinoza, coordinadora del grupo de Hernández, Immigrants with Disabilities (Inmigrantes con Discapacidades).

Las personas a las que se les otorga asilo político o de otro tipo pueden comprar un seguro médico privado a través de la Ley de Cuidado de Salud a Bajo Precio (ACA) o, si califican, obtener asistencia pública. Además, Medi-Cal, el programa de Medicaid en California, brinda servicios a personas menores de 26 años, independientemente de su estatus migratorio. Esos beneficios se ampliarán la próxima primavera para incluir a personas indocumentadas de 50 años en adelante que cumplan con los requisitos de ingresos.

“Esa es una pequeña victoria para nosotros”, dijo Blanca Angulo, inmigrante indocumentada de 60 años originaria de México que ahora vive en Riverside. Fue bailarina profesional y comediante de en la Ciudad de México antes de emigrar a los Estados Unidos en 1993. A los 46 años, a Angulo le diagnosticaron retinosis pigmentaria, un trastorno genético poco común que gradualmente la ha ido dejando ciega.

“Estuve deprimida por dos años después de mi diagnóstico”, dijo, casi ciega y desempleada, sin papeles y luchando para pagar las visitas médicas y los costosos medicamentos para los ojos.

La situación es particularmente sombría para los inmigrantes indocumentados con discapacidades detenidos en centros de detención, dijo Pilar González Morales, abogada del Civil Rights Education and Enforcement Center, en Los Ángeles.

“Siempre sufren más por la falta de atención y la falta de alojamiento”, dijo. Además, “y covid ha dificultado más la obtención del cuidado médico que necesitan”.

González Morales es una de los abogadas que trabaja en una demanda colectiva a nivel nacional presentada por personas con discapacidades que han sido retenidas en centros de detención de inmigrantes en los Estados Unidos. La demanda acusa al Servicio de Inmigración y Control de Aduanas de EE.UU. (ICE) y al Departamento de Seguridad Nacional de discriminar a los detenidos al no brindarles atención de salud física y mental adecuada.

Los 15 demandantes nombrados en la demanda, cuyo juicio comenzará abril, tienen afecciones que van desde trastorno bipolar hasta parálisis, así como sordera o ceguera. No buscan resarcimiento económico, pero exigen que el gobierno de los Estados Unidos mejore la atención de las personas que están bajo su custodia, por ejemplo, proporcionando sillas de ruedas o intérpretes de lenguaje de señas, y evitando la segregación prolongada de personas con discapacidades.

La mayoría de los demandantes han sido puestos en libertad o deportados. José Baca Hernández, que ahora vive en Santa Ana, es uno de ellos.

Lo trajeron de niño al condado de Orange, y Baca no recuerda Cuernavaca, la ciudad mexicana en donde nació. Pero la falta de un estatus legal en los Estados Unidos ha eclipsado sus esfuerzos por obtener la atención que necesita desde que quedó ciego al recibir un disparo hace seis años. Baca se negó a describir las circunstancias de su lesión, pero solicitó una visa especial para las víctimas de delitos.

ICE arrestó a Baca poco después de su lesión y estuvo cinco años detenido. Contó que un oculista lo visitó una vez durante ese tiempo; confió en otros detenidos para que le leyeran información sobre su atención médica y su caso de inmigración. La mayor parte del tiempo estaba solo en una celda con poco que hacer.

“Tenía un libro en audio”, dijo Baca. “Eso fue todo”.

Según la demanda, el tratamiento y la atención a las discapacidades son prácticamente nulas en los centros de detención del gobierno, dijo Rosa Lee Bichell, miembro de Disability Rights Advocates, uno de los grupos que presentó el caso.

Sus clientes dicen que “a menos que te estés retorciendo o te desmayes en el suelo, es casi imposible obtener ningún tipo de atención médica relacionada con discapacidades”, agregó.

“Hay una especie de vacío en el panorama de la defensa de la inmigración que no se centra directamente en abordar las necesidades de las personas con discapacidades”, dijo Munmeeth Soni, director de litigios y defensa del Immigrant Defenders Law Center en Los Ángeles. “Es una población que creo que realmente se ha pasado por alto”.

ICE y Seguridad Nacional no respondieron a las solicitudes de comentarios sobre la demanda.

Covid-19 representa una amenaza particular para las personas con discapacidades detenidas por ICE. Por ejemplo, el 25 de agosto, 1,089 de las más de 25,000 personas en las instalaciones de ICE estaban en aislamiento o en observación por el virus.

En un fallo interino, el juez federal que escuchó la demanda colectiva de Baca este verano ordenó a ICE que ofreciera vacunación a todos los inmigrantes detenidos que tengan afecciones médicas crónicas o discapacidades, o que tengan 55 años o más. La administración Biden apeló la orden el 23 de agosto.

Hernández, quien perdió sus extremidades en el accidente de tren, fue uno de los cientos de miles de inmigrantes centroamericanos que anualmente viajan hacia el norte a través de México en trenes a los que se denominan colectivamente como “La Bestia”, según el Migration Policy Institute. Las lesiones son habituales en “La Bestia”. Y se han reportado más de 500 muertes en México desde 2014 entre personas que buscan entrar a los Estados Unidos.

Hernández, quien finalmente llegó en 2015, recibió asilo humanitario después de pasar dos meses en un centro de detención en Texas, pero rápidamente se dio cuenta de que había poco apoyo para las personas con sus desventajas.

En 2019, con la ayuda de una iglesia local, formó el grupo de inmigrantes con discapacidades, que trata de realizar reuniones regulares para sus más de 40 miembros, aunque la pandemia ha dificultado estos encuentros. Hernández es la única persona del grupo con papeles y beneficios de salud, dijo.

Angulo ha encontrado consuelo al conectarse con otros en el grupo. “Nos damos ánimo unos a otros”, dijo. “Nos sentimos menos solos”.

La mujer es voluntaria como guía para las personas recientemente diagnosticadas con ceguera en el Braille Institute, enseñándoles cómo cocinar, ducharse y arreglarse, con la meta de que logran ser autosuficientes. A Angulo le gustaría tener un trabajo, pero dijo que no tiene oportunidades.

“Quiero trabajar. Soy capaz”, dijo. “Pero la gente no quiere arriesgarse conmigo. Me ven como un riesgo”.

También desconfía de cualquier organización que ofrezca asistencia médica o financiera a inmigrantes indocumentados. “Piden toda mi información y, al final, dicen que no califico”, dijo. “Ser ciega y sin papeles me hace sentir especialmente vulnerable”.

Esta historia fue producida por KHN, que publica California Healthline, un programa editorialmente independiente de la California Health Care Foundation.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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No Papers, No Care: Disabled Migrants Seek Help Through Lawsuit, Activism

Thu, 09/16/2021 - 5:00am

Desperation led José Luis Hernández to ride atop a speeding train through northern Mexico with hopes of reaching the United States 13 years ago. But he didn’t make it. Slipping off a step above a train coupling, he slid under the steel wheels. In the aftermath, he lost his right arm and leg, and all but one finger on his left hand.

He had left his home village in Honduras for the U.S. “to help my family, because there were no jobs, no opportunities,” he said. Instead, he ended up undergoing a series of surgeries in Mexico before heading home “to the same miserable conditions in my country, but worse off.”

It would be years before he finally made it to the United States. Now, as a 35-year-old living in Los Angeles, Hernández has begun organizing fellow disabled immigrants to fight for the right to health care and other services.

No statistics are available on the number of undocumented disabled immigrants in the United States. But whether in detention, working without papers in the U.S. or awaiting asylum hearings on the Mexican side of the border, undocumented immigrants with disabling conditions are “left without any right to services,” said Monica Espinoza, the coordinator of Hernández’s group, Immigrants With Disabilities.

People granted political or other types of asylum can buy private health insurance through the Affordable Care Act or get public assistance if they qualify. In addition, Medi-Cal, California’s Medicaid program, provides services to people under 26, regardless of immigration status. Those benefits will expand next spring to include income-eligible undocumented people age 50 and up.

“That’s a small victory for us,” said Blanca Angulo, a 60-year-old undocumented immigrant from Mexico now living in Riverside, California. She was a professional dancer and sketch comedian in Mexico City before emigrating to the United States in 1993. At age 46, Angulo was diagnosed with retinitis pigmentosa, a rare genetic disorder that gradually left her blind.

“I was depressed for two years after my diagnosis,” she said — nearly sightless and unemployed, without documents, and struggling to pay for medical visits and expensive eye medication.

The situation is particularly grim for undocumented immigrants with disabilities held in detention centers, said Pilar Gonzalez Morales, a lawyer for the Civil Rights Education and Enforcement Center in Los Angeles.

“They always suffer more because of the lack of care and the lack of accommodations,” she said. Furthermore, “covid has made it harder to get the medical attention that they need.”

Gonzalez Morales is one of the attorneys working on a nationwide class action lawsuit filed by people with disabilities who have been held in U.S. immigration detention facilities. The complaint accuses U.S. Immigration and Customs Enforcement and the Department of Homeland Security of discriminating against the detainees by failing to provide them with adequate mental and physical health care. The 15 plaintiffs named in the lawsuit, which is set for trial in April, have conditions ranging from bipolar disorder to paralysis, as well as deafness or blindness. They are not seeking monetary damages but demand the U.S. government improve care for those in its custody, such as by providing wheelchairs or American Sign Language interpreters, and refraining from prolonged segregation of people with disabilities.

Most of the plaintiffs have been released or deported. José Baca Hernández, now living in Santa Ana, California, is one of them.

Brought to Orange County as a toddler, Baca has no memory of Cuernavaca, the Mexican city where he was born. But his lack of legal status in the U.S. has overshadowed his efforts to get the care he needs since being blinded by a gunshot six years ago. Baca declined to describe the circumstances of his injury but has filed for a special visa provided to crime victims.

ICE detained Baca shortly after his injury, and he spent five years in detention. An eye doctor saw Baca once during that time, he says; he relied on other detainees to read him information on his medical care and immigration case. Mostly, he was alone in a cell with little to do.

“I had a book on tape,” said Baca. “That was pretty much it.”

According to the lawsuit, treatment and care for disabilities are practically nil in government detention centers, said Rosa Lee Bichell, a fellow with Disability Rights Advocates, one of the groups that filed the case.

Her clients say that “unless you are writhing or fainted on the floor, it’s nearly impossible to get any kind of medical care related to disabilities,” she said.

“There is kind of a void in the immigration advocacy landscape that doesn’t directly focus on addressing the needs of people with disabilities,” said Munmeeth Soni, litigation and advocacy director at the Immigrant Defenders Law Center in Los Angeles. “It’s a population that I think has really gone overlooked.”

ICE and Homeland Security did not respond to requests for comment on the lawsuit.

Covid-19 poses a particular threat to people with disabilities who are detained by ICE. On Aug. 25, for example, 1,089 of the 25,000-plus people in ICE facilities were under isolation or observation for the virus.

In an interim ruling, the federal judge hearing Baca’s class action lawsuit this summer ordered ICE to offer vaccination to all detained immigrants who have chronic medical conditions or disabilities or are 55 or older. The Biden administration appealed the order on Aug. 23.

Hernández, who lost his limbs in the train accident, was among the hundreds of thousands of Central American immigrants who annually ride north through Mexico atop the trains, known collectively as “La Bestia,” or “the Beast,” according to the Migration Policy Institute. Injuries are common on La Bestia. And more than 500 deaths have been reported in Mexico since 2014 among people seeking to enter the U.S.

Hernández, who finally made it to the U.S. in 2015, was granted humanitarian asylum after spending two months in a detention center in Texas but quickly realized there was little support for people with his disadvantages.

In 2019, with the help of a local church, he formed the Immigrants With Disabilities group, which tries to hold regular gatherings for its 40-plus members, though the pandemic has made meetups difficult. Hernández is the only person in the group with legal papers and health benefits, he said.

Angulo has found solace in connecting with others in the group. “We encourage each other,” she said. “We feel less alone.”

She volunteers as a guide for people recently diagnosed with blindness at the Braille Institute, teaching them how to cook, shower and groom themselves in pursuit of self-sufficiency. Angulo would like to have a job but said she lacks opportunities.

“I want to work. I’m capable,” she said. “But people don’t want to take a chance on me. They see me as a risk.”

She’s also wary of any organization that offers medical or financial assistance to undocumented immigrants. “They ask for all my information and, in the end, they say I don’t qualify,” she said. “Being blind and without papers makes me feel especially vulnerable.”

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

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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How Fauci and the NIH Got Ahead of the FDA and CDC in Backing Boosters

Thu, 09/16/2021 - 5:00am

[UPDATED at 12:30 p.m. ET]

In January — long before the first jabs of covid-19 vaccine were even available to most Americans — scientists working under Dr. Anthony Fauci at the National Institute of Allergy and Infectious Diseases were already thinking about potential booster shots.

A month later, they organized an international group of epidemiologists, virologists and biostatisticians to track and sequence covid variants. They called the elite group SAVE, or SARS-Cov-2 Variant Testing Pipeline. And by the end of March, the scientists at NIAID were experimenting with monkeys and reviewing early data from humans showing that booster shots provided a rapid increase in protective antibodies — even against dangerous variants.

Fauci, whose team has closely tracked research from Israel, the United Kingdom and elsewhere, said in an exclusive interview with KHN on Wednesday that “there’s very little doubt that the boosters will be beneficial.” But, he emphasized, the official process, which includes reviews by scientists at the Food and Drug Administration and the Centers for Disease Control and Prevention, needs to take place first.

“If they say, ‘We don’t think there’s enough data to do a booster,’ then so be it,” Fauci said. “I think that would be a mistake, to be honest with you.”

The support for an extra dose of covid vaccine clearly emerged, at least in part, from an NIH research dynamo, built by Fauci, that for months has been getting intricate real-time data about covid variants and how they respond to vaccine-produced immunity. The FDA and CDC were seeing much of the same data, but as regulatory agencies, they were more cautious. The FDA, in particular, won’t rule on a product until the company making it submits extensive data. And its officials are gimlet-eyed reviewers of such studies.

On boosters, Americans have heard conflicting messages from various parts of the U.S. government. Yet, Fauci said, “there is less disagreement and conflicts than seem to get out into the tweetosphere.” He ticked off a number of prominent scientists in the field — including Surgeon General Vivek Murthy, acting FDA Commissioner Janet Woodcock and covid vaccine inventor Barney Graham — who were on board with his position. All but Graham are members of the White House covid task force.

Another task force member, CDC Director Rochelle Walensky, said her agency was tracking vaccine effectiveness and “we’re starting to see some waning in terms of infections that foreshadows what we may be seeing soon in regard to hospitalizations and severe disease.” As to when so-called boosters should start, she told PBS NewsHour on Tuesday, “I’m not going to get ahead of the FDA’s process.”

Differences in the scientific community are likely to be voiced Friday when the FDA’s vaccine advisory board meets to review Pfizer-BioNTech’s request for approval of a third shot. Indeed, even the FDA’s official briefing paper before the meeting expressed skepticism. “Overall,” agency officials noted, “data indicate that currently US-licensed or authorized COVID-19 vaccines still afford protection against severe COVID-19 disease and death.” The agency also stated that it’s unclear whether an additional shot might increase the risk of myocarditis, which has been reported, particularly in young men, following the second Pfizer and Moderna shots.

Part of the disagreement arose because President Joe Biden had announced that Americans could get a booster as soon as Sept. 20, a date Fauci and colleagues had suggested to him as practical and optimal in one of their frequent meetings just days before — though he cautioned that boosters would need CDC and FDA approval.

Now it appears that that decision and the timing rest with the FDA, which is the normal procedure for new uses of vaccines or drugs. And Fauci said he respects that process — but he thinks it should come as quickly as possible. “If you’re doing it because you want to prevent people from getting sick, then the sooner you do it, the better,” Fauci said.

Researchers at the NIH typically focus on early-stage drug development, asking how a virus infects and testing ways to treat the infection. The job of reviewing and approving a drug or vaccine for public use is “just not how the NIH was set up. NIH does relatively little research on actual products,” said Diana Zuckerman, a former senior adviser to Hillary Clinton and president of the nonprofit National Center for Health Research in Washington, D.C.

“It’s no secret that FDA doesn’t have the disease experts in the way that the NIH does,” Zuckerman said. “And it’s no secret that the NIH doesn’t have the experts in analyzing industry data.”

‘Data in Spades’

Yet no other infectious disease expert in any branch of the U.S. government has Fauci’s influence. And while other scientific leaders support boosters, many scientists believe Fauci and his colleagues at the NIAID — some of the world’s leaders in immunology and vaccinology, men and women in daily contact with their foreign peers and their research findings — are leading the charge.

Fauci was hard-pressed to give exact dates for when his thinking turned on the need for boosters. The past 18 months are a blur, he said. But “there’s very little doubt that the boosters will be beneficial. The Israelis already have that data in spades. They boost, they get an increase by tenfold in the protection against infection and severe disease.”

In July, Israel, which started vaccinating its population early and used only the Pfizer-BioNTech vaccine, began reporting severe breakthrough cases in previously vaccinated elderly people. Israel’s Ministry of Health announced boosters July 29. Fauci noted that Israel and — to a lesser extent — the U.K. were about a month and a half ahead of the U.S. at every stage of dealing with covid.

And once Israel had boosted its population, the Israeli scientists showed their NIH counterparts, hospitalizations of previously vaccinated people, which had been rising, dropped dramatically. Emerging evidence suggests boosters make people far less likely to transmit the virus to others, an important added benefit.

To be sure, members of the White House covid response team — including Fauci and former FDA Commissioner David Kessler — had begun preparing a timeline for boosters months earlier. Kessler, speaking to Congress in May, said that it was unclear then whether the boosters would be needed but that the U.S. had the money to purchase them and ensure they were free.

Fauci explained that “practically speaking, the earliest we could do it would be the third week in September. Hence the date of the week of September the 20th was chosen.” The hope was that would give regulators enough time. The FDA’s advisory board meeting Friday is set to be followed next week by a gathering of the CDC’s immunization advisory committee, which offers recommendations for vaccine use that can lead to legal mandates.

Tuesday, Dr. Sharon Alroy-Preis, Israel’s head of public health services, told a Hebrew-language webinar that her country’s booster launch came at a critical time. She provided supporting data that Israeli scientists are bringing to the FDA meeting Friday.

Some U.S. scientists have discussed limiting the boosters mostly to those over 60, Alroy-Preis noted, but “if you don’t keep it under control, it’s like a pot on the flame. If you don’t start lowering the flames of the pandemic, you can’t control it.”

Real-Time Science

Scientists tracking the coronavirus are swimming in data. Hundreds of covid studies are published or released onto pre-publication servers every day. Scientists also share their findings on group email lists and in Zoom meetings every week — and on Twitter and in news interviews.

Kessler, chief science officer of the White House covid response team, said the case for boosters is “rooted in NIH science” but includes data from Israel, the Mayo Clinic, the pharmaceutical companies and elsewhere.

As Fauci put it: “Every 15 minutes, a pre-print server comes out with something I don’t know.”

The SAVE group, active since February, was organized by NIH officials who in normal times track influenza epidemics. The 60 to 70 scientists are mostly from U.S. agencies such as the NIH, CDC, FDA and Biomedical Advanced Research and Development Authority, but also from other countries, including Israel and the Netherlands.

“This is very much the basic scientists who are in the weeds trying to figure things out,” said Dr. Daniel Douek, chief of the human immunology section within NIAID. Douek said the larger SAVE group meets every Friday but several subgroups meet several times a week, focusing on different aspects of the virus, such as early detection of viral variants and testing suspicious variants for their ability to evade vaccine-induced immunity and sicken vaccinated mice and monkeys.

The sharing of data and information is free-flowing, Douek said. SAVE is “an amazing thing.”

Dr. Robert Seder, an NIH senior investigator, was in a group testing the booster theory long before America’s “Summer of Delta.” The researchers injected rhesus macaque monkeys with the Moderna vaccine for the “express purpose of looking at the immune responses over a long period of time.”

“Are they durable? And would you need to boost?” Seder said. 

Matthew Frieman, a participant and associate professor of microbiology at the University of Maryland School of Medicine, said the data makes it clear that the time for boosters is approaching. Biden’s booster announcement “may have gotten ahead of the game, but the trajectory is pointing toward the need for boosters,” Frieman said. “The level of antibody you need to protect against delta is higher because it replicates faster.”

While SAVE is an elite group, it’s not the only forum for discussing late-breaking data, said Natalie Dean, a biostatistician at the Rollins School of Public Health at Emory University. “We all saw the same data out of Israel,” she said. Dean, like many other scientists, found that data unconvincing.

Monday, an international group of scientists led by Dr. Philip Krause, deputy chief of the FDA’s vaccine regulation office, and including his boss, Dr. Marion Gruber, published an essay in The Lancet that questioned the need for widespread booster shots at this time.

Krause and Gruber had announced their retirements from the FDA on Aug. 30 — at least partly in response to the booster announcement, according to four scientists who know them. Gruber, who will remain at the agency until later this fall, is listed as a participant in Friday’s meeting.

The Lancet paper argues that vaccine-based protection against severe covid is still strong, while evidence is lacking that booster shots will be safe and effective. University of Florida biostatistician Ira Longini, a co-author on the Lancet paper, said it would be “immoral” to begin widespread boosters before the rest of the world was better vaccinated. As the disease continues its global spread, he noted, it is likely to develop deadlier and more vaccine-evasive mutants.

Longini was also skeptical of an August study, which Israeli scientists are to present to the FDA on Friday, that NIH officials had touted as strong evidence in support of boosters. On an Aug. 24 call with Israeli officials, Fauci urged them to publish that data, and a version appeared in the New England Journal of Medicine on Wednesday.

That study found that people receiving a third dose of the Pfizer-BioNTech vaccine were 11 times more likely to be protected from covid infection than those who had gotten only two doses. But the study observed people for less than two weeks after their booster vaccinations kicked in. Biostatisticians felt it had irregularities that raised questions about its worth.

“I don’t want to say the study isn’t correct, but it hasn’t been reviewed and there are possible biases,” said Longini, who helped design the 2015 trial that resulted in a successful Ebola vaccine and now works on global covid vaccine trials.

Fauci emphasized that no single study or piece of data led Biden or the members of the White House covid response team to conclude that boosting was necessary. The compilation of evidence of waning immunity combined with reams of research was a factor. Now the crucial decisions are in the hands of the regulators, awaiting the FDA and CDC’s judgment on how the nation should proceed.

“It isn’t as if,” Fauci said, “one day we’re sitting in the Oval Office saying, ‘You know, Mr. President, I think we need to boost.’ And he says, ‘Tony, go ahead and do it.’ You can’t do it that way. You’ve got to go through the process.”

Journalist Nathan Guttman contributed to this report.

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

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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When Covid Deaths Are Dismissed or Stigmatized, Grief Is Mixed With Shame and Anger

Thu, 09/16/2021 - 5:00am

[Editor’s note: This story contains language references that some readers may find offensive.]

Months after Kyle Dixon died, his old house in Lanse, Pennsylvania, is full of reminders of a life cut short.

His tent and hiking boots sit on the porch where he last put them. The grass he used to mow has grown tall in his absence. And on the kitchen counter, there are still bottles of the over-the-counter cough medicine he took to try to ease his symptoms at home as covid-19 began to destroy his lungs.

Dixon was a guard at a nearby state prison in rural, conservative Clearfield County, Pennsylvania. He died of the virus in January at age 27. His older sister Stephanie Rimel was overwhelmed with emotion as she walked through Dixon’s home and talked about him.

“I’ll never get to be at his wedding,” Rimel said. “I’ll never see him old.”

Her expressions of grief, however, quickly turned to anger. Rimel recounted the misinformation that proliferated last year: Masks don’t work. The virus is a Democratic hoax to win the election. Only old people or people who are already sick are at risk.

Rimel said her brother believed some of that. He heard it from other prison guards, from family and friends on Facebook, she said, and from the former president, whom he voted for twice.

Falsehoods and conspiracies have fostered a dismissive attitude about the coronavirus among many people in rural Pennsylvania, where she and her siblings grew up, Rimel said. And, because of the misinformation, her brother didn’t always wear a mask or practice physical distancing.

When family members expressed dismissive beliefs about covid, Rimel’s grief became even more painful and isolating. Rimel recalled a particularly tough time right after her brother had to be hospitalized. Even then, family members were repeating conspiracy theories on social media and bragging about not wearing masks, Rimel said.

Some of the people who attended Dixon’s funeral are still sharing covid misinformation online, said another sister, Jennifer Dixon.

“I wish that they could have been there his last days and watched him suffer,” she said. “Watch his heart still be able to beat. His kidneys still producing urine because [they were] so strong. His liver still working. Everything. It was his lungs that were gone. His lungs. And that was only due to covid.”

Both sisters wanted their brother’s death notice to be unambiguous about what had killed him. It reads, “Kyle had so much more of life to live and COVID-19 stopped his bright future.”

While these sisters have chosen to be outspoken about what happened, other families have opted to keep quiet about deaths from covid, according to Mike Kuhn, a funeral director in Reading, Pennsylvania.

Kuhn’s business did not handle Kyle Dixon’s funeral, but his chain of three funeral homes has helped bury hundreds of people who died from the coronavirus. He said about half of those families asked that covid not be mentioned in obituaries or death notices.

“You know, I’ve had people say, ‘My mother or my father was going to die, probably in the next year or two anyway, and they were in a nursing home, and then they got covid, and you know, I don’t really want to give a lot of credence to covid,'” Kuhn said.

Some families wanted to have their loved one’s official death certificate changed so that covid was not listed as the cause of death, Kuhn added. Death certificates are official state documents, so Kuhn could not make that change even if he wanted to. But the request shows how badly some people want to minimize the role of the coronavirus in a loved one’s death.

Refusing to face the truth about what killed a family or community member can make the grieving process much harder, said Ken Doka, who works as an expert in end-of-life care for the Hospice Foundation of America and has written books about aging, dying, grief and end-of-life care.

When a person dies from something controversial, Doka said, that’s called a “disenfranchising death.” The term refers to a death that people don’t feel comfortable talking about openly because of social norms.

So, for instance, if I say my brother died of lung cancer, what’s the first question you’re going to ask — was he a smoker? And somehow, if he was a smoker, he’s responsible.”

Ken Doka, an expert in end-of-life care for the Hospice Foundation of America

Doka first explored the concept in the 1980s, along with a related concept: “disenfranchised grief.” This occurs when mourners feel they don’t have the right to express their loss openly or fully because of the cultural stigma about how the person died. For example, deaths from drug overdoses or suicide are frequently viewed as stemming from a supposed “moral” failure, and those left behind to mourn often fear others are judging them or the dead person’s choices and behaviors, Doka said.

“So, for instance, if I say my brother died of lung cancer, what’s the first question you’re going to ask — was he a smoker?” Doka said. “And somehow, if he was a smoker, he’s responsible.”

Doka predicts that Americans who have lost loved ones to covid in communities where the disease isn’t taken seriously may also encounter similar efforts to shift responsibility — from the virus to the person who died.

Dixon’s sisters said that’s the attitude they often perceive in people’s responses to the news of their brother’s death — asking whether he had preexisting conditions or if he was overweight, as if he were to blame.

Those who criticize or dismiss victims of the pandemic are unlikely to change their minds easily, said Holly Prigerson, a sociologist specializing in grief. She said judgmental comments stem from a psychological concept known as cognitive dissonance.

If people believe the pandemic is a hoax, or that the dangers of the virus are overblown, then “anything, including the death of a loved one from this disease … they compartmentalize it,” Prigerson said. “They’re not going to process it. It gives them too much of a headache to try to reconcile.”

She advises that people whose families or friends aren’t willing to acknowledge the reality of covid might have to set new boundaries for those relationships.

As Rimel continues to mourn her brother’s death, she has found relief by joining bereavement support groups with others who agree on the facts about covid. In August, she and her mother attended a remembrance march for covid victims in downtown Pittsburgh, organized by the group Covid Survivors for Change.

And in June, a headstone was placed on Dixon’s grave.

Near the bottom is a blunt message for the public, and for posterity: F— COVID-19.

Long after they are gone, the family wants the truth to endure.

“We want to make sure that people know Kyle’s story, and that he passed away from the virus,” Rimel said.

This story is from a partnership that includes NPR, WITF and KHN.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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Más de la mitad de los estados han revertido poderes de salud pública durante la pandemia

Wed, 09/15/2021 - 12:01pm

Motivados por votantes enojados por los cierres y los mandatos sobre el uso de máscaras durante la pandemia, legisladores republicanos en más de la mitad de los estados de EE.UU. están quitando los poderes que los funcionarios estatales y locales usan para proteger al público contra las enfermedades infecciosas.

Una revisión de KHN encontró que, desde que comenzó la pandemia, legisladores en los 50 estados han propuesto proyectos de ley para frenar estos poderes. Al menos 26 aprobaron leyes que debilitan permanentemente la autoridad del gobierno para proteger la salud pública. En otros tres, una orden ejecutiva, una iniciativa de votación o un fallo de la Corte Suprema estatal limitaron los poderes de salud pública que existían desde hace mucho tiempo.

En Arkansas, los legisladores prohibieron los mandatos de máscaras excepto en empresas privadas o entornos de atención médica administrados por el estado, calificándolos de “una carga para la paz pública, la salud y la seguridad de los ciudadanos de este estado”. En Idaho, comisionados de los condados, que normalmente no tienen experiencia en el tema, pueden vetar órdenes de salud pública en todo el condado. Y en Kansas y Tennessee, las juntas escolares son las que tienen el poder de cerrar las escuelas, no los funcionarios de salud.

El presidente Joe Biden anunció el jueves 9 de septiembre amplios mandatos de vacunación y otras medidas sobre covid, diciendo que se vio obligado a actuar en parte debido a estas legislaciones. Como ejemplo:

  • En al menos 16 estados, los legisladores han limitado el poder de los funcionarios de salud pública para ordenar mandatos sobre el uso de cubrebocas, cuarentenas o aislamientos. En algunos casos, se otorgaron a sí mismos o a políticos locales la autoridad para prevenir la propagación de enfermedades infecciosas.
  • Al menos 17 estados aprobaron leyes que prohíben los pasaportes de vacunación o los mandatos para vacunarse, o facilitaron eludir los requisitos de vacunas.
  • Al menos nueve estados tienen nuevas leyes que prohíben o limitan los mandatos del uso de máscaras. En cinco más, órdenes ejecutivas o fallos judiciales limitan estos requisitos.

Gran parte de esta legislación ha estado entrando en vigencia a medida que las hospitalizaciones por covid en algunas áreas están aumentando a sus números más altos desde que comenzó la pandemia.

“Realmente podríamos ver a más personas enfermas, heridas, hospitalizadas o incluso más muertes, dependiendo de lo extremo de la legislación y la restricción de la autoridad”, dijo Lori Tremmel Freeman, directora de la National Association of County and City Health Officials.

Académicos de salud pública y funcionarios están frustrados porque ellos mismos, en lugar del virus, se han convertido en el enemigo. Argumentan que estas acciones tendrán consecuencias que durarán mucho más allá de esta pandemia, disminuyendo no solo su capacidad para combatir la última oleada de covid sino también futuros brotes de enfermedades.

"Es como tener las manos atadas en medio de una pelea de boxeo", dijo Kelley Vollmar, directora ejecutiva del Departamento de Salud del condado de Jefferson en Missouri.

Pero defensores de los nuevos límites dicen que son un control necesario de los poderes ejecutivos y que les dan a los legisladores una voz durante emergencias que duran mucho tiempo. El senador estatal de Arkansas Trent Garner, republicano que copatrocinó el exitoso proyecto de ley de su estado para prohibir los mandatos de máscaras, dijo que estaba tratando de reflejar el deseo de la gente.

“Lo que la gente de Arkansas quiere es que la decisión quede en sus manos, en ellos y en sus familias”, dijo Garner. "Es hora de quitarles el poder a los llamados expertos, cuyas ideas han sido lamentablemente inadecuadas".

Después de firmar inicialmente el proyecto de ley, el gobernador republicano Asa Hutchinson expresó su descontento y convocó a una sesión legislativa extraordinaria a principios de agosto para pedir a los legisladores que establecieran una excepción para las escuelas. Rechazaron el pedido. La ley está actualmente bloqueada por un juez de Arkansas que la consideró inconstitucional. Más batallas legales se están desarrollando en otros estados.

La legislatura de Montana aprobó algunas de las leyes más restrictivas, limitando severamente los poderes de salud pública para decretar cuarentenas y aislamientos, aumentando el poder de los funcionarios locales por sobre las juntas de salud, impidiendo límites a las reuniones religiosas y prohibiendo a los empleadores, incluso en entornos de atención médica, exigir vacunas contra covid, la gripe o cualquier otra cosa.

La pérdida de la capacidad para ordenar cuarentenas ha dejado a Karen Sullivan, oficial de salud del departamento de Butte-Silver Bow de Montana, aterrorizada por lo que vendrá, no solo durante esta pandemia sino también por futuros brotes de sarampión.

"Confiar en la moralidad y la buena voluntad no es una buena práctica de salud pública", dijo.

Freeman dijo que el grupo de funcionarios de salud de su ciudad y condado tiene poca influencia y recursos, especialmente en comparación con el American Legislative Exchange Council (ALEC), un grupo conservador respaldado por corporaciones que promovió un proyecto de ley modelo para restringir los poderes de emergencia de los gobernadores y otros funcionarios.

El proyecto de ley parece haber inspirado a docenas de otros a nivel estatal, según la revisión de KHN. Al menos 15 estados aprobaron leyes que limitan los poderes de emergencia. En algunos, los gobernadores ya no pueden ordenar mandatos de uso de máscaras, y los legisladores pueden revocar sus órdenes ejecutivas.

Las nuevas leyes están destinadas a reducir el poder de los gobernadores y restablecer el equilibrio entre los poderes ejecutivos y legislativos de los estados, dijo Jonathon Hauenschild, director del grupo de trabajo de ALEC sobre comunicaciones y tecnología. “A los gobernadores se los elige, pero delegaban mucha autoridad en el funcionario de salud pública, al que generalmente ellos mismos habían designado”, dijo Hauenschild.

Cuando la legislatura de Indiana anuló el veto del gobernador para aprobar un proyecto de ley que daba a los comisionados del condado el poder de revisar las órdenes de salud pública, el doctor David Welsh, el oficial de salud pública en el condado rural de Ripley, quedó devastado.

De inmediato, la gente dejó de llamarlo para denunciar violaciones a las normas de covid. Fue "como apagar un interruptor de luz", dijo Welsh.

Está considerando renunciar. Si lo hace, se unirá a los cerca de 303 líderes de salud pública que ya se han retirado, renunciado o han sido despedidos desde que comenzó la pandemia, según un análisis en curso de KHN y AP. Eso significa que 1 de cada 5 estadounidenses ha perdido a un líder de salud local en ese tiempo.

“Esto es un golpe mortal” para el campo de la salud pública, dijo Brian Castrucci, director ejecutivo de la Beaumont Foundation, que aboga por la salud pública.

Los grupos de salud pública esperan una legislación más combativa.

El ex senador estatal demócrata de Oregon Wayne Fawbush dijo que algunos de los políticos de hoy pueden llegar a lamentar estas leyes.

Fawbush fue uno de los patrocinadores de la legislación de 1989 que 32 años después significa que Oregon no puede exigir que los trabajadores de salud se vacunen contra covid. Fawbush calificó la producción de leyes como un "negocio caótico" y dijo que no habría impulsado el proyecto de ley si hubiera sabido lo que iba a significar ahora.

La reportera de datos de KHN Hannah Recht, la corresponsal de Montana Katheryn Houghton y la escritora de Associated Press Michelle R. Smith colaboraron con este informe.

 Esta historia es parte de una colaboración entre The Associated Press y KHN. Para comunicarse con el equipo de investigación de AP, envíe un correo electrónico a investigative@ap.org.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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Over Half of States Have Rolled Back Public Health Powers in Pandemic

Wed, 09/15/2021 - 5:00am

Republican legislators in more than half of U.S. states, spurred on by voters angry about lockdowns and mask mandates, are taking away the powers state and local officials use to protect the public against infectious diseases.

A KHN review of hundreds of pieces of legislation found that, in all 50 states, legislators have proposed bills to curb such public health powers since the covid-19 pandemic began. While some governors vetoed bills that passed, at least 26 states pushed through laws that permanently weaken government authority to protect public health. In three additional states, an executive order, ballot initiative or state Supreme Court ruling limited long-held public health powers. More bills are pending in a handful of states whose legislatures are still in session.

In Arkansas, legislators banned mask mandates except in private businesses or state-run health care settings, calling them “a burden on the public peace, health, and safety of the citizens of this state.” In Idaho, county commissioners, who typically have no public health expertise, can veto countywide public health orders. And in Kansas and Tennessee, school boards, rather than health officials, have the power to close schools.

President Joe Biden last Thursday announced sweeping vaccination mandates and other covid measures, saying he was forced to act partly because of such legislation: “My plan also takes on elected officials in states that are undermining you and these lifesaving actions.”

All told:

  • In at least 16 states, legislators have limited the power of public health officials to order mask mandates, or quarantines or isolation. In some cases, they gave themselves or local elected politicians the authority to prevent the spread of infectious disease.
  • At least 17 states passed laws banning covid vaccine mandates or passports, or made it easier to get around vaccine requirements.
  • At least nine states have new laws banning or limiting mask mandates. Executive orders or a court ruling limit mask requirements in five more.

Much of this legislation takes effect as covid hospitalizations in some areas are climbing to the highest numbers at any point in the pandemic, and children are back in school.

“We really could see more people sick, hurt, hospitalized or even die, depending on the extremity of the legislation and curtailing of the authority,” said Lori Tremmel Freeman, head of the National Association of County and City Health Officials.

Public health academics and officials are frustrated that they, instead of the virus, have become the enemy. They argue this will have consequences that last long beyond this pandemic, diminishing their ability to fight the latest covid surge and future disease outbreaks, such as being able to quarantine people during a measles outbreak.

“It’s kind of like having your hands tied in the middle of a boxing match,” said Kelley Vollmar, executive director of the Jefferson County Health Department in Missouri.

But proponents of the new limits say they are a necessary check on executive powers and give lawmakers a voice in prolonged emergencies. Arkansas state Sen. Trent Garner, a Republican who co-sponsored his state’s successful bill to ban mask mandates, said he was trying to reflect the will of the people.

“What the people of Arkansas want is the decision to be left in their hands, to them and their family,” Garner said. “It’s time to take the power away from the so-called experts, whose ideas have been woefully inadequate.”

After initially signing the bill, Republican Gov. Asa Hutchinson expressed regret, calling a special legislative session in early August to ask lawmakers to carve out an exception for schools. They declined. The law is currently blocked by an Arkansas judge who deemed it unconstitutional. Legal battles are ongoing in other states as well.

A Deluge of Bills

In Ohio, legislators gave themselves the power to overturn health orders and weakened school vaccine mandates. In Utah and Iowa, schools cannot require masks. In Alabama, state and local governments cannot issue vaccine passports and schools cannot require covid vaccinations.

Montana’s legislature passed some of the most restrictive laws of all, severely curbing public health’s quarantine and isolation powers, increasing local elected officials’ power over local health boards, preventing limits on religious gatherings and banning employers — including in health care settings — from requiring vaccinations for covid, the flu or anything else.

Legislators there also passed limits on local officials: If jurisdictions add public health rules stronger than state public health measures, they could lose 20% of some grants.

Losing the ability to order quarantines has left Karen Sullivan, health officer for Montana’s Butte-Silver Bow department, terrified about what’s to come — not only during the covid pandemic but for future measles and whooping cough outbreaks.

“In the midst of delta and other variants that are out there, we’re quite frankly a nervous wreck about it,” Sullivan said. “Relying on morality and goodwill is not a good public health practice.”

While some public health officials tried to fight the national wave of legislation, the underfunded public health workforce was consumed by trying to implement the largest vaccination campaign in U.S. history and had little time for political action.

Freeman said her city and county health officials’ group has meager influence and resources, especially in comparison with the American Legislative Exchange Council, a corporate-backed conservative group that promoted a model bill to restrict the emergency powers of governors and other officials. The draft legislation appears to have inspired dozens of state-level bills, according to the KHN review. At least 15 states passed laws limiting emergency powers. In some states, governors can no longer institute mask mandates or close businesses, and their executive orders can be overturned by legislators.

When North Dakota’s legislative session began in January, a long slate of bills sought to rein in public health powers, including one with language similar to ALEC’s. The state didn’t have a health director to argue against the new limits because three had resigned in 2020.

Fighting the bills not only took time, but also seemed dangerous, said Renae Moch, public health director for Bismarck, who testified against a measure prohibiting mask mandates. She then received an onslaught of hate mail and demands for her to be fired.

Lawmakers overrode the governor’s veto to pass the bill into law. The North Dakota legislature also banned businesses from asking whether patrons are vaccinated against or infected with the coronavirus and curbed the governor’s emergency powers.

The new laws are meant to reduce the power of governors and restore the balance of power between states’ executive branches and legislatures, said Jonathon Hauenschild, director of the ALEC task force on communications and technology. “Governors are elected, but they were delegating a lot of authority to the public health official, often that they had appointed,” Hauenschild said.

‘Like Turning Off a Light Switch’

When the Indiana legislature overrode the governor’s veto to pass a bill that gave county commissioners the power to review public health orders, it was devastating for Dr. David Welsh, the public health officer in rural Ripley County.

People immediately stopped calling him to report covid violations, because they knew the county commissioners could overturn his authority. It was “like turning off a light switch,” Welsh said.

Another county in Indiana has already seen its health department’s mask mandate overridden by the local commissioners, Welsh said.

He’s considering stepping down after more than a quarter century in the role. If he does, he’ll join at least 303 public health leaders who have retired, resigned or been fired since the pandemic began, according to an ongoing KHN and AP analysis. That means 1 in 5 Americans have lost a local health leader during the pandemic.

“This is a deathblow,” said Brian Castrucci, CEO of the de Beaumont Foundation, which advocates for public health. He called the legislative assault the last straw for many seasoned public health officials who have battled the pandemic without sufficient resources, while also being vilified.

Public health groups expect further combative legislation. ALEC’s Hauenschild said the group is looking into a Michigan law that allowed the legislature to limit the governor’s emergency powers without Democratic Gov. Gretchen Whitmer’s signature. 

Curbing the authority of public health officials has also become campaign fodder, particularly among Republican candidates running further on the right. While Republican Idaho Gov. Brad Little was traveling out of state, Lt. Gov. Janice McGeachin signed a surprise executive order banning mask mandates that she later promoted for her upcoming campaign against him. He later reversed the ban, tweeting, “I do not like petty politics. I do not like political stunts over the rule of law.”

At least one former lawmaker — former Oregon Democratic state Sen. Wayne Fawbush — said some of today’s politicians may come to regret these laws.

Fawbush was a sponsor of 1989 legislation during the AIDS crisis. It banned employers from requiring health care workers, as a condition of employment, to get an HIV vaccine, if one became available. 

But 32 years later, that means Oregon cannot require health care workers to be vaccinated against covid. Calling lawmaking a “messy business,” Fawbush said he certainly wouldn’t have pushed the bill through if he had known then what he does now.

“Legislators need to obviously deal with immediate situations,” Fawbush said. “But we have to look over the horizon. It’s part of the job responsibility to look at consequences.”

KHN data reporter Hannah Recht, Montana correspondent Katheryn Houghton and Associated Press writer Michelle R. Smith contributed to this report.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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Biden Releases a New Plan to Combat Covid, but Experts Say There’s Still a Ways to Go

Wed, 09/15/2021 - 5:00am

Promise: “I’m never going to raise the white flag and surrender. We’re going to beat this virus. We’re going to get it under control, I promise you. “

On the campaign trail last year, Joe Biden promised that, if elected president, he would get covid-19 under control. Since assuming office in January, Biden has continued to pledge that his administration would do its best to get Americans vaccinated against covid and allow life to return to some semblance of normal.

Both signs of progress and setbacks have cropped up along the way.

Initially, as covid vaccines became available early this year, demand exceeded supply, frustrating many. Eventually, all those who wanted to were able to become fully vaccinated.

In May and June, new covid cases, hospitalizations and deaths dramatically fell, prompting the Biden administration to ease mask requirements and guidance for fully vaccinated people. But many states and localities responded by dropping mask mandates altogether, even for people who were not inoculated.

The summer also ushered in the highly contagious delta variant, causing another pandemic wave. By Labor Day, daily cases in the U.S. were at their highest point since last winter. Deaths, too, were rising.

On Sept. 9, Biden announced a six-part plan to combat the delta variant and step up efforts to get control of covid. The plan includes vaccine mandates for federal workers, government contractors and those working at private companies with 100 or more employees; requirements that employers offer paid time off for those getting a shot; increased distribution and lower costs for covid tests, including rapid at-home tests; and stronger covid safety protocols in schools and on interstate transportation.

The vaccine mandate for private employers includes an option for workers to be tested weekly instead of getting the shot. Federal workers won’t have that option.

KHN teamed up with our partners at PolitiFact to analyze Biden’s promises during the 2020 presidential campaign. We asked the experts for their take on whether this list of action items will help make this promise — to beat the virus — a reality.

Limitations and Benefits of Biden’s Plan

While the plan is a “big step in the right direction,” according to Dr. Leana Wen, a visiting professor of health policy and management at George Washington University, it should have been released two months ago. That would have slowed the delta variant from gaining such a strong foothold in the U.S.

“Had they acted much earlier, we would be in a different position,” she said.

And the current plan doesn’t go far enough, said Wen, who urged the Biden administration to give companies and jurisdictions incentives to require proof of vaccination for entry into restaurants and other businesses, as New York City and San Francisco did.

“That would send the message of ‘You don’t get to enjoy the privileges of pre-pandemic life unless you’re vaccinated,’” said Wen. “Right now, the vaccinated are being held hostage by the unvaccinated. The vaccinated are having breakthrough infections and the unvaccinated are endangering those who cannot get vaccinated, like kids.”

Dr. Marcus Plescia, chief medical officer at the Association of State and Territorial Health Officials, is optimistic that Biden’s plan will move the needle, “but it’s hard to know how much.”

The vaccination mandates for employers, for example, will definitely be helpful in states where similar measures, such as requirements that state workers get vaccinated or test regularly, have already started, he said. It “will reinforce what the state is trying to do.”

But it’s less clear what will happen in states with strong political opposition to mandates. “There will be partisan disagreement on this,” Plescia predicted.

Biden’s proposal has elicited broad opposition from many Republican governors, with some pledging to fight it. Others issued more tempered statements. Ohio Gov. Mike DeWine, a Republican, told a Cincinnati radio station the plan may hamper efforts to educate people on the importance of vaccines, because “we’re going to now be talking about a federal mandate, which no one likes, instead of talking about ‘Look, here’s the science.’”

But Plescia is pleased the vaccination mandate broadly extends the requirement for health care workers to get vaccinated. It now goes beyond an earlier announcement affecting only nursing home workers to include staffers at nearly all health facilities that receive federal funding, such as Medicare or Medicaid.

An August announcement that targeted mainly nursing home workers raised concern that some employees would simply quit and find work in health care settings where vaccines were not required, further exacerbating a shortage of nursing home workers.

With the president’s new move, “this levels the playing field,” Plescia said. The same goes for other industries.

And the mandate might prove less objectionable for some unvaccinated adults, said Dr. Georges Benjamin, executive director of the American Public Health Association, because the employer becomes the enforcer.

“The person telling them what to do is their boss at their job,” he said. “That’s a different leverage point than the government.”

However, Jen Kates, director of global health and HIV policy at KFF, said the testing option for companies with 100 or more workers could slow any positive impact of the vaccine push.

It will also take time to see how the mandates and requirements are implemented. Possible legal challenges could delay results, as could the regulatory steps involved in the enforcement of the employer vaccination requirement, which will rely on the Occupational Safety and Health Administration for enforcement.

The goal to get more testing kits to health centers and to make home test kits available through major retailers for a lower price could also be helpful, Plescia said.

Benjamin gives Biden a “healthy B-plus” on progress in getting covid under control, citing the more than 200 million Americans who have had at least one shot, even as he acknowledges that, “as a nation, we haven’t achieved critical vaccination levels in enough of the country.” Currently, 63% of the U.S. population age 12 and over is fully vaccinated.

But, in many pockets of the country, not even half the population is vaccinated, far short of the levels many public health experts believe necessary to tamp down the virus.

“It’s pretty clear the carrot has not worked,” said Benjamin, referring to the carrot-and-stick metaphor. “We have enormous forces pushing back, both the usual anti-vaccine community plus the politicization at the most senior levels.”

Disparities remain in vaccination rates among people of color compared with that of white people, though the gap has been shrinking recently. Still, the share of doses Black and Hispanic people have received is disproportionately smaller than their share of covid cases in most states.

Continuing to reach out to these populations will be an important tool to boost the vaccination rate across the U.S. — and to slow the delta variant surge.

When Will We (If Ever) Get Covid Under Control?

Despite all this, Dr. William Schaffner, a professor of medicine in the Division of Infectious Diseases at Vanderbilt University in Nashville, Tennessee, is hopeful.

If things move forward expeditiously, “by sometime this winter we could have covid under control,” he said. By that, he does not mean the virus will be vanquished. Instead, Schaffner said, “we would be on the same track as before delta, entering a new normal.”

Kates envisions covid becoming manageable if the U.S. can achieve a much higher rate of vaccination coverage. But she also thinks it’s likely the virus will continue to circulate and covid will become an endemic disease.

“The likelihood of it not being an issue is diminishing since vaccine coverage is so poor in other countries. Containing covid depends on what we do globally, too,” said Kates. “The likely scenario of the U.S. is we’ll be living with it for a while and containment will be dependent on vaccination rates.” We continue to rate this promise In the Works.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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Census: Insured Population Holds Steady, With a Slight Shift From Private to Public Coverage

Tue, 09/14/2021 - 5:57pm

Despite a pandemic-fueled recession, the number of uninsured Americans has increased only slightly since 2018, according to Census Bureau health insurance data released Tuesday.

Twenty-eight million people, or 8.6% of Americans, were uninsured for all of 2020. In 2019, 8% of people were uninsured during the full year; in 2018, it was 8.5%.

During a press conference, Census officials said there was no statistically significant difference in the number of uninsured when comparing 2018 and 2020 data. (The Census Bureau has cautioned against comparing 2020 data to 2019 data because of a disruption in data collection and individual responses due to the covid-19 pandemic — which is why 2018 served as the primary comparison.)

“It’s remarkable that, during a pandemic with massive job losses, the share of Americans uninsured did not go up,” said Larry Levitt, executive vice president for health policy at KFF. “This is likely a testament to what is now a much more protective health insurance safety net.”

Still, the annual report shows a shift in where Americans get their insurance coverage. Private insurance coverage decreased by 0.8 percentage points from 2018. Public coverage rose by 0.4 percentage points from 2018. That shift was likely driven partly by older Americans becoming eligible for Medicare, at age 65, and showed a 0.5 percentage point increase from 2018 to 2020.

Coverage through employers also dropped significantly, said Joseph Antos, a senior fellow in health care policy at the American Enterprise Institute, and low-income people were hit especially hard as pandemic cutbacks led to job and health insurance losses. Employment-based coverage dropped by 0.7 percentage points compared with 2018.

The Census 2020 data did show a decline in the number of workers employed full time year-round, and an increase in the number of workers who worked less than full time, suggesting that many individuals shifted to part-time work.

This changing nature of work is “part of the overall story,” said Sharon Stern, assistant division chief of employment characteristics at the Census Bureau. For the group that didn’t work full time, the uninsured rate increased to 16.4% in 2020 from 14.6% in 2018. And that impact was concentrated at the bottom of the earnings index.

“Almost certainly, the people most prone to lose coverage because they lost their jobs were lower-paid workers to begin with,” Antos said.

Antos said the Census Bureau data, which showed there wasn’t a significant difference between 2018 and 2020 in the percentage of Americans covered by the Affordable Care Act, misses the larger role the ACA played in helping those who lost coverage get it through the program. Many of those who looked into ACA plans may have met income requirements for Medicaid and joined those rolls instead. Medicaid is a federal-state program for the poor and coverage is free or available at a very low cost. Even with a subsidy, many ACA enrollees may face premium or deductibles or both.

Joan Alker, executive director of the Center for Children and Families at Georgetown University, said one of the main points that jumped out for her was the sharp rise in children below the federal poverty level who were uninsured, rising from 7.8% in 2018 to 9.3% in 2020.

“The rich kids actually did a little bit better, and the poor kids did a whole lot worse,” said Alker.

Overall, the percentage of uninsured children ticked up only slightly and wasn’t considered statistically significant.

Further research is needed to determine the causes of rising uninsurance among the poorest children, Alker said.

Oddly, the Census report did not show an uptick in Medicaid enrollment, although other reports have shown a big increase.

Data from the Centers for Medicare & Medicaid Services, which comes from state insurance records, shows a 15.6% increase in the number of Medicaid and Children’s Health Insurance Program enrollees from February 2020 to March 2021.

A recent report from KFF, which analyzed the CMS data, found enrollment in Medicaid and CHIP increased by 10.5 million from February 2020 to March 2021. Enrollment increased steadily each consecutive month, with increases attributed to people losing their jobs and thus becoming eligible for public coverage and the Families First Coronavirus Response Act, which passed in 2020 and ensured continuous Medicaid coverage.

This disconnect may be a result of the nature of Census data, which is self-reported by individuals.

“That’s always subject to error, and probably especially so right now,” said Levitt. “It could also be a result of particularly high non-response rates among some groups.”

Census officials acknowledged during the Tuesday press conference that response rates to their surveys were lower than normal in 2020 and have only just started rebounding in 2021. Other data sources do seem to confirm that the uninsured rate has remained relatively constant over the past couple of years.

Another important takeaway from the data was illustrating the continuing gap in the number of uninsured people between states that chose to expand Medicaid under the ACA and states that didn’t. The Census data showed that in 2020, 38.1% of poor, non-elderly adults were uninsured in non-expansion states, compared with 16.7% in expansion states.

“That became a huge gap after the ACA, and it’s not surprising at all that it remains a huge gap,” said Gideon Lukens, director of research and data analysis for health policy at the Center on Budget and Policy Priorities. “That highlights the need to close the coverage gap.”

The Census Bureau report also offered insights into national income and poverty rates:

  • The official poverty rate in 2020 was 11.4%, up 1 percentage point from 2019, marking the first increase in poverty after five consecutive annual declines. In 2020, 37.2 million people lived in poverty, approximately 3.3 million more than in 2019.
  • Medical expenses boosted the number of impoverished people by 5 million in 2020.
  • The median household income in 2020 decreased 2.9% from 2019 to 2020. This is the first statistically significant decline in median household income since 2011.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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Justice Department Targets Data Mining in Medicare Advantage Fraud Case

Tue, 09/14/2021 - 11:38am

The Justice Department has accused an upstate New York health insurance plan for seniors and its medical analytics company of cheating the government out of tens of millions of dollars.

The civil complaint of fraud, filed late Monday, is the first by the federal government to target a data mining company for allegedly helping a Medicare Advantage program game federal billing regulations to overcharge for patient treatment.

The suit names the medical records review company DxID and Independent Health Association, of Buffalo, which operates two Medicare Advantage plans. Betsy Gaffney, DxID’s founder and CEO, also is named as a defendant. DxID, which shut down in August, is owned by Independent Health through another subsidiary.

The Centers for Medicare & Medicaid Services, or CMS, pays the health plans using a complex formula called a “risk score,” which is intended to render higher rates for sicker patients and less for those in good health. The data mining company combed electronic medical records to identify missed diagnoses — pocketing up to 20% of new revenue it generated for the health plan.

But the DOJ alleges that DxID’s reviews triggered “tens of millions” of dollars in overcharges by exaggerating how sick patients were or by submitting charges for medical conditions the patients did not have.

In an email, Frank Sava, a spokesperson for Independent Health, wrote:

“We are aware of the DOJ complaint filed late yesterday and will continue to defend ourselves vigorously against the allegations. Because this is an open case I cannot comment further.”

Gaffney’s lawyer did not respond to requests for comment.

The DOJ complaint expands on a 2012 whistleblower suit filed by Teresa Ross, a former medical coding official at Group Health Cooperative in Seattle, one of the nation’s oldest and most prestigious health plans.

Ross alleged that Group Health hired DxID in 2011 to boost revenues. The company submitted more than $30 million in new disease claims to Medicare on behalf of Group Health for 2010 and 2011, many of which were not valid, according to Ross.

For instance, she alleged that the plan billed for “major depression” in a patient described by his doctor as having an “amazingly sunny disposition.” Group Health, now known as the Kaiser Foundation Health Plan of Washington, denied wrongdoing, but in November 2020 settled the case by paying $6.3 million.

Now DOJ is taking over the case and targeting DxID for its work on behalf of both Group Health and Independent Health. DOJ alleges that DxID submitted thousands of “unsupported” medical condition codes on behalf of Independent Health from 2010 to 2017.

“Hopefully the case sends a message that coding companies that exist only to enrich themselves by violating many, many CMS rules will face consequences,” said Max Voldman, an attorney who represents Ross.

Timothy Layton, an associate professor of health care policy at Harvard Medical School who has studied Medicare Advantage payment policy, said he has not seen the government take legal actions against data analytics companies before.

“They are often the ones doing a lot of the scraping for [billing] codes, so I wouldn’t be surprised if they came under more scrutiny,” he said.

In the complaint filed Monday, DOJ alleged that Gaffney pitched DxID’s revenue-generating tools as “too attractive to pass up.”

“There is no upfront fee, we don’t get paid until you get paid and we work on a percentage of the actual proven recoveries,” she wrote, according to the complaint.

The 102-page suit describes DxID’s chart review process as “fraudulent,” and says it “relied on ‘trolling’ patient medical records to gin up, in many cases, ‘new’ diagnoses exclusively from information derived from impermissible sources.”

The complaint cites medical conditions that it says were either exaggerated or weren’t supported by the medical records, such as billing for treating chronic depression that had been resolved. It also cites allegedly unsupported claims for renal failure, the most severe form of chronic kidney disease. The suit alleges that Gaffney said these cases were “worth a ton of money to IH [Independent Health] and the majority of people (over) 70 have it at some level.”

The complaint says that CMS would have tried to recover money paid to the health plan improperly had it known about DxID’s tactics and “has now done so via this suit.”

The DOJ is seeking treble damages in the False Claims Act suit, plus an unspecified civil penalty for each violation of the law.

Medicare Advantage, a fast-growing private alternative to original Medicare, has enrolled more than 26 million people, according to AHIP, an industry trade group.

While popular with seniors, Medicare Advantage has been the target of multiple government investigations, Department of Justice and whistleblower lawsuits and Medicare audits. One 2020 report estimated improper payments to the plans topped $16 billion the previous year.

At least two dozen whistleblower cases, some dating to 2009, have alleged fraud by Medicare Advantage plans related to manipulating patient risk scores to boost revenues.

In July, the DOJ consolidated six such cases against Kaiser Permanente health plans, while in August California-based Sutter Health agreed to pay $90 million to settle a similar fraud case. Previous settlements have totaled more than $300 million.

(KHN is not affiliated with the Kaiser Foundation Health Plan of Washington or with Kaiser Permanente.)

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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ICUs Are Filled With Covid — And Regret

Tue, 09/14/2021 - 5:00am

It’s a struggle for Joe Gammon to talk. Lying in his bed in the intensive care unit at Ascension Saint Thomas Hospital in Nashville, Tennessee, this month, he described himself as “naive.” 

“If I would have known six months ago that this could be possible, this would have been a no-brainer,” said the 45-year-old father of six, who has been in critical condition with covid-19 for weeks. He paused to use a suction tube to dislodge some phlegm from his throat. “But I honestly didn’t think I was at any risk.”

Tennessee hospitals are setting new records each day, caring for more covid patients than ever, including 3,846 of the more than 100,000 Americans hospitalized with the virus as of Sept. 9. The most critical patients are almost all unvaccinated, hospital officials say, meaning ICUs are filled with regretful patients hoping for a second chance.

In hospitals throughout the South as well as in parts of California and Oregon, more than 50% of the inpatients are being treated for covid, an NPR analysis shows

Gammon is a truck driver from rural Lascassas in Middle Tennessee who said he listens to a lot of conservative talk radio. The daily diatribes downplaying the pandemic and promoting personal freedom were enough to dissuade him from vaccination.

Gammon said he’s not an “anti-vaxxer.” And he said he’s a committed believer in the covid vaccine now. He’s also thankful he didn’t get anyone else so sick they’re in an ICU like him.

“Before you say no, seek a second opinion,” he advised people who think the way he did before being hospitalized. “Just to say ‘no’ is irresponsible. Because it might not necessarily affect you. What if it affected your spouse? Or your child? You wouldn’t want that. You sure wouldn’t want that on your heart.”

Gammon’s lungs are too damaged from covid for a ventilator. He is on the last-resort life support ECMO, which stands for extracorporeal membrane oxygenation. Unlike previous generations of life support, people on ECMO can be fully conscious, can speak to their loved ones (or even reporters), and can even move around with the help of a team of nurses and technicians. 

But it is an intense treatment, with a machine doing the work of both the heart and the lungs. Thick tubes run out of a hole in Gammon’s neck, and pump all of his blood through the ECMO machine to be oxygenated, then back into his body through other tubes. A mask over his nose forces air into his lungs as they’re given time to heal.

Even for patients who survive ECMO, many face months of rehabilitation or even permanent disability or dependence on oxygen.

This Saint Thomas West ICU is treating covid patients only, and that data point should be pretty convincing to vaccine holdouts, said critical care nurse Angie Gicewicz.

“We don’t have people in the hospital suffering horrible reactions to the vaccine,” she noted.

If all the patients on this hall could talk — and some can’t because they’re sedated on ventilators — Gicewicz said they’d tell people to learn from their mistakes. She recounted the story of an elderly woman who was admitted in recent weeks and spent her first days in isolation to control infection.

Gicewicz said she’d wave at the nurses from her sealed room, desperate for anyone to talk to. “The first day I took care of her, she said, ‘I guess I should have taken that vaccine.’ I said, ‘Well, yeah honey, probably. But we’re here where we are now, and let’s do what we can for you.’ ”

That woman, like so many who didn’t take the vaccine, never recovered, Gicewicz said. She died at this hospital, which averaged more than one covid death every day during the month of August.

This story is part of a partnership that includes Nashville Public RadioNPR and KHN.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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Under Pressure, Montana Hospital Considers Adding Psych Beds Amid a Shortage

Tue, 09/14/2021 - 5:00am

Gary Popiel had to drive more than 200 miles round trip to visit his adult daughters in separate behavioral health facilities as they received psychiatric and medical treatment.  

It was 2000, and the family’s only options for inpatient psychiatric beds were in Helena and Missoula — far from their Bozeman, Montana, home and from each other. Fast-forward 21 years, and Montana’s fourth-largest city still lacks a hospital behavioral health unit.

“This would be just as traumatic now as it was then. We still would have to leave Bozeman,” Popiel said. “Why should families have to witness their loved one being hauled off or take them themselves to another facility — or outside the state — to receive help?”

For years, health care workers and people such as Popiel who’ve had to travel for family members’ mental health hospitalizations have been pushing the city’s major hospital system, the nonprofit Bozeman Health, to add a behavioral health unit at its Deaconess Hospital. On Sept. 30, the system’s board plans to consider whether to add one as part of an expansion of its mental health services.

Hospital leaders have said initial talks have been broad so far, without specifics on the number of potential beds and whether they’re designed for adults or kids.

But even if Bozeman Health adds inpatient psychiatric beds, the gaps in emergency mental health care could continue. Across Montana, such units routinely hit capacity and some struggle to find enough workers to staff them.

Montana’s quandary reflects a national shortage of inpatient psychiatric beds that can leave people with serious mental illnesses far from the services they need when a crisis hits. Ideally, patients would have treatment options to prevent such a crisis. But more than 124 million Americans live in mental health “professional shortage areas,” according to federal data, and the country needs at least 6,500 more practitioners to fill the gaps.

The national nonprofit Treatment Advocacy Center, which aims to make care for severe mental illness more accessible, recommends a minimum of 50 inpatient psychiatric beds per 100,000 people. It is still debated, though, who should provide those beds and where they’re prioritized on a long list of stretched-thin mental health services.

Given the patient capacity of Montana State Hospital and private hospital behavioral health units, Montana comes close to that recommendation. But those beds are concentrated in pockets of the state, so access isn’t uniform.

For example, Bozeman Health sits in a city of 50,000 in a county of 120,000 and also serves two neighboring counties. The city has 10 crisis beds at the Western Montana Mental Health Center’s facility there — the only beds for roughly 100 miles in any direction. The crisis center cares for roughly 400 people a year, providing nurses and psychiatrists who can offer safety plans and medication management, but it can’t treat children or offer full medical services as a hospital could. The center also faced criticism for closing its two involuntary beds for six months last year because of a worker shortage amid the pandemic.

Bozeman Health’s leadership estimated that on average 13 people who live in its primary three-county service area of Gallatin, Park and Madison counties are admitted to behavioral health units elsewhere each month.

Some patients leave handcuffed in the back of a law enforcement vehicle. Last year, the Gallatin County Sheriff’s Office transported 101 people experiencing a mental health crisis — 85 of whom were taken to crisis centers hours away or the state hospital. That’s up from 2019 when authorities took 36 out of 45 people in crisis outside the county.

“Every other major city in Montana besides us has managed to get inpatient care” at their hospitals, said Dr. Colette Kirchhoff, a physician in Bozeman.

One man went to Bozeman Health to have a cancerous tumor removed in early August, and the next day he had panic attacks that turned into suicidal thoughts. He was driven two hours in the back of an ambulance to the Billings Clinic. His wife, who asked KHN not to publish their names since her husband wasn’t in a condition to give his consent, said she wished they’d had a closer option.

“I was there when he got strapped into a gurney and taken away,” she said. “I had to book a hotel and get money from the bank and pack clothes.”

Bozeman Health leaders have said the hospital hadn’t actively considered a behavioral health unit until now because it had prioritized outpatient mental health services. In recent years, it added mental health treatment into primary care, including hiring licensed clinical social workers. It started telepsychiatry to help local providers with patient assessments. It also plans to provide short-term crisis stabilization and medication management.

“The gold standard is let’s make the need for high-acuity inpatient care go away completely,” said Jason Smith, Bozeman Health’s chief advancement officer. “Getting there may be impossible. At the very least, it’s going to be difficult.”

Elizabeth Sinclair Hancq, director of research for the Treatment Advocacy Center, is skeptical that would be possible. “Efforts to intervene as early as possible are an important step forward, but that doesn’t mean that inpatient beds will become obsolete,” she said.

Smith said creating inpatient psychiatric services isn’t as simple as adding beds. A construction project would be years away. Adding a unit also would mean ensuring discharged patients have access to additional services and recruiting mental health workers to Bozeman amid the national shortage.

“Whether we’re going to be able to recruit the behavioral health professionals that are necessary to lead it and provide that care on a day-to-day basis is a major question mark,” Smith said.

Dr. Scott Ellner, CEO of the Billings Clinic, said the number of patients who travel to his hospital for care is evidence the state needs more beds. Last year, the hospital treated 161 psychiatric patients from Bozeman Health’s service area. Ellner said Billings Clinic loses money on its psych unit, but the service is part of the hospital’s job.

“There’s so few resources across the state,” Ellner said. “We strongly recommend that there be inpatient beds in Gallatin County.”

Where the services do exist, they’re often stretched.

Benefis Health System in Great Falls has 20 inpatient psychiatric beds. In an email, spokesperson Kaci Husted said those beds hit capacity a few times a week. When that happens, the hospital puts patients in overflow beds until a spot opens.

And in Helena last year, St. Peter’s Health turned away 102 patients because its behavioral health unit was out of space or because a patient needed more care than the hospital could manage. Gianluca Piscarelli, the unit’s director, said the system’s eight adult beds are often full. The hospital also has 14 geriatric psychiatric beds — the only inpatient program in the state designed for seniors who may have dementia and a serious mental illness — but Piscarelli said the unit may deny someone a spot if it already has too many high-needs patients to manage.

Shodair Children’s Hospital in Helena has 74 beds for kids in a crisis but, because of a shortage of mental health workers, the facility could admit only 40 patients as of mid-August, said CEO Craig Aasved. In May, a 15-year-old patient died by suicide there, with a state report blaming understaffing as a contributing factor.

The hospital is working on an expansion with a new building design that would make it easier to group patients by diagnosis, but staffing will still be a strain. He said that while more beds are always needed, some kids come from towns where they don’t even have access to a therapist.

Having every hospital add psychiatric beds isn’t a perfect solution, Aasved said. “The end result is we’ll just have a lot of beds and no staff.”

NEED HELP?

If you or someone you know is in a crisis, please call the National Suicide Prevention Lifeline at 1-800-273-TALK (8255) or contact the Crisis Text Line by texting HOME to 741741.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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