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Health Care Unions Defending Newsom From Recall Will Want Single-Payer Payback

Mon, 09/13/2021 - 5:01am

SACRAMENTO, Calif. — Should Gavin Newsom survive the Republican-driven attempt to oust him from office, the Democratic governor will face the prospect of paying back supporters who coalesced behind him.

And the leaders of California’s single-payer movement will want their due.

Publicly, union leaders say they’re standing beside Newsom because he has displayed political courage during the covid-19 pandemic by taking actions such as imposing the nation’s first statewide stay-at-home order. But behind the scenes, they are aggressively pressuring him to follow through on his 2018 campaign pledge to establish a government-run, single-payer health care system.

“I expect him to lead on California accomplishing single-payer and being an example for the rest of the country,” said Sal Rosselli, president of the National Union of Healthcare Workers, which is urging Newsom to get federal permission to fund such a system.

Another union, the California Nurses Association, is pushing Newsom to back state legislation early next year to do away with private health insurance and create a single-payer system. But “first, everyone needs to get out and vote no on this recall,” said Stephanie Roberson, the union’s lead lobbyist.

“This is about life or death for us. It’s not only about single-payer. It’s about infection control. It’s about Democratic and working-class values,” she said. “We lose if Republicans take over.”

Together, the unions have made hundreds of thousands of dollars in political contributions, funded anti-recall ads and phone-banked to defend Newsom. The latest polling indicates Newsom will survive Tuesday’s recall election, which has become a battle between Democratic ideals and Republican angst over government coronavirus mandates. The Democratic Party closed ranks around the governor early and kept well-known Democratic contenders off the ballot, leaving liberal voters with little choice other than Newsom.

“This is a crucial moment for Newsom, and for his supporters who are lining up behind him,” said Mark Peterson, a professor of public policy, political science and law at UCLA who specializes in the politics of health care. “They’re helping him stay in office, but that comes with an expectation for some action.”

But it’s not clear that Newsom — who will face competing demands to pay back other supporters pushing for stronger action on homelessness, climate change and public safety — could deliver such a massive shift.

Reorganizing the health system under a single-payer financing model would be tremendously expensive — around $400 billion a year — and difficult to achieve politically, largely because it would require tax increases.

The concept already faces fierce opposition from some of Newsom’s strongest supporters, including insurer Blue Shield of California and the California Medical Association, which represents doctors.

No state has a single-payer system. Vermont tried to implement one, but its former governor, a Democrat, abandoned his plan in 2014 partly because of opposition to tax increases. California would not only need to raise taxes, but would also likely have to seek voter approval to change the state constitution, and get permission from the federal government to use money allocated for Medicare and Medicaid to help fund the new system.

The last big push for single-payer in California ended in 2017 because it did not adequately address financing and other challenges. Leading up to the 2018 gubernatorial election, Newsom campaigned on single-payer health care, telling supporters “you have my firm and absolute commitment as your next governor that I will lead the effort to get it done,” and “single-payer is the way to go.”

In office, though, Newsom has distanced himself from that promise as he has expanded the existing health system, which relies on a mix of public and private insurance company payers. For instance, he and Democratic lawmakers imposed a health insurance mandate on Californians and expanded public coverage for low-income people, both of which enrich health insurers.

Newsom has, however, convened a commission to study single-payer and in late May wrote to President Joe Biden, asking him to work with Congress to pass legislation giving states freedom and financing to establish single-payer systems. “California’s spirit of innovation is stifled by federal limits,” Newsom wrote.

Newsom’s recall campaign, asked about his stance on single-payer, referred questions to his administration. The governor’s office said in prepared comments that Newsom remains committed to the idea.

“Governor Newsom has consistently said that single-payer health care is where we need to be,” spokesperson Alex Stack wrote. “It’s just a question of how we get there.”

Stack also highlighted a new initiative that will build up the state’s public health insurance program, Medi-Cal, saying it “paves a path toward a single-payer principled system.”

Activists say Newsom has let them down on single-payer but are standing behind him because he represents their best shot at obtaining it. However, some say they’re not willing to wait long. If Newsom doesn’t embrace single-payer soon, liberal activists say, they will look for a Democratic alternative when he comes up for reelection next year.

“Newsom is an establishment candidate, and we as Democrats aren’t shy about ripping the endorsement out from under someone who doesn’t share our values,” said Brandon Harami, Bay Area vice chair of the state Democratic Party’s Progressive Caucus, who opposes the recall. “Newsom has been completely silent on single-payer. A lot of us are really gunning to see some action on his part.”

State Assembly member Ash Kalra (D-San Jose), who also opposes the recall, will reintroduce his single-payer bill, AB 1400, in January after he paused it earlier this year to work on a financing plan. Its chief sponsor is the California Nurses Association.

Using lessons learned from the failed 2017 attempt to pass single-payer legislation, the nurses union is deploying activists to pressure state and local lawmakers into supporting the bill. Resolutions have been approved or are pending in multiple cities.

“This is an opportunity for California to lead the way on health care,” Los Angeles City Council member Mike Bonin said before an 11-0 vote backing Kalra’s single-payer bill in late August.

Kalra argued that support from Los Angeles shows his bill is gaining momentum. He is also preparing a new strategy to take on doctors, hospitals, health insurers and other health industry players that oppose single-payer: highlighting their profits.

“They are the No. 1 obstacle to this passing,” Kalra said. “They’re going to do whatever they can to discredit me and this movement, but I’m going to turn the mirror around on them and ask why we should continue to pay for wild profits.”

An industry coalition called Californians Against the Costly Disruption of Our Health Care was instrumental in killing the 2017 single-payer bill and is already lobbying against Kalra’s measure. The group again argues that single-payer would push people off Medicare and private employer plans and result in less choice in health insurance.

Single-payer would “force these millions of Californians who like their health care into a single new, untested government program with no guarantee they could keep their doctor,” coalition spokesperson Ned Wigglesworth said in a statement.

Bob Ross, president and CEO of the California Endowment, a nonprofit that works to expand health care access, is on Newsom’s single-payer commission. He said it will work through “tension” in the coming months before issuing a recommendation to the governor on the feasibility of single-payer.

“We have a camp of single-payer zealots who want the bold stroke of getting to single-payer tomorrow, and the other approach that I call bold incrementalism,” Ross said. “I’m not ruling out any bold stroke on single-payer; I would just want to know how we get it done.”

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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Georgia Eyes New Medicaid Contract. But How Is the State Managing Managed Care?

Mon, 09/13/2021 - 5:00am

Just before Frank Berry left his job as head of Georgia’s Medicaid agency this summer, he said the state “will be looking for the best bang for the buck” in its upcoming contract with private insurers to cover the state’s most vulnerable.

But whether the state — and Medicaid patients — are getting an optimal deal on Medicaid is up for debate.

Georgia pays three insurance companies — CareSource, Peach State Health Plan and Amerigroup — over $4 billion in total each year to run the federal-state health insurance program for low-income residents and people with disabilities. As a group, the state’s insurers averaged $189 million per year in combined profits in 2019 and 2020, according to insurer filings recorded by the National Association of Insurance Commissioners. Yet Georgia lacks some of the financial guardrails used by other states.

“Relative to other states, Georgia’s Medicaid market is an attractive business proposition for managed-care companies,” said Andy Schneider, a professor at Georgetown University’s Center for Children and Families.

Georgia is among more than 40 states that have turned to managed-care companies to control Medicaid costs. These contracts are typically among the biggest in these states, with billions of government dollars going to insurance companies. Insurers assume the financial risk and administrative burden of providing services to members in exchange for a set monthly fee paid for each member.

The health plans, though, have at times drawn questions both on spending and quality of care delivered to Medicaid members.

“The transition to managed care was supposed to save states money, but it’s not clear that it did,” said Katherine Hempstead, a senior policy adviser at the Robert Wood Johnson Foundation. (KHN receives funding support from the foundation.)

States can require Medicaid insurers to pay back money if they don’t hit a specified patient-spending threshold. That threshold is typically 85% of the amount paid to the insurance companies, with the rest going to administration and profit.

But Georgia does not require its Medicaid insurers to hit a specific target for spending on patient care, a federal inspector general report noted. Though Georgia is trying to “claw back” $500 million paid to its Medicaid insurers, it could have lost out on recoupment dollars, the report indicated.

And state documents show that the Peach State company, which now has the largest Medicaid enrollment of the three insurers, failed to reach the 85% mark from 2018 to 2020.

Overall, Georgia’s Medicaid “medical loss ratio,” which assesses how much was spent on patients’ claims and expenses, was fifth from the bottom nationwide last year, behind only Mississippi; Washington, D.C.; Wisconsin; and Arkansas, according to data from the insurance commissioners association. Spending rates on patient care in the state fell from 82.9% to 80.8% in 2020. (The NAIC uses a different method for calculating the ratio than the state and federal governments do.)

“Profits for Georgia Medicaid HMOs are very healthy,” said Allan Baumgarten, an independent analyst and consultant.

When asked whether Georgia planned a spending requirement in the new contract, Fiona Roberts, spokesperson for the Department of Community Health, which runs Medicaid, said “a number of considerations are being discussed.” She noted that the state having a low medical loss ratio does not necessarily translate to “unreasonable profit” for the insurers.

The insurers also make money off their management services firms. In 2020, the insurer Peach State paid a subsidiary of its parent company, Centene Management Company, $114.7 million for administrative services. The nonprofit CareSource paid its management services firm $86.5 million in 2020.

“Fees paid to subsidiary companies represent another source of revenues for the parent companies,” said Baumgarten. “And it’s done in a way that does not allow the state to hold the HMOs accountable.”

The state’s latest performance data, which covers 2019, shows the plans did as well or better than the national median on many measures, including on access to a primary care provider.

But low birthweight rates appear to be on the rise despite the state’s goal of bringing them down to 8.6% or less. The companies hovered at an average of about 9.8% in 2019, the latest available data.

“We continue to hear stories from families and health care providers about children in Medicaid managed care who have considerable trouble getting the services they need — whether it’s medication to control their asthma, getting connected to behavioral health care after a mental health crisis lands them in the emergency room, or any number of health challenges,” said Melissa Haberlen DeWolf, who directs research and policy at the Voices for Georgia’s Children advocacy group.

Compared with other states, Georgia has a stunningly low rate of referring poor children to specialty services under Medicaid, according to a recently released National Health Law Program report. DCH said recently it’s investigating why the rate is so low.

And, currently, the state is reporting low covid vaccination rates for those 12 and older covered by the Medicaid managed-care companies. A state posting shows the rates for the three companies are each below 10%, far lower than Georgia’s overall rate.

The companies, when asked about profitability, quality of care and administrative costs, directed a reporter to Jesse Weathington, executive director of the Georgia Quality Healthcare Association trade group. He said he could not comment on individual companies’ financial performance.

“Our goal is to continue to drive quality improvement, and successful patient outcomes, in the most cost-efficient manner for taxpayers who fund Georgia Medicaid,” Weathington said.

Georgia is expected to open the high-stakes bidding process on a new Medicaid contract next year. The bid process typically is fierce and the results often contested.

It’s not clear, though, when Georgia’s new contract process will be completed as the timelines have hit snags in several other states. North Carolina rolled out its managed-care system July 1 after two years of delays. It will spend $6 billion annually, the largest contract in the state health agency’s history.

Last year, Louisiana’s contract process fell apart after insurers that lost out disputed the results. And Centene and other companies are protesting Pennsylvania’s decision not to award them contracts, delaying implementation.

St. Louis-based Centene has more Medicaid managed-care business nationally than any other company. Centene last year acquired WellCare, a Medicaid insurer in Georgia, then closed down that operation in May.

Centene has also faced questions about overbilling. Ohio settled an $88 million pharmacy fraud lawsuit it filed against Centene months before awarding it a contract, while Mississippi settled with it for nearly $56 million. Now Georgia is expected to get money back under the $1 billion that Centene set aside to settle with other states affected by the pharmacy overbilling.

Consumer groups want the state to take stronger steps to advance the health of those who rely on Medicaid and to make the deals with the insurers more transparent.

“Medicaid members are best served when they have ready access to providers, insurers are eager to resolve their health care needs, and policymakers exercise strong oversight to ensure members’ health and well-being are prioritized over profits,” said Laura Colbert, executive director of Georgians for a Healthy Future, a consumer advocacy group.

A bill that aimed to bring more transparency and accountability to the state’s health care plans was vetoed last year by Republican Gov. Brian Kemp. The legislation would have allowed a committee to examine records of health care contractors and compel the state to respond to questions about them. Kemp said the bill would have violated the separation of powers doctrine between the executive and legislative branches of government.

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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Why At-Home Rapid Covid Tests Cost So Much, Even After Biden’s Push for Lower Prices

Mon, 09/13/2021 - 5:00am

Rapid at-home covid tests are flying off store shelves across the nation and are largely sold out online as the delta variant complicates a return to school, work and travel routines.

But at $10 or $15 a test, the price is still far too high for regular use by anyone but the wealthy. A family with two school-age children might need to spend $500 or more a month to try to keep their family — and others — safe.

For Americans looking for swift answers, the cheapest over-the-counter covid test is the Abbott Laboratories BinaxNOW two-pack for $23.99. Close behind are Quidel’s QuickVue tests, at $15 a pop. Yet supplies are dwindling. After a surge in demand, CVS is limiting the number of tests people can buy, and Amazon and Walgreen’s website were sold out as of Friday afternoon.

President Joe Biden said Thursday he would invoke the Defense Production Act to make 280 million rapid covid tests available. The administration struck a deal with Walmart, Amazon and Kroger for them to sell tests for “up to 35 percent less” than current retail prices for three months. For those on Medicaid, the at-home tests will be fully covered, Biden said.

An increased supply should help to lower prices. As schools open and much of the country languishes without pandemic-related restrictions, epidemiologists say widespread rapid-test screening — along with vaccination and mask-wearing — is critical to controlling the delta variant’s spread. Yet shortages, little competition and sticky high prices mean routine rapid testing remains out of reach for most Americans, even if prices drop 35%.

Consumers elsewhere have much cheaper — or free — options. In Germany, grocery stores are selling rapid covid tests for under $1 per test. In India, they’re about $3.50. The United Kingdom provides 14 tests per person free of charge. Canada is doling out free rapid tests to businesses.

Michael Mina, assistant professor of epidemiology at Harvard University, lauded Biden’s announcement on Twitter while saying he “had some reservations” about its scale and noted that 280 million tests represent “less than one test per person over the course of a year.”

Rep. Kim Schrier (D-Wash.) for months has advocated for rapid testing at a lower cost. “In an ideal world, a test would either be free or cost less than a dollar so that people could take one a few times a week to every day,” she said in the days before Biden’s announcement.

Biden’s initiative “is a great start” for broader rapid testing, Schrier said Friday. “But there is a lot more to be done, and that must be done quickly, to use this really important tool to combat this virus.”

A nationwide survey released in February by the Harvard T.H. Chan School of Public Health and Hart Research found that 79% of adults would regularly test themselves at home if rapid tests cost a dollar. But only a third would do so if the cost was $25.

Billions in taxpayer dollars have been invested in these products. Abbott Laboratories, for instance, cashed in on hundreds of millions in federal contracts and gave its shareholders fat payouts last year, increasing its quarterly dividend by 25%. Even so, according to a New York Times investigation, as demand for rapid tests cratered in early summer, Abbott destroyed its supplies and laid off workers who had been making them.

More than a year ago, Abbott said the company would sell its BinaxNOW in bulk for $5 a test to health care providers, but that option is not available over the counter to the public. Even with the anticipated price decrease, a two-pack will be more than $15. Abbott did not comment further.

Schrier said in spring that test prices were high because “big companies are buying up all the supplies.” Also, “their profit is far higher making 1,000 $30 tests than 30,000 $1 tests” — in other words, they can make the same amount of money for many fewer tests.

In March, the Biden administration allocated $10 billion as part of the American Rescue Plan Act to perform covid testing in schools, leaving the rollout largely to states. This followed $760 million spent by the Trump administration to buy 150 million of Abbott’s rapid-response antigen tests, many of which went to schools. The rollout has been mixed, with states like Missouri mired in logistical challenges.

In late August, Schrier wrote a letter asking four federal agencies to update their distribution plans. She also urged the government to increase spending on rapid testing, saying “time is of the essence” as children returned to school.

Antigen tests can give real-time information to people exposed to covid, said Dr. Dara Kass, an associate professor of emergency medicine at Columbia University Medical Center. Waiting for lab results from polymerase chain reaction (PCR) tests can take days, and many states — particularly in the hard-hit South — are seeing appointments fill up days in advance. At-home collection kits for PCR tests can cost over $100.

Rapid tests take under 15 minutes to detect covid by pinpointing proteins, called antigens. The tests are similar to a pregnancy test, with one or two lines displayed, depending on the result.

The Centers for Disease Control and Prevention recommends that fully vaccinated people exposed to covid wear a mask indoors for two weeks and get tested three to five days after exposure. The unvaccinated should quarantine for 14 days. But that leaves gray area for those vaccinated people hoping to attend classes or go about their lives, Kass said.

“Rapid tests give information,” she added, “that allows somebody to engage in society safely.” People can follow up with a PCR test, which is more sensitive, for confirmation of a diagnosis.

In Massachusetts, for example, a “Test and Stay” strategy for students exposed to covid allows them to remain in school: Students take BinaxNOW tests five days in a row following close contact with an infected person.

More than 30 antigen tests have been developed in the U.S. — though just six companies have FDA authorization for over-the-counter use. No rapid covid tests have full FDA approval. Two rapid molecular options, made by Lucira Health and Cue Health, also have emergency use authorization (EUA).

“Unfortunately, many submissions are incomplete or contain insufficient information for FDA to determine that they meet the statutory criteria,” FDA spokesperson James McKinney said.

The agency has taken a stricter stance than its European counterparts. In June, the FDA warned Americans to stop using Innova Medical Group’s rapid antigen test, stating that the agency had “significant concerns that the performance of the test has not been adequately established.” Yet in the U.K., which has contracts worth billions with the California company, the regulatory agency OK’d the product.

In Germany, regulators have given special authorization to dozens of antigen tests.

“As long as these tests are regulated as medical devices, the FDA has to regulate them not as critical public health tools, but as medical tools, with all of the onerous clinical trials that slow everything down 100-fold,” Mina said on Twitter.

With only a handful of rapid tests on the market, it is harder for companies that have not yet received FDA authorization to catch up and, in turn, drive the prices down, said Michael Greeley, co-founder and general partner at Flare Capital Partners, a venture capital firm focused on health care technology. “If we’re talking about people testing their kids every day going to school,” he added, “for many families, the current costs are a real burden.”

Broad adoption of rapid testing seems premature, he said, even with a mass purchase of tests by the U.S. government: “We can’t even get people to floss, so the idea that people are now going to start rapid testing as their standard operating procedure is a flawed assumption.”

Regardless, companies can’t keep up with demand.

Ellume said it saw a 900% spike in the use of its tests over the past month. Its at-home rapid test costs up to $38.99. On Walmart’s website, it was listed for $26.10 Friday but was out of stock.

The Australian manufacturer received $232 million from the U.S. Defense Department in February to scale up production, after the FDA authorized its at-home use late last year. But the federal Health Care Enhancement Act, which furnished the funding, does not impose pricing restrictions. Ellume said it will begin production at a Frederick, Maryland, plant this fall. For now, it is shipping tests from Australia.

This summer, Lucira Health stopped selling its about $50 molecular rapid test online to focus on larger clients, including San Francisco’s Chase Center, home to the Golden State Warriors, and the Olympics, Dan George, Lucira’s chief financial officer, said during a recent earnings call.

The company is still losing money as it ramps up production but hopes to return to selling directly on its website and Amazon later this year.

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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Categories: National News Content

Journalists Explain Ramifications of Theranos Trial and Texas’ New Abortion Law

Sat, 09/11/2021 - 5:00am

KHN Editor-in-Chief Elisabeth Rosenthal discussed health tech and the start of the fraud trial of Elizabeth Holmes, who founded the biological screening company Theranos, on WGN’s “The John Williams Show” on Wednesday.

KHN senior correspondent Julie Appleby discussed abortion law in Texas, covid-19 and vaccination rates on NPR’s weekly news roundup “1A” on Sept. 3.

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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It’s Not Just Covid: Recall Candidates Represent Markedly Different Choices on Health Care

Fri, 09/10/2021 - 5:00am

SACRAMENTO, Calif. — Gov. Gavin Newsom’s covid-19 rules have been a lightning rod in California’s recall election.

But there’s a lot more at stake for Californians’ health care than mask and vaccine mandates.

Newsom, a first-term Democrat, argues that their fundamental ability to get health insurance and medical treatments is on the line.

Republicans are seeking to “take away health care access for those who need it,” according to his statement in the voter guide sent to Californians ahead of Tuesday’s recall election.

Exactly where all the leading Republican recall candidates stand on health care is unclear. Other than vowing to undo state worker vaccine mandates and mask requirements in schools, none have released comprehensive health care agendas. Nor has Kevin Paffrath, the best-known Democrat in the race, who wants to keep existing vaccine and mask mandates.

Outside of his pandemic measures, Newsom has, in conjunction with the legislature, funded state subsidies to help low- and middle-income Californians buy health insurance; imposed a state tax penalty on uninsured people; and extended eligibility for Medi-Cal, the state’s Medicaid program for low-income people, to undocumented immigrants ages 19 to 26. This year, he signed legislation to further expand eligibility to unauthorized immigrants ages 50 and up. Republicans opposed all those initiatives.

Voters, who have been mailed ballots, have two choices to make: First, should Newsom be removed? Second, who among the 46 replacement candidates should replace him? A Public Policy Institute of California poll released Sept. 1 showed that 58% of likely voters want to keep Newsom in office.

To see where the leading recall candidates stand on health care, KHN combed through their speeches and writings, and scoured media coverage. Republicans John Cox and Kevin Kiley and Democrat Paffrath also consented to interviews. Republicans Larry Elder and Kevin Faulconer did not respond to repeated requests for interviews.

Larry Elder

Elder, 69, a conservative talk radio host, is far ahead of other candidates in polls. Elder believes health care is a “commodity,” not a right, and wants government out of health insurance.

He opposes Obamacare — even some of the most popular provisions of the 2010 law embraced by other Republicans, such as allowing children to stay on their parents’ health insurance until age 26 and guaranteeing coverage for people with preexisting medical conditions.

“Forcing an insurance company to cover people with pre-existing conditions completely destroys the concept of insurance,” Elder wrote in a 2017 opinion piece on his website.

In a 2010 opinion piece on creators.com, he wrote that he would end Medicaid, the state-federal health insurance program for low-income people, and phase out Medicare, the federal insurance program for older Americans and some people with disabilities. (As governor, he would not have the authority to do either.)

Instead, he wants people to rely primarily on high-deductible health plans and pay their hefty out-of-pocket costs with money they have saved in tax-free accounts.

Elder told CalMatters he doesn’t think taxpayers should spend money on “health care for illegal aliens” but also recently told CNN he has no plans to limit their eligibility for Medi-Cal, saying it’s “not even close to anything on my agenda.”

Elder calls himself “pro-life” but has said he doesn’t foresee abortion access changing in California. Still, anti-abortion activist Lila Rose tweeted that Elder had promised her he would cut abortion funding and veto legislation that made abortion more accessible.

Kevin Faulconer

In campaign stops and debates, the mayor of San Diego from 2014 to 2020 has cast himself as a moderate, experienced leader who worked with Democrats to clear the city’s streets and provide shelters for homeless people.

Faulconer, 54, often refers to San Diego’s success at decreasing homelessness as one of his greatest achievements in office. But that success came only after a 2017 hepatitis A outbreak killed 20 people and sickened nearly 600 others, most of whom were homeless. Faulconer and the city council were criticized for not intervening sooner to open more restrooms and hand-washing stations, despite warnings from health officials.

The city’s 12% reduction in the number of people sleeping on the streets from 2019 to 2020 resulted largely from efforts to curb the spread of covid by placing people in shelters.

A fiscal conservative, Faulconer is moderate on health care. He supports abortion rights and two years ago vowed not to restrict them.

If elected governor, Faulconer said, he would push to expand California’s paid parental leave program to 12 weeks at full pay. Currently, new parents get up to 70% of their income for up to eight weeks.

John Cox

Cox, 66, has centered his campaign — as he did his unsuccessful 2018 gubernatorial bid against Newsom — on his business credentials. The lawyer and accountant thinks the solution to California’s health care troubles lies in the free market, for example by letting patients know the cost of care ahead of time so they can shop for a better deal.

“I understand that health care is expensive, and families can’t afford it very well,” Cox said in an interview with KHN. But that’s because “there’s not enough price discrimination, not enough consumer orientation, not enough consumer choice.”

Health care is expensive partly because doctors and hospitals can charge whatever they want, and patients overutilize care because they don’t have to pay the full price, he said.

He favors health savings accounts with some government assistance for low-income people, which he said would make consumers more discriminating and keep health care prices in check. But he doesn’t want to take profit completely out of health care.

“I certainly want companies to make money from providing health care,” Cox said. “Because I think that’s what gives them an incentive to innovate.”

Kevin Kiley

Kiley, 36, a state Assembly member representing a suburban Sacramento district, often speaks out against government interference in people’s lives. The former teacher and attorney believes government rules about insurance coverage, doctor-patient relationships and independent contracting have contributed to higher health costs.

Like Elder and Cox, he wants more transparency and consumer choice in health care.

“I’m not sure it’s necessary to be continually specifying what every single plan needs to entail,” Kiley said in an interview with KHN. “I don’t know that legislators are always in the best position to be weighing in.”

Rather than provide health benefits to undocumented immigrants, Kiley said, lawmakers should scrutinize Medi-Cal, which covers about one-third of Californians but is failing to provide basic preventive care, including childhood vaccines, to some of its neediest patients.

Kiley downplayed the coverage gains made under Obamacare that have reduced the state’s uninsured rate from about 17% in 2013 to about 7%, saying a reduction was inevitable because of state and federal requirements to get health insurance or be penalized.

He has authored legislation, which did not pass, to increase funding for K-12 student mental health, which he says has only become more urgent in the pandemic.

Kevin Paffrath

Paffrath, 29, made his fortune giving financial advice on YouTube and renovating houses in Southern California.

If elected, Paffrath said, he would create 80 emergency facilities across the state to connect homeless people with doctors and substance use and mental health treatment. And he would require schools to offer better mental health education.

He also wants to create vocational programs for interested students ages 16 and up. With better job training and higher salaries, Medi-Cal rolls would naturally shrink, he argues.

“It’s not Californians’ fault that one-third of Californians are on Medi-Cal,” Paffrath said in an interview with KHN. “It’s our schools’.”

Paffrath supports the Affordable Care Act and said he is willing to consider questions such as whether California should adopt a single-payer health system or manufacture generic prescription drugs.

Paffrath said he’s most interested in cutting health insurance red tape, which creates bureaucratic hurdles for patients, makes doctors spend more time on paperwork than patient care, and discourages new providers from entering the field.

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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Categories: National News Content

ECMO Life Support Is a Last Resort for Covid, and in Short Supply in South

Fri, 09/10/2021 - 5:00am

Hospital discharge day for Phoua Yang was more like a pep rally.

On her way rolling out of TriStar Centennial Medical Center in Nashville, Tennessee, she teared up as streamers and confetti rained down on her. Nurses chanted her name as they wheeled her out of the hospital for the first time since she arrived in February with covid-19, barely able to breathe.

The 38-year-old mother is living proof of the power of ECMO — a method of oxygenating a patient’s blood outside the body, then pumping it back in. Her story helps explain why a shortage of trained staff members who can run the machines that perform this extracorporeal membrane oxygenation has become such a pinch point as covid hospitalizations surge.

“One hundred forty-six days is a long time,” Yang said of the time she spent on the ECMO machine. “It’s been like a forever journey with me.”

For nearly five months, Yang had blood pumping out a hole in her neck and running through the rolling ECMO cart by her bed.

ECMO is the highest level of life support — beyond a ventilator, which pumps oxygen via a tube through the windpipe, down into the lungs. The ECMO process, in contrast, basically functions as a heart and lungs outside the body.

The process, more often used before the pandemic for organ transplant candidates, is not a treatment. But it buys time for the lungs of covid patients to heal. Often they’ve been on a ventilator for a while. Even when it’s working well, a ventilator can have its own side effects after prolonged use — including nerve damage or damage to the lung itself through excessive air pressure.

Doctors often describe ECMO as a way to let the lungs “rest” — especially useful when even ventilation isn’t fully oxygenating a patient’s blood.

Many more people could benefit from ECMO than are receiving it, which has made for a messy triaging of treatment that could escalate in the coming weeks as the delta variant surges across the South and in rural communities with low vaccination rates.

The ECMO logjam primarily stems from just how many people it takes to care for each patient. A one-on-one nurse is required, 24 hours a day. The staff shortages that many hospitals in hot zones are facing compound the problem.

Yang said she sometimes had four or five clinical staff members helping her when she needed to take a daily walk through the hospital halls to keep her muscles working. ECMO is unusual as life support, because patients can be conscious and mobile, unlike patients on ventilators who often are sedated. This presents its own challenges, however. For Yang, one person’s job was just to make sure no hoses kinked as she moved, since the machine was literally keeping her alive.

Of all the patients treated in an intensive care unit, those on ECMO require the most attention, said nurse Kristin Nguyen, who works in the ICU at Vanderbilt University Medical Center.

“It’s very labor-intensive,” she said one morning, after a one-on-one shift with an ECMO patient who had already been in the ICU three weeks.

The Extracorporeal Life Support Organization said the average ECMO patient with covid spends two weeks on the machine, though many physicians say their patients average a month or more.

“These patients take so long to recover, and they’re eating up our hospital beds because they come in and they stay,” Nguyen said. “And that’s where we’re getting in such a bind.”

Barriers to using ECMO are not merely that there aren’t enough machines to go around or the high cost — estimated at $5,000 a day or significantly more, depending on the hospital.

“There are plenty of ECMO machines — it’s people who know how to run it,” said Dr. Robert Bartlett, a retired surgeon at the University of Michigan who helped pioneer the technology.

Every children’s hospital has ECMO, where it’s regularly used on newborns who are having trouble with their lungs. But Bartlett said that, before the pandemic, there was no point in training teams elsewhere to use ECMO when they might use the technology only a few times a year.

It’s a fairly high-risk intervention with little room for error. And it requires a round-the-clock team.

“We really don’t think it should be that every little hospital has ECMO,” Bartlett said.

Bartlett said his research team is working to make it so ECMO can be offered outside an ICU — and possibly even send patients home with a wearable device. But that’s years away.

Only the largest medical centers offer ECMO currently, and that has meant most hospitals in the South have been left waiting to transfer patients to a major medical center during the recent pandemic surge. But there’s no formal way to make those transfers happen. And the larger hospitals have their own covid patients eligible for ECMO who would be willing to try it.

“We have to make tough choices. That’s really what it comes down to — how sick are you, and what’s the availability?” said Dr. Harshit Rao, chief clinical officer overseeing ICU doctors with physician services firm Envision. He works with ICUs in Dallas and Houston.

There is no formal process for prioritizing patients, though a national nonprofit has started a registry. And there’s limited data on which factors make some covid patients more likely to benefit from ECMO than others.

ECMO has been used in the United States throughout the pandemic. But there wasn’t as much of a shortage early on when the people dying of covid tended to be older. ECMO is rarely used for anyone elderly or with health conditions that would keep them from seeing much benefit.

Even before the pandemic, there was intense debate about whether ECMO was just an expensive “bridge to nowhere” for most patients. Currently, the survival rate for covid patients on ECMO is roughly 50% — a figure that has been dropping as more families of sicker patients have been pushing for life support.

But the calculation is different for the younger people who make up this summer’s wave of largely unvaccinated covid patients in ICUs. So there’s more demand for ECMO.

“I think it’s 100% directed at the fact that they’re younger patients,” said Dr. Mani Daneshmand, who leads the transplant and ECMO programs at Emory University Hospital.

Even as big as Emory is, the Atlanta hospital is turning down multiple requests a day to transfer covid patients who need ECMO, Daneshmand said. And calls are coming in from all over the Southeast.

“When you have a 30-year-old or 40-year-old or someone who has just become a parent, you’re going to call. We’ve gotten calls for 18-year-olds,” he said. “There are a lot of people who are very young who are needing a lot of support, and a lot of them are dying.”

Even for younger people, who tend to have better chances on ECMO, many are debilitated afterward.

Laura Lyons was a comedian with a day job in New York City before the pandemic. Though just 31 when she came down with covid, she nearly died. ECMO, she said, saved her life. But she may never be the same.

“I was running around New York City a year and a half ago, and now I’m in a wheelchair,” she said. “My doctors have told me I’ll be on oxygen forever, and I’m just choosing not to accept that. I just don’t see my life attached to a cord.”

Lyons now lives at her parents’ house in central Massachusetts and spends most days doing physical therapy. Her struggle to regain her strength continues, but she’s alive.

Since it’s kind of the wild West to even get someone an ECMO bed, some families have made their desperation public, as their loved one waits on a ventilator.

As soon as Toby Plumlee’s wife was put on a ventilator in August, he started pressing her doctors about ECMO. She was in a northern Georgia community hospital, and the family searched for help at bigger hospitals — looking 500 miles in every direction.

“But the more you research, the more you read, the more you talk to the hospital, the more you start to see what a shortage it really is,” he said. “You get to the point, the only thing you can do is pray for your loved one — that they’re going to survive.”

Plumlee said his wife made it to sixth in line at a hospital 200 miles away — TriStar Centennial Medical Center, where Phoua Yang was finishing her 146-day ECMO marathon.

Yang left with a miracle. Plumlee and their children were left in mourning. His wife died before ever getting ECMO — a few days after turning 40.

This story was produced as part of NPR’s partnership with Kaiser Health News and Nashville Public Radio.

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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‘Luckiest Man Alive’: Why 9/11 First Responders’ Outlooks May Improve Even as Physical Health Fails

Fri, 09/10/2021 - 5:00am

Ray Pfeifer and Luis Alvarez’s names are on the federal 9/11 legislation that establishes benefits for first responders. Both men fought to make Congress pass it while they were dying of cancer — and they had another thing in common. In spite of it all, they were content.

“I am the luckiest man alive,” Pfeifer, a former New York City firefighter, told me in 2017, just about two months before he died of cancer linked to his time working in the ruins of the World Trade Center. It was something he said often.

“I love doing this,” retired NYC police Detective Luis Alvarez told me 19 days before he died, the night before he testified to Congress in 2019 with Jon Stewart to help win passage of the legislation that would come to bear his and Pfeifer’s names. Several months earlier, just after his 63rd chemotherapy treatment, he’d called himself “blessed.”

Having run into a toxic scene of chaos and destruction, as New York City firefighters and police officers did on Sept. 11, 2001, and getting sick because of it, may not seem like a recipe for any sort of happiness.

But a new report released by the New York City Fire Department finds that Alvarez and Pfeifer are not rare cases. Indeed, ever since 2006, when doctors and researchers in the department’s World Trade Center Health Program began detailed tracking of the mental health status of its responders, they found a remarkable fact — that even as 9/11 responders’ self-reported physical health has declined over the years, they have consistently reported their mental health-related quality of life as better than that of average Americans.

According to the extensive report on how members of the FDNY World Trade Center Health Program have fared in the past 20 years, about three-quarters of more than 15,000 Fire Department responders are now suffering at least one 9/11-related ailment, including 3,097 cases of cancer. Remarkably, even those with cancer reported their mental health-related quality of life as better than average.

“What we’re seeing is a complete turnaround, where the mental health outcome, despite the illnesses going on, is a positive one,” said Dr. David Prezant, chief medical officer of the FDNY and director of its Trade Center program.

Exactly why a group of people might experience improving outlooks on life even as they are increasingly struggling with health problems is hard to say definitively.

Alvarez’s brother, Phil, said he couldn’t speak for others but thought that, in his brother’s case, it had a lot to do with a sense of service, and that he was able to keep helping people even as he ailed.

“The only time I saw him hang his head was towards the end,” Phil Alvarez said. “I said to him, ‘Hey, brother, you know this is going south on us, don’t you?’ And he said, ‘Yeah, I know.’ And that was it. No complaints, not like ‘F–k, it got me,’ not like, ‘I lost.’ It was just, ‘Yeah, I know.’ And before that, you never heard him complain. Never. It was always about others, and I think that’s what keeps you alive.”

George Bonanno, a professor of clinical psychology at Columbia University who just released a book called “The End of Trauma: How the New Science of Resilience Is Changing How We Think About PTSD,” said that emerging research suggests there can be something of a hero or survivor effect, which can buoy a person’s spirits. “The suffering has a reason, it has a purpose, and your pain is in the context of you did something remarkable,” Bonanno said. “Because suffering is not easy, and if it’s just plain old suffering because ‘Too bad you got this thing and nobody else has it’ — that’s really hard to deal with. Because it feels unfair. So instead of being unfair, [for] firefighters, they did it intentionally — they willfully went in there.”

The sense of satisfaction first responders can take from their actions is one factor behind this finding, agreed Prezant.

“They know that where they are today from a health perspective is because they stepped up and helped their co-workers, New Yorkers, this country, deal with the largest attack on civilians ever in modern history. They were there that day,” Prezant said. “And when you ask our guys and gals, fire and EMS, would they have changed a single thing that they did that day, I’ve never heard a single one say otherwise.”

He and Bonanno also pointed to the support networks first responders have, especially in the Fire Department, where the health program Prezant runs offers care for both physical and mental health problems.

Prezant, who survived the collapse of the south tower because he got blown under a pedestrian bridge that didn’t completely cave in, said he knew that day his members would need a long-term commitment to their health.

“You view the future differently, especially when you know that you have not been abandoned,” Prezant said.

Pfeifer and Alvarez often talked about making sure others had support to live with the residual effects of that traumatic period. When Alvarez described himself as blessed, he said his main concerns in traveling to the Capitol between his chemo treatments were to make sure people who didn’t have city pensions would be taken care of, and that guys like him would seek treatment and medical monitoring sooner.

Perhaps just as important for people who watched so many of their brethren die on 9/11 was appreciating the chance to see their own families thrive.

“I am the luckiest man alive,” Pfeifer said again during a 2017 visit to Arlington National Cemetery. “Knock wood. 9/11 happens. I’m supposed to work. I lived. Why? Because I switched my tour. So, then a couple years later, I get cancer. So what? You know, I had time with my kids, to watch my kids grow up.”

Similarly, Alvarez kept making the trips to Washington even though it exhausted him because, he said, “it’s like my legacy. I want my kids to know that Dad did everything he could to help.”

Bonanno said that the research for his book included interviews with many of the people who fled the burning twin towers, and nearly every person he interviewed talked of the firefighters going up the stairs while they went down, reassuring evacuees along the way.

“It’s an iconic story, and this will go down in history, really, and to be part of it is, I think, a remarkable thing,” Bonanno said.

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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Las exenciones “religiosas” agregan más complicación a los mandatos de vacunación que se avecinan

Thu, 09/09/2021 - 6:01pm

En el norte de California, el pastor de una mega iglesia reparte formularios de exención religiosa a sus feligreses. Un senador estatal de Nuevo México ayudará con este documento, apuntando al uso de células fetales en el desarrollo de algunas vacunas, décadas atrás.

Y un evangelista con sede en Texas ofrece cartas de exención a cualquier persona, por una “donación” sugerida a partir de $25.

Con los mandatos de vacunas en los lugares de trabajo más cerca, los que se oponen están recurriendo a un argumento, que en muchas ocasiones ha sido efectivo, para evitar vacunarse contra covid-19: que las vacunas interfieren con sus creencias religiosas.

Ninguna iglesia mayor se opone a la vacunación. Incluso la Christian Science Church, cuyos seguidores dependen en gran medida de la oración en lugar de la medicina, no impone una política oficial. Aconseja “respeto por las autoridades de salud pública y obediencia consciente a las leyes del país, incluidas las que requieren vacunación”.

Y si una persona afirma que sus creencias religiosas prohíben la vacunación, es poco probable que el argumento se pueda sostener en una corte, dicen expertos legales. Aunque algunos miembros del clero se han manifestado en contra las vacunas, no tienen una justificación en los textos religiosos para sostener sus posiciones.

Aún así, la Comisión de Igualdad de Oportunidades en el Empleo (EEOC) de los Estados Unidos otorga un amplio margen de maniobra a lo que constituye una creencia religiosa sincera. Como resultado, algunos expertos predicen que la mayoría de los empleadores y administradores no querrán desafiar tales objeciones de sus empleados.

“Tengo la sensación de que no mucha gente va a querer pelear por este tema”, dijo el doctor John Swartzberg, experto en enfermedades infecciosas y profesor de la Universidad de California-Berkeley.

La aprobación completa por parte de la Administración de Alimentos y Medicamentos (FDA) de la vacuna de Pfizer-BioNTech el 23 de agosto podría llevar el tema a un punto crítico. Muchas agencias gubernamentales, proveedores de atención médica, universidades y el Ejército habían estado esperando antes de volverla mandatoria.

California, que abolió las exenciones no médicas para la vacunación infantil en 2015, ha liderado el camino en los mandatos de vacunas contra covid. La orden del 26 de julio del gobernador demócrata Gavin Newsom para que los empleados estatales y los trabajadores de salud se vacunen por completo o se sometan a pruebas semanales fue la primera de su tipo, al igual que una declaración similar el 11 de agosto para todos los maestros y el personal de las escuelas públicas y privadas.

El sistema de la Universidad Estatal de California de 23 campus se unió a la Universidad de California (UC) para exigir la vacunación de todos los estudiantes y el personal, y compañías como Google, Facebook y Twitter han anunciado una prueba obligatoria de vacunación para los empleados que regresan a sus oficinas.

UC exige prueba de vacunación para todo el personal y los estudiantes en sus 10 campus, una decisión que potencialmente afecta a medio millón de personas. Pero como muchas otras empresas, deja espacio para aquellos que quieran solicitar una exención “por motivos médicos, de discapacidad o religiosos”, y agrega que la ley lo exige.

Nada en la historia sugiere que una gran cantidad de estudiantes o miembros del personal usen este recurso, pero ninguna conversación previa sobre vacunas ha sido tan abiertamente politizada como la que surgió en torno a covid.

“Este país va a cumplir mandatos. Así es. Se han probado todas las demás alternativas”, dijo la doctora Monica Gandhi, experta en enfermedades infecciosas de UC-San Francisco. “Esa frase, ‘exención religiosa’, es muy amplia. Pero va a ser bastante difícil en el clima actual, en una crisis de salud masiva, con una vacuna que funciona, simplemente dejar pasarlas”.

Las iglesias anti-vacunas han ofrecido durante mucho tiempo a los padres reacios formas de eximir a sus hijos de las vacunas, pero en estos días las iglesias, los negocios religiosos basados ​​en Internet y otros parecen estar ofreciendo exenciones de vacunación por covid al por mayor.

El doctor Gregg Schmedes, senador estatal republicano y otorrinolaringólogo en Nuevo México, usó una publicación de Facebook del 19 de agosto para dirigir a los trabajadores de salud “con la creencia religiosa de que el aborto es inmoral” hacia un sitio que intenta catalogar el uso de células de fetos producto de abortos para probar o producir varias vacunas contra covid. Una vacuna distribuida en los Estados Unidos, la de Johnson & Johnson, no las usa, pero sí se produce utilizando un cultivo celular que se originó en parte en las células de la retina de un feto abortado en 1985.

Así y todo, el Vaticano ha considerado “moralmente aceptable” vacunarse contra covid. De hecho, el Papa Francisco lo declaró “una elección moral porque se trata de su vida, pero también de la vida de los demás”. En un número creciente de diócesis, Chicago, Philadelphia, Los Ángeles y Nueva York, entre otras, los obispos han instruido a los sacerdotes y diáconos a no firmar ninguna carta que otorgue el “imprimatur” (el sello oficial) de la iglesia a una solicitud de exención religiosa.

Schmedes no respondió a las preguntas formuladas por KHN por correo electrónico.

Mientras tanto, en la ciudad de Rocklin, en el área de Sacramento, una iglesia que desafió abiertamente las órdenes de cierre de Newsom el año pasado ha entregado cientos de cartas de exención. Greg Fairrington, pastor de la Iglesia Cristiana Destiny, dijo a los asistentes a un servicio religioso: “Nadie debería poder exigir que se vacunen a riesgo de perder el trabajo. Eso no está bien aquí en los Estados Unidos”.

Las pautas de la EEOC sugieren que los empleadores hagan “ajustes razonables” para aquellos que tengan una objeción religiosa sincera a una regla del lugar de trabajo. Eso podría significar trasladar a un empleado no vacunado a una parte aislada de la oficina, que implique menos contacto interpersonal. Pero el empleador no está obligado a hacer nada que genere en una dificultad excesiva.

En cuanto a la objeción en sí, el consejo de la comisión es vago. Los empleadores “normalmente deberían asumir que la solicitud de un empleado se basa en una creencia religiosa sincera”, dice la EEOC. Los empleadores tienen derecho a solicitar documentación de respaldo, pero las creencias religiosas de los empleados no tienen que ceñirse a ninguna fe específica u organizada.

La distinción entre religión e ideología se vuelve difusa entre quienes buscan exenciones.

Una maestra de preescolar en Turlock, California, recibió una carta de exención de su pastor, que las ofrecía a quienes sentían que recibir una vacuna era “moralmente comprometedor”. Cuando KHN le preguntó a través de un mensaje directo por qué buscaba la exención, la mujer dijo que no se sentía cómoda de vacunarse debido a “lo que hay en la vacuna”, y luego agregó: “¡Personalmente, he superado a ‘Covid’ y al control que está tratando de imponernos el gobierno!”.

Al igual que otros solicitantes de exenciones, incluso aquellos que han publicado en grupos antivacunas de Facebook, temían que otras personas supieran que habían pedido una exención.

Una técnica quirúrgica que trabaja en Dignity Health, que ordenó que sus empleados estén completamente vacunados para el 1 de noviembre, dijo que estaba esperando una respuesta del departamento de recursos humanos de la compañía sobre su solicitud de una exención religiosa.

La mujer explicó libremente sus razones haciendo referencia a dos pasajes de la Biblia y enumerando los ingredientes de la vacuna que dijo son “dañinos para el cuerpo humano”. Pero no quería que nadie supiera que había solicitado la exención religiosa.

El derecho de un estado a exigir la vacunación se ha establecido como ley desde un fallo de la Corte Suprema de 1905 que confirmó la vacunación obligatoria contra la viruela en Massachusetts. Los expertos legales dicen que ese derecho se ha defendido en repetidas ocasiones, incluso en una decisión de la Corte Suprema de 1990 de que las acciones por motivos religiosos no están aisladas de las leyes, a menos que una ley señale la religión como trato desfavorecido.

En agosto, la jueza de la Corte Suprema Amy Coney Barrett declinó, sin comentarios, un desafío a la regla de la Universidad de Indiana de que todos los estudiantes, el personal y los profesores deben estar vacunados.

“Según la ley actual, está claro que no se requiere ninguna exención religiosa”, dijo a KHN Erwin Chemerinsky, decano de la escuela de derecho de UC-Berkeley. Claramente, eso no impide que la gente busque una.

Esta historia fue producida por KHN, que publica California Healthline, un servicio 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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KHN’s ‘What the Health?’: The Future of Public Health

Thu, 09/09/2021 - 12:15pm

Can’t see the audio player? Click here to listen on SoundCloud. You can also listen on Spotify, Apple Podcasts, Stitcher, Pocket Casts or wherever you listen to podcasts.

Click here for a transcript of the episode.

The covid-19 pandemic has shone a spotlight on public health, a key part of the health care system that usually operates in the background. Public health has, over the past century, helped ensure that Americans have clean water to drink, untainted food to eat and vaccines that have helped obliterate once-common deadly diseases.

But like other issues related to the pandemic, public health has become politicized and controversial, leading some public health officials to quit or retire. Some even have been physically threatened just for doing their jobs, trying to keep people healthy and safe.

KHN’s “What the Health?” podcast this week takes a deep dive into public health, its past and future. First, host Julie Rovner talks with Dr. Ashish Jha, dean of the Brown University School of Public Health, about the importance of public health.

Then panelists Joanne Kenen of Politico and Lauren Weber of KHN join Rovner for a discussion of public health’s prospects for the future.

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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‘An Arm and a Leg’: How Charity Care Made It Into the ACA

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

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Charity care is one tiny provision in the giant Affordable Care Act, and it can make a big difference for patients who face huge bills. How did it get into the law? One Republican senator made sure the ACA required nonprofit hospitals to act more like charities — and less like loan sharks — but he still voted against the whole bill.

The national requirement to offer charity care emerged from the Obama White House’s failed courtship of GOP Sen. Chuck Grassley of Iowa. In this episode, we hear how that political tango almost tanked the ACA — and how the battle over the ACA “broke America.” Featured are David Axelrod, a former adviser to President Barack Obama; longtime health policy reporter and KHN chief Washington correspondent Julie Rovner; and a top Grassley aide.

This is the second in a four-part series that looks at the (slow, uneven) development of legal protections for consumers (aka patients, aka people who just don’t want to die and aren’t Bill Gates) against outrageous medical bills and draconian collection practices.

Catch up on the first episode, before or after listening to this one. It’s about how a legendary lawyer — the guy who beat Big Tobacco in the 1990s — tried to sue nonprofit hospitals into acting more like charities and less like loan sharks. (He lost, but it wasn’t a total dead end; that’s where this episode picks up.) 

Here’s a transcript for this episode.

“An Arm and a Leg” is a co-production of KHN and Public Road Productions.

To keep in touch with “An Arm and a Leg,” subscribe to the newsletter. You can also follow the show on Facebook and Twitter. And if you’ve got stories to tell about the health care system, the producers would love to hear from you.

To hear all KHN podcasts, click here.

And subscribe to “An Arm and a Leg” on Spotify, Apple Podcasts, StitcherPocket 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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Even in Red States, Colleges Gravitate to Requiring Vaccines and Masks

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

As students head to college this fall, hundreds of schools are requiring employees and students to be vaccinated against covid, wear masks on campus or both.

But at some schools, partisan politics have bolstered efforts to stymie public health protections.

Events at the University of South Carolina, in a deeply conservative state, demonstrate the limits of political pressure in some cases, even though “South Carolina is a red state and its voters generally eschew mandates,” said Jeffrey Stensland, a spokesperson for the school.

As the fall semester approached, Richard Creswick, an astrophysics professor at the University of South Carolina, was looking forward to returning to the classroom and teaching in person. He felt it would be fairly safe. His graduate-level classes generally had fewer than a dozen students enrolled, and the school had announced it would require everyone on campus to wear masks indoors unless they were in their dorm rooms, offices or dining facilities. For Creswick, 69, that was important because he did not want his working on campus to add to the covid risk for his wife, Vickie Eslinger, 73, who has been undergoing treatment for breast cancer.

But state Attorney General Alan Wilson weighed in early in August, sending a letter to the school’s interim president, Harris Pastides, that a budget provision passed by the state legislature prohibited the university from imposing a mask mandate. Pastides, who previously served as dean of the university’s school of public health, rescinded the mask mandate, although he encouraged people to still use them.

“We were very upset,” Creswick said.

After the university revoked its mask mandate, within days Wilson sent out a campaign fundraising letter touting his intervention in public health measures and stating, “The fight over vaccines and masks has never been about science or health. It’s about expanding the government’s control over our daily lives.”

Creswick and Eslinger, who felt strongly that the mask mandate was indeed about health, filed a lawsuit, arguing that the legislative provision cited by the attorney general did not prohibit a universal mask mandate. The state Supreme Court took up the case on an expedited basis and on Aug. 20 ruled 6-0 in their favor.

The school immediately reinstated its mask mandate and other colleges in the state followed suit.

After the court ruling, Creswick said he heard from professors at several other South Carolina colleges. “They’re calling me a hero,” he said, sounding bemused.

The attorney general’s office didn’t respond to a request for comment.

The Centers for Disease Control and Prevention recommends that everyone at colleges and universities wear masks indoors, even if they are fully vaccinated, in locales with substantial or high transmission of the coronavirus. Most of the country meets that standard at this point. The CDC also recommends that colleges offer and promote covid vaccines.

To be sure, many colleges and universities already require students to mask up or be vaccinated.

As of Aug. 26, the Chronicle of Higher Education had tallied 805 campuses that require at least some employees or students to be vaccinated. Most schools grant exemptions from the vaccine mandate, often for religious or medical reasons. And hundreds of colleges are requiring students and staff members to wear masks on campus this fall, according to a running tally by University Business.

Still, 12 conservative-leaning states prohibit vaccine mandates at higher education institutions, according to an analysis by the National Academy for State Health Policy. The rules vary, and some apply only to public institutions. The group is in the process of analyzing mask mandate bans that apply to colleges and universities.

At Indiana University, a group of students challenged the school’s vaccine mandate on the grounds it violated their constitutional right to “bodily integrity, autonomy and medical choice.” The U.S. Court of Appeals for the 7th Circuit refused to block the school’s policy. The court reasoned the universities can decide what they need to do to keep students safe in communal settings. The students then appealed to U.S. Supreme Court Justice Amy Coney Barrett, who refused without explanation to block the mandate.

Red states with Republican leadership are hardly the only ones where colleges and universities are facing restrictions on their ability to put public health protections in place. But for teachers, whose professions are rooted in encouraging the pursuit of learning and knowledge, prohibitions that fly in the face of science and jeopardize public health can be tough to swallow.

“It’s completely demoralizing to realize that our health and safety has been trumped by politics,” said Becky Hawbaker, an assistant professor in the College of Education at the University of Northern Iowa in Cedar Falls, Iowa, who is president of United Faculty, the union representing 600 faculty members at the school. “It seems like you know a train wreck is coming and you’re sounding the alarm, and no one seems to listen.”

At the University of Georgia in Athens in August, a professor who made masks mandatory in his classroom because of his advanced age and health conditions promptly resigned when a student refused to don a mask. Georgia’s university system does not mandate masks or vaccines.

In May, Iowa Gov. Kim Reynolds, a Republican, signed a law prohibiting mask mandates at K-12 schools, and within city and county governments. A few days later, the Iowa Board of Regents, which oversees the University of Northern Iowa, the University of Iowa and Iowa State University, lifted emergency rules that had been in place the previous year requiring indoor masking and physical distancing at the colleges.

The University of Northern Iowa held classes in person throughout the past school year, without major problems, using those mask and distancing requirements, Hawbaker said. But with the rise of the delta variant and the increase in covid cases in the community, now is not the time to remove safety restrictions, the union asserts.

So far, more than 200 people have signed an August letter sent by the union to the Board of Regents requesting mask and vaccine mandates on campus, and classroom changes to allow physical distancing, Hawbaker said.

“Both the Board and our universities recommend and encourage individuals to wear a mask or other face covering while on campus, and anyone who wishes to wear a mask may do so,” Josh Lehman, a spokesperson for the board, wrote in an email. The board also supports students and staffers getting covid vaccines, which are available on campus.

At Clemson University in Clemson, South Carolina, associate professor Kimberly Paul planned a protest with other faculty members in August to push for a mask mandate. After the state Supreme Court ruled in favor of Creswick, Clemson announced a mask mandate until Oct. 8. That stretch covers the period of greatest covid risk, according to the school’s modeling.

Paul and her colleagues want a mask mandate for the entire semester, after which the need can be reevaluated, she said.

“I’m a biologist, and this hits close to home,” she said.

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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‘Religious’ Exemptions Add Legal Thorns to Looming Vaccine Mandates

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

In Northern California, the pastor of a megachurch hands out religious exemption forms to the faithful. A New Mexico state senator will “help you articulate a religious exemption” by pointing to the decades-old use of aborted fetal cells in the development of some vaccines. And a Texas-based evangelist offers exemption letters to anyone — for a suggested “donation” starting at $25.

With workplace vaccine mandates in the offing, opponents are turning to a tried-and-true recourse for avoiding a covid-19 shot: the claim that vaccination interferes with religious beliefs.

No major denomination opposes vaccination. Even the Christian Science Church, whose adherents rely largely on prayer rather than medicine, does not impose an official policy. It counsels “respect for public health authorities and conscientious obedience to the laws of the land, including those requiring vaccination.”

And if a person claims their privately held religious beliefs forbid vaccination, that defense is unlikely to hold up in court if challenged, legal experts say. Although individual clergy members have mounted the anti-vaccine bandwagon, they have no obvious justification in religious texts for their positions. Many seem willing to cater to people who reject vaccination for another reason.

Still, the U.S. Equal Employment Opportunity Commission (EEOC) grants broad leeway to what constitutes a sincerely held religious belief. As a result, some experts predict most employers and administrators won’t want to challenge such objections from their employees.

“I have a feeling that not a lot of people are going to want to fight on this topic,” said Dr. John Swartzberg, an expert on infectious diseases and professor at the University of California-Berkeley.

The Food and Drug Administration’s full approval of the Pfizer-BioNTech vaccine on Aug. 23 could bring the matter to a head. Many government agencies, health care providers, colleges and the military had been awaiting the move before enforcing mandates.

California, which abolished nonmedical exemptions for childhood vaccination in 2015, has led the way on covid vaccine mandates. Democratic Gov. Gavin Newsom’s July 26 order for state employees and health care workers to be fully vaccinated or submit to weekly testing was the first of its kind, as was a similar declaration Aug. 11 for all teachers and staff at both public and private schools. The 23-campus California State University system joined UC in requiring vaccination of all students and staff, and companies like Google, Facebook and Twitter have announced mandatory proof of employee vaccination for those who return to their offices.

The University of California is requiring proof of vaccination for all staffers and students across its 10 campuses, a decision that potentially affects half a million people. But like many other businesses, it makes room for those who wish to request an exemption “on medical, disability or religious grounds,” adding that it is required by law to do so.

Nothing in history suggests that a large number of students or staff members will seek such an out — but then, no previous vaccine conversation has been as overtly politicized as the one around covid.

“This country is going to mandates. It just is. Every other alternative has been tried,” said Dr. Monica Gandhi, an infectious diseases expert at UC-San Francisco. “That phrase, ‘religious exemption,’ is very big. But it’s going to be quite hard in the current climate — in a mass health crisis, with a vaccine in place that works — to just let any such religious claims go.”

Indeed, while pop-up anti-vaccine churches have long offered reluctant parents ways to exempt their kids from shots, these days churches, internet-based religious businesses and others seem to be offering covid vaccination exemptions wholesale.

Dr. Gregg Schmedes, a Republican state senator and otolaryngologist in New Mexico, used an Aug. 19 Facebook post to direct health care workers “with a religious belief that abortion is immoral” to a site that attempts to catalog the use of cells from aborted fetuses to test or produce various covid vaccines. One U.S.-distributed vaccine, the Johnson & Johnson product, is made using a cell culture that partly originated in retinal cells from a fetus aborted in 1985.

Yet the Vatican has deemed it “morally acceptable” to get a covid vaccination. In fact, Pope Francis declared it “the moral choice because it is about your life but also the lives of others.” In an increasing number of dioceses — Chicago, Philadelphia, Los Angeles and New York, among others — bishops have instructed priests and deacons not to sign any letter that lends the church’s imprimatur to a request for religious exemption.

Schmedes did not respond to questions posed by KHN via email.

In the Sacramento-area city of Rocklin, meanwhile, a church that openly defied Newsom’s covid shutdown orders last year has handed out hundreds of exemption letters. Greg Fairrington, pastor of Destiny Christian Church, told attendees at a church service, “Nobody should be able to mandate that you have to take a vaccine or you lose your job. That’s just not right, here in America.”

EEOC guidelines suggest that employers make a “reasonable accommodation” to those with a sincerely held religious objection to a workplace rule. That might mean moving an unvaccinated employee to an isolated part of the office, or from a forward-facing position to one that involves less interpersonal contact. But the employer isn’t required to do anything that results in an undue hardship or more than a “de minimis” cost.

As for the objection itself, the commission’s advice is vague. Employers “should ordinarily assume that an employee’s request for religious accommodation is based on a sincerely held religious belief,” the EEOC says. Employers have the right to ask for supporting documentation, but employees’ religious beliefs don’t have to hew to any specific or organized faith.

The distinction between religion and ideology is blurring among those seeking exemptions. In Turlock, California, a preschool teacher was provided an exemption letter by her pastor, who offered the documents to those who felt taking a vaccine was “morally compromising.” Asked by KHN via direct message why she sought the exemption, the woman said she didn’t feel comfortable being vaccinated because of “what’s in the vaccine,” then added, “I personally am over ‘Covid’ and the control the government is trying to implement on us!” Like other exemption seekers, even those who have posted in Facebook anti-vaccine groups, she feared having other people know she sought an exemption.

A surgical technician working at Dignity Health, which has ordered its employees to be fully vaccinated by Nov. 1, said she was awaiting a response from the company’s human resources department on her request for a religious exemption. She freely explained her reasons for applying by referencing two Bible passages and listing vaccine ingredients she said are “harmful to the human body.” But she didn’t want anyone to know she applied for the religious exemption.

A state’s right to require vaccination has been settled law since a 1905 Supreme Court ruling that upheld compulsory smallpox vaccination in Massachusetts. Legal experts say that right has been upheld repeatedly, including in a 1990 Supreme Court decision that religiously motivated actions aren’t insulated from laws, unless a law singles out religion for disfavored treatment. In August, Supreme Court Justice Amy Coney Barrett declined, without comment, a challenge to Indiana University’s rule that all students, staff and faculty be vaccinated.

“Under current law it is clear that no religious exemption is required,” Erwin Chemerinsky, dean of UC-Berkeley’s law school, told KHN. Clearly, that is not preventing people from seeking one.

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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Listen: Many Schools Are Buying High-Tech Air Purifiers. What Should Parents Know?

Wed, 09/08/2021 - 5:00am

This is a collaboration between KHN and “Science Friday.” Listen to the conversation between KHN senior correspondent Christina Jewett and Science Friday’s host and executive producer, Ira Flatow.

As students return to school, parents are getting a lot of mail about what schools are doing to better protect kids in the classroom — including details on mask policies and how kids will sit at lunch. One item on many administrators’ lists of protective measures is improving ventilation in the classroom.

Many studies have shown that better ventilation and air circulation can greatly reduce covid-19 transmission. But rather than stocking up on HEPA filters, some school districts are turning to high-tech air purification strategies, including the use of untested electronic methods and airborne chemicals.

KHN has written extensively about school air filtration. Senior correspondent Christina Jewett joins Ira Flatow to explain why some air-quality experts are less than convinced by the marketing claims made by many electronic air purifier companies.

Don’t miss the simple snail-mail hack Jewett shares to gauge whether the device your school is using might be of concern.

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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Florida Spine Surgeon and Device Company Owner Charged in Kickback Scheme

Wed, 09/08/2021 - 5:00am

A Florida orthopedic surgeon and designer of costly spinal surgery implants was arrested Tuesday and charged with paying millions of dollars in kickbacks and bribes to surgeons who agreed to use his company’s devices.

Dr. Kingsley R. Chin, 57, of Fort Lauderdale, Florida, is the founder, chief executive officer and owner of SpineFrontier, a device company based in Malden, Massachusetts. He and the company’s chief financial officer, Aditya Humad, 36, of Cambridge, Massachusetts, were each indicted on one count of conspiring to violate federal anti-kickback laws, six counts of violating the kickback statute and one count of conspiracy to commit money laundering, officials said.

The indictment alleges that SpineFrontier, Chin and Humad paid surgeons between $250 and $1,000 per hour in sham consulting fees for work they did not perform. In exchange, the surgeons agreed to use SpineFrontier’s products in operations paid for by federal health care programs such as Medicare and Medicaid. Surgeons accepted between $32,625 and $978,000 in improper payments, according to the indictment.

“Kickback arrangements pollute federal health care programs and take advantage of patient needs for financial gains,” said Nathaniel Mendell, acting U.S. attorney for the District of Massachusetts.

“Medical device manufacturers must play by the rules, and we will keep pursuing those who fail to do so, regardless of how their corruption is disguised.”

Chin and SpineFrontier were the subjects of a KHN investigation published in June that found that manufacturers of hardware for spinal implants, artificial knees and hip joints had paid more than $3.1 billion to orthopedic and neurosurgeons from August 2013 through 2019. These surgeons collected more than half a billion dollars in industry consulting fees, federal payment records show.

Chin, a self-styled “doctorpreneur,” formed SpineFrontier about a decade after completing his training at Harvard Medical School.

Chin has patented dozens of pieces of spine surgery hardware, such as doughnut-shaped plastic cages, titanium screws and other products that generated some $100 million in sales for SpineFrontier, according to government officials. In 2018, SpineFrontier valued Chin’s ownership of the company at $75 million, though its current worth is unclear. He maintains a medical practice in Hollywood, Florida. Neither Chin nor Humad could be reached for comment Tuesday.

Seth Orkand, a Boston attorney who represents Humad, said his client “denies all charges, and looks forward to his day in court.”

The Department of Justice filed a civil lawsuit against Chin and SpineFrontier in March 2020, accusing the company of illegally funneling more than $8 million to nearly three dozen spine surgeons through the “sham” consulting fees. Chin and SpineFrontier have yet to file a response to that suit.

However, at least six surgeons have admitted wrongdoing in the civil case and paid a total of $3.3 million in penalties. Another, Dr. Jason Montone, 45, of Lawson, Missouri, pleaded guilty to criminal kickback charges and is set to be sentenced early next year. Federal law prohibits doctors from accepting anything of value from a device-maker for agreeing to use its products, though most offenders don’t face criminal prosecution.

The grand jury indictment lists seven surgeons as having received bribes totaling $2,747,463 to serve as “sham consultants.” One doctor, identified only as “surgeon 7,” received $978,831, according to the indictment. Many of the illicit payments were made through a Fort Lauderdale company controlled by Chin and Humad, according to the indictment.

The SpineFrontier executives set up the separate company partly to evade requirements for device companies to report payments to surgeons to the government, according to the indictment. Some surgeons were told they could bill for more consulting hours if they used more expensive SpineFrontier products, officials said.

Conspiring to violate the kickback laws can bring a sentence of up to five years in prison, while violating the kickback laws can result in a sentence of up to 10 years, officials said.

“Kickbacks paid to surgeons as sham medical consultants, as alleged in this case, cheat patients and taxpayers alike,” said Phillip Coyne, special agent in charge of the U.S. Department of Health and Human Services Office of Inspector General.

“Working with our law enforcement partners, we will continue to investigate kickback schemes that threaten the integrity of our federal health care system, no matter how those schemes are disguised.”

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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California Set to Spend Billions on Curing Homelessness and Caring for ‘Whole Body’ Politic

Wed, 09/08/2021 - 5:00am

OAKLAND, Calif. — Living unmedicated with schizophrenia and bipolar disorder, Eugenia Hunter has a hard time recalling how long she’s been staying in the tent she calls home at the bustling intersection of San Pablo Avenue and Martin Luther King Jr. Way in Oakland’s hip Uptown neighborhood. Craft coffee shops and weed dispensaries are plentiful here and one-bedroom apartments push $3,000 per month.

“At least the rats aren’t all over me in here,” the 59-year-old Oakland native said on a bright August afternoon, stretching her arm to grab the zipper to her front door. It was hot inside and the stench of wildfire smoke hung in the air. Still, after sleeping on a nearby bench for the better part of a year, she felt safer here, Hunter explained as she rolled a joint she’d use to ease the pain from also living with what she said is untreated pancreatic cancer.

Hunter has been hospitalized repeatedly, including once last summer after she overdosed on alcohol and lay unconscious on a sidewalk until someone stopped to help. But she is reluctant to see a doctor or use Medi-Cal, California’s health insurance program for low-income and disabled people, largely because it would force her to leave her tent.

“My stuff keeps on getting taken when I’m not around and, besides, I’m waiting until I got a place to live to start taking my medication again,” Hunter said, tearing up. “I can’t get anything right out here.”

Hunter’s long and complex list of ailments, combined with her mistrust of the health care system, make her an incredibly difficult and expensive patient to treat. But she is exactly the kind of person California intends to prioritize under an ambitious experiment to move Medi-Cal beyond traditional doctor visits and hospital stays into the realm of social services. Under the program, vulnerable patients like Hunter will be assigned a personal care manager to coordinate their health care treatments and daily needs like paying bills and buying groceries. And they will receive services that aren’t typically covered by health insurance plans, such as getting security deposits paid, receiving deliveries of fruits and vegetables, and having toxic mold removed from homes to reduce asthma flare-ups.

Over the next five years, California is plowing nearly $6 billion in state and federal money into the plan, which will target just a sliver of the 14 million low-income Californians enrolled in Medi-Cal: homeless people or those at risk of losing their homes; heavy users of hospital emergency rooms; children and seniors with complicated physical and mental health conditions; and people in — or at risk of landing in — expensive institutions like jails, nursing homes or mental health crisis centers.

Gov. Gavin Newsom is trumpeting the first-in-the-nation initiative as the centerpiece of his ambitious health care agenda — and vows it will help fix the mental health and addiction crisis on the streets and get people into housing, all while saving taxpayer money. His top health care advisers have even cast it as an antidote to California’s worsening homelessness crisis.

But the first-term Democrat, who faces a Sept. 14 recall election, is making a risky bet. California does not have the evidence to prove this approach will work statewide, nor the workforce or infrastructure to make it happen on such a large scale.

Critics also fear the program will do nothing to improve care for the millions of other Medi-Cal enrollees who won’t get help from this initiative. Medi-Cal has been slammed for failing to provide basic services, including vaccinations for kids, timely appointments for rural residents and adequate mental health treatment for Californians in crisis. Yet the managed-care insurance companies responsible for most enrollees’ health will nonetheless be given massive new power as they implement this experiment. The insurers will decide which services to offer and which high-needs patients to target, likely creating disparities across regions and further contributing to an unequal system of care in California.

“This will leave a lot of people behind,” said Linda Nguy, a policy advocate at the Western Center on Law & Poverty.

“We haven’t seen health plans excel in even providing basic preventative services to healthy people,” she said. “I mean, do your basic job first. How can they be expected to successfully take on these additional responsibilities for people with very high health needs?”

This revolution in Medi-Cal’s scope and mission is taking place alongside a parallel initiative to hold insurance companies more accountable for providing quality health care. State health officials are forcing Medi-Cal managed-care plans to reapply and meet stricter standards if they want to continue doing business in the program. Together, these initiatives will fundamentally reinvent the biggest Medicaid program in the country, which serves about one-third of the state population at a cost of $124 billion this fiscal year.

If California’s experiment succeeds, other states will likely follow, national Medicaid experts say. But if the richest state in the country can’t pull off better health outcomes and cost savings, the movement to put health insurers into the business of social work will falter.

*****

When Newsom signed the “California Advancing and Innovating Medi-Cal” initiative into law in late July — “CalAIM” for short — he celebrated it as a “once-in-a-generation opportunity to completely transform the Medicaid system in California.” He declined an interview request.

Beginning next year, public and private managed health care plans will pick high-need Medi-Cal enrollees to receive nontraditional services from among 14 broad categories, including housing and food benefits, addiction care and home repairs.

The approach is known as “whole person care,” and insurers will be required to assign patients a personal care manager to help them navigate the system. Insurers will receive incentive payments to offer new services and boost provider networks and, over time, the program will expand to more people and services. For instance, members of Native American tribes will eventually be eligible to receive treatment for substance misuse from natural healers, and inmates will be enrolled in Medi-Cal automatically upon release.

The insurers — currently 25 are participating — will focus most intensely on developing housing programs to combat the state’s worsening homelessness epidemic. The state was home to at least 162,000 homeless people in 2020, a 6.8% increase since Newsom took office in 2019.

Jacey Cooper, the state’s Medicaid director, said all Medi-Cal members will eventually be eligible for housing services. Initially, though, they will be available only to the costliest patients. State Medi-Cal expenditure data shows that 1% of Medi-Cal enrollees, many of the homeless patients who frequently land in hospitals, account for a staggering 21% of overall spending. And 5% account for 44% of the budget.

“You really need to focus on your top 1% to 5% of utilizers — that’s your most vulnerable,” Cooper said. “If you generally focus on that group, you will be able to yield better health outcomes for those individuals and, ultimately, cost savings.”

State officials do not have a savings estimate for the program, nor a projection of how many people will be enrolled.

The plan, Cooper said, builds on more than 25 successful regional experiments underway since 2016. From Los Angeles to rural Shasta, big and small counties have provided vulnerable Medi-Cal patients with different services based on their communities’ needs, from job placement services to providing a safe place for a homeless person to get sober.

Cooper highlighted interim data from the experiments that showed patients hospitalized due to mental illness were more likely to receive follow-up care, obtain treatment for substance abuse, avoid hospitalizations and emergency department visits, and see improvements in chronic diseases like diabetes.

She argued that data — even though it is not comprehensive — is enough to prove the initiative will work on a statewide scale.

However, studies of similar programs elsewhere have yielded mixed results. New York provided housing services to high-cost Medicaid enrollees with chronic diseases and mental health and substance use disorders and found major reductions in hospital admissions and emergency department visits between 2012 and 2017, and saw a 15% reduction in Medicaid spending.

In Camden, New Jersey, an early test of the “whole person care” approach provided expensive Medicaid patients with intensive care coordination, but not nontraditional services. A study concluded in 2020 that it hadn’t lowered hospital readmissions — and thus didn’t save health care dollars.

“We found we just couldn’t help people with housing as quickly as they needed help,” said Kathleen Noonan, CEO of the Camden Coalition of Healthcare Providers. “Many of these clients have bad credit, they may have a record, and they’re still using. Those are huge challenges.”

California may find success where the coalition hadn’t because it will offer social services, she said, which the coalition has also started doing.

But it will take time. California will have five years to prove to the federal government it can save money and improve health care quality. Insurers will be required to track health outcomes and savings, and can boost services over time or drop programs that don’t work.

So far, the regional experiments have failed to serve low-income Black and Latino residents, according to the interim assessments conducted by Nadereh Pourat, director of the UCLA Center for Health Policy Research. She concluded that they have primarily benefited white, English-speaking, middle-aged men.

Cooper said the statewide initiative will tackle “systemic racism,” initially as it targets homeless people, who are disproportionately Black.

Consider Eugenia Hunter, who is African American, and whose many untreated mental and physical illnesses, intertwined with her addictions, mean it will take a herculean effort — and cost — to get her off the street.

Hunter has been homeless for at least three years. Or maybe it’s five; her mental illness clouds her memory, and she erupts in anger when pressed for details. She eases her frustration sometimes with sleep, sometimes by smoking crystal meth.

A stack of unopened health insurance letters sat beside Hunter one evening in late August. Her eyes were glassy when she struggled to remember when she received a cancer diagnosis — if she ever did at all.

*****

Health insurers will not be required to offer social services to patients like Hunter because federal law requires nontraditional Medicaid services to be optional. But California is enticing insurers with bigger payouts and higher state rankings.

“We are asking the plans and providers to stretch. We’re asking them to reform,” Cooper said.

The state is urging insurers to start with the roughly 130,500 Medi-Cal patients already enrolled in the local experiments. To prepare, they are cobbling together networks of nonprofits and social service organizations to provide food, housing and other services — much as they do with doctors and hospitals contracted to deliver medical care.

Services will vary by insurer and region. The Inland Empire Health Plan, for example, will offer some patients home repairs that reduce asthma triggers, such as mold removal and installing air filters. But Partnership HealthPlan of California will not offer those benefits in its wildfire-prone Northern California region because it doesn’t have an adequate network of organizations equipped to provide those services.

In interviews with nearly all of California’s Medi-Cal managed-care plans, executives said they support the dual goals of helping patients get healthier while saving money, but “it is a lot to take on,” said Richard Sanchez, CEO of CalOptima, which serves Orange County and will start modestly, primarily with housing services. “The last thing I want to do is make promises that we can do all these things and not come through.”

Nearly all the health plans will offer housing services right away, focusing on three categories of aid: helping enrollees secure housing and rent subsidies; providing temporary rent and security deposit payments; and helping tenants stay housed, like intervening with a landlord if a patient misses rent.

Partnership HealthPlan, which serves 616,000 Medi-Cal patients in 14 Northern California counties, will prioritize its most at-risk enrollees with housing services, food deliveries and a “homemaker” benefit to help them cook dinner, do laundry and pay bills.

“It’s a great deal of money for a small number of members and, frankly, there’s no guarantee it’s going to work,” said Dr. Robert Moore, the plan’s chief medical officer. “We are building something extraordinarily ambitious quickly, without the infrastructure in place to make it successful.”

Even if offering new services costs more money than it saves, it’s a worthwhile investment, said John Baackes, CEO of L.A. Care Health Plan, the largest Medi-Cal plan, which serves more than 2 million patients in Los Angeles County.

“When somebody has congestive heart failure, their diet should be structured around alleviating that chronic condition,” he said, explaining his plan to offer patients healthful food. “What are we going to do — let them eat ramen noodles for the rest of their lives?”

In Alameda County, two plans are available to serve Hunter. The Alameda Alliance for Health, a public insurer established by the county, and Anthem Blue Cross, a private insurance company, will expand housing services.

“People like Eugenia Hunter are exactly who we want to serve, and we’re prepared to go out and help her,” said Scott Coffin, CEO of the Alameda Alliance, who is also on a local street medicine team.

But they’d have to find her first — chaos and homeless encampment sweeps force her to move her tent frequently. And then they’d have to win her trust.

In one moment, Hunter angrily described how health plans have tried to enroll her in services, but she declined, mistrustful of their motives. In the next moment, fighting back voices in her head, she said she desperately wants care.

“Someone is going to help me?” she asked. “All I want to do is pay my rent and succeed.”

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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Colorado Clinic’s Prescription for Healthier Patients? Lawyers

Wed, 09/08/2021 - 5:00am

COMMERCE CITY, Colo. — In her 19 years of living with cerebral palsy, scoliosis and other ailments, Cynthia Enriquez De Santiago has endured about 60 surgeries and her heart has flatlined at least four times.

But the most unusual doctor’s referral of her life came last year: Go see an attorney.

Enriquez De Santiago sought help at a Colorado health clinic that takes a novel approach to improving the health of its patients: It incorporates legal assistance into its medical practice for patients facing eviction or deportation proceedings, among other legal woes. And the state’s Medicaid program helps fund the initiative.

Although Medicaid traditionally doesn’t fund clinics to supply legal assistance, Colorado is one of several states that have been given permission to use some of their Medicaid money to help pay for such programs. Every day in Commerce City, four lawyers join the physicians, psychiatrists and social workers at Salud Family Health Centers’ clinic in this suburb north of Denver, as part of Salud’s philosophy that mending legal ills is as important for health as diet and exercise.

The goal: Reduce toxic stress and keep families intact, on the premise that it will serve their health for years to come, said Marc Scanlon, the attorney who directs the program.

Mostly, that has meant helping people with unemployment benefit claims and Social Security Disability Insurance denials. But it also regularly entails helping patients — many of whom speak only Spanish after having arrived here from Mexico or Central America — with immigration hearings.

The program is among at least 450 existing medical-legal partnerships across the nation that typically serve impoverished people and migrants. The vast majority don’t rely on Medicaid dollars, which are used only in fewer than 10 states, according to the National Center for Medical-Legal Partnership.

The role of these sorts of medical-legal partnerships has grown over the past year as millions of people in the U.S. have faced lost income and the threat of losing their homes during the covid-19 pandemic. Some partnerships have helped patients secure unemployment checks, while others have fought some of the evictions that weren’t already barred by state or federal moratoriums.

“All the issues that people are struggling with in the pandemic are all the same issues that medical-legal partnerships have been trying to work with forever,” said Vicki Girard, a law professor and co-director of the Georgetown University Health Justice Alliance in Washington, D.C.

In Montana, Kallie Dale-Ramos helped persuade a primary care association, the state’s legal aid organization and six community health centers operating in cities across Montana to pool $20,000 to help hire an attorney, who can split time among the clinics to help patients affected by the pandemic.

Since the start of 2020, that investment has helped more than 130 patients seek unemployment claims — and potentially stave off financial ruin.

One woman had been waiting for unemployment assistance since applying in March 2020, and only recently received her first check, said Dale-Ramos. Without legal help along the way, the woman “would have just been like, ‘I can’t do this anymore,’” Dale-Ramos said.

This sort of legal-medical partnership is centered on the notion that doctors can do only so much to keep their patients healthy.

Proponents See Lasting Impact

Advocates for such programs cite the example of a child suffering from asthma caused by mold in a dilapidated apartment. While a doctor couldn’t force a landlord to clean up the property or break the lease, a letter from a lawyer might be persuasive, said Dr. Tillman Farley, Salud’s chief medical officer.

“Some of these impacts carry out for decades,” Farley said. “And once you get into effects like that, then you’re really talking generational changes in health outcomes.”

Beyond common sense, evidence from emerging research suggests the approach can work. Patients at Veterans Affairs clinics in Connecticut and New York, for example, saw their mental health improve significantly within three months of consulting a clinic attorney, according to a 2017 study in Health Affairs.

And at Colorado’s partnership, a survey of patients from 2015 to 2020 found statistically significant drops in stress and poor physical health, as well as fewer missed medical appointments among its 69 respondents, said Dr. Angela Sauaia, a professor at the Colorado School of Public Health who led the research.

The possible reasons for missing fewer doctor appointments after getting the legal help, Sauaia said, included patients having more income, being less depressed and having an improved immigration status that made them less fearful to venture into public.

Medical-legal partnerships should be considered part of health care, Sauaia believes. “You should be referring to them the same way a provider would be referring a patient to a specialty, such as endocrinology or surgery.”

The biggest challenge for these programs is securing stable funding. Many are funded with a small amount of seed money, or by grants that run only a year or two.

Medicaid, established in 1965, is a nationwide health care program for people who have low incomes or are disabled. It’s jointly funded by the federal government and each state, and traditionally has covered medical costs such as physician visits and hospital stays.

In recent years, though, some states have increasingly sought to use Medicaid dollars to fund initiatives such as using social workers or offering legal assistance to address the social determinants of health. That includes North Carolina, which is using a federal waiver and hundreds of millions of dollars in a highly scrutinized effort to transform its Medicaid program. Among its strategies is more legal aid for patients.

Some Critics See Overreach by Medicaid Plans

The nationwide shift has prompted some health policy experts to question whether Medicaid is beginning to run too far afield of its purpose.

“Everybody agrees that social factors play a very large role in health outcomes; the question is what to do about it,” said James Capretta, a resident fellow of the American Enterprise Institute who was an associate director of the Office of Management and Budget during the George W. Bush administration.

“Medicaid is already an immense program with lots of financial challenges,” Capretta noted. “The program was not built for Medicaid to pay for too many services beyond the more direct services that are related to a medical condition or a disability.”

The small-scale use of waivers and supplemental Medicaid dollars to fund programs aimed at the social factors of poor health — such as housing for people with severe mental illness — works in some places, said Matt Salo, executive director of the National Association of Medicaid Directors. But for Medicaid to provide widespread funding for such social service programs would be unsustainable, and shouldn’t happen, he said.

“It is not — and should not be — Medicaid’s responsibility to figure out how to pay for it,” he said.

Some advocates for legal assistance programs and health policy experts worry about a potential public backlash based on misperceptions about how the little-known medical-legal partnerships use Medicaid. For one, the programs generally aren’t reimbursed for services in the same way traditional Medicaid programs are, said Sara Rosenbaum, a health law and policy professor at George Washington University. Medicaid is more of “an indirect funder,” she said.

A 2019 Manatt Health Strategies report on funding for medical-legal partnerships said “the time is ripe” for these partnerships to explore the little-used avenues available in Medicaid.

The states that administer the Medicaid programs and the managed care organizations that contract with them have some discretion to fund non-clinical services that improve access or outcomes for social determinants of health, according to the report.

States also can write the medical-leaderships programs into a larger federal waiver application for experimental, pilot or demonstration projects that promote Medicaid’s objectives.

“The dollars are minimal,” said Ellen Lawton, former director of the National Center for Medical-Legal Partnership, and a senior fellow at HealthBegins, a consulting firm. “And I think what we’re seeing is that — appropriately — the Medicaid programs are pacing themselves. They’re looking to see what works — what works in our state, what works in our region, what works with the populations that we’re focused on.”

States have been creative in funding these sorts of legal assistance programs. Colorado officials said they amended their Medicaid spending plan to provide grants to two such partnerships. Other states have sought federal waivers allowing them to support those programs. The Department of Veterans Affairs also offers the services of medical-legal partnerships funded by outside organizations.

Scanlon, the attorney at the Salud clinic, is part of a nonprofit organization called Medical Legal Partnership Colorado that operates under a joint agreement with the clinic. Colorado’s Medicaid program approved a $300,000 grant to the partnership that was renewed this year to pay for three attorneys’ salaries.

Authorizing the funding took little convincing, said Michelle Miller, chief nursing officer for the state’s Medicaid program. “When we were asked to approve funding for this, I jumped at it,” Miller said.

One Woman’s Story

For Cynthia Enriquez De Santiago, the 19-year-old patient from Salud’s Commerce City clinic, legal advice made all the difference in her medical care.

In addition to her cerebral palsy, the teen is blind and has difficulty speaking; she needs round-the-clock care, including help eating and using the bathroom. Her doctor at the clinic put Rafaela De Santiago, Cynthia’s mother, in touch with an attorney who could help her continue to be her daughter’s legal guardian after the teen turned 18 last year.

The timing of that legal help proved critical: Several months after seeing the attorney, Enriquez De Santiago was rushed to a hospital. For no obvious reason, she had become hypothermic; her blood pressure dropped and her blood-oxygen levels cratered.

“The doctors were telling me I had to be ready for the worst,” the teen’s mother said through a Spanish-to-English interpreter.

Because she was Enriquez De Santiago’s legal guardian, her mother was able to sign off on follow-up tests after that emergency to quickly get to the root of the medical problem and help prevent it from happening again.

Without guardianship, “it would have been really, really hard, because I wouldn’t know where to begin the process,” Rafaela De Santiago said.

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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The Pandemic Almost Killed Allie. Her Community’s Vaccination Rate Is 45%.

Tue, 09/07/2021 - 5:00am

The Allie Henderson who stepped out of her mother’s car to a driveway full of cheering friends and family holding “Welcome Home” signs was a wisp of her former self.

After 10 days in the hospital with a near-fatal case of covid inflammatory syndrome, the then-13-year-old softball phenom and beloved, straight-A student was lethargic and frail and braced herself against the car’s door frame.

But six months later, as the highly contagious delta variant swarms Mississippi, the state has one of the highest per capita infection rates in the nation and one of the lowest vaccination rates. In Hinds County, where the Hendersons live, the vaccination rate is 45%, well below the national average of 53%, as of last week. Some of Allie’s closest friends and family remain unvaccinated.

“I feel like it hasn’t been tested enough,” said Erin Acey, 16, of the vaccine. Erin is a cousin of Allie’s who lives a block away and grew up playing whiffle ball with Allie in the backyard.

Erin’s parents are also not vaccinated, nor is another cousin, Cara McClure, 23, a hairstylist in nearby Clinton who is suspicious of conflicting information she’s heard about the vaccine.

“I try not to watch the news. I get it from Facebook,” said McClure. “I really try not to talk about it at work because it’s like politics: You don’t talk about politics at work.”

***

The gravity of Allie’s condition last winter became clear when the prayer requests went out, months before vaccines were widely available.

Congregations across the area in Crystal Springs, Hazelhurst, Wesson and Georgetown prayed for Allie; teachers at her small, independent Christian school in Gallman, Copiah Academy, prayed before class.

Allie’s grandmother texted Wayne Hall, the pastor at Jackson First, where the Hendersons have been regular parishioners. Allie was a fixture in the Children’s Ministry, a vivacious child always in the middle of the action, and the Hendersons are an admired family of go-getters. “Please pray,” the text said. “Allie is in the hospital.”

“When the request went out, it was all hands on deck,” said Hall, who hunts with Allie’s dad, Brook. He said his own prayers: “We believe in God to heal her body and are praying for Mom and Dad, who are walking through this, because there are a lot of unknowns.”

Allie had felt crummy at school on a Monday in late January but still managed to play in a basketball game that evening. A few days later, she was doubled over with stomach pain and no remedy — Tylenol, Motrin, baths — would break her 104-degree fever. LeAnn Henderson, Allie’s mother, asked her best friend, Caroline Young, a nurse and fellow softball mom, “Why can’t we get this fever to go away?”

At the emergency room, Allie tested negative for covid, strep and influenza, and doctors settled on removing her inflamed appendix. But soon after the surgery, her fever spiked again, her blood pressure and oxygen levels dropped, her eyes were eerily bloodshot, her hands splotchy.

“Allie was so weak, she was talking about giving up,” said LeAnn.

An ambulance whisked Allie to Children’s of Mississippi, a hospital in Jackson with a pediatric intensive care unit where doctors diagnosed her with multisystem inflammatory syndrome in children. MIS-C, as it is known, appears to affect children two to eight weeks after an asymptomatic or mild covid-19 infection. A blood test found covid antibodies, and Allie began receiving steroids, blood pressure medication and intravenous antibiotics to fight the syndrome.

McClure, who often styled Allie’s hair and took her to the local waterpark, video chatted with her cousin. “She looked tired, drained, her face was white,” said McClure. Already thin, Allie was losing weight. At the hair salon, McClure tried to keep the unfolding family crisis away from clients already spooked by the pandemic. Her co-workers would see her crying between appointments.

Outside the hospital windows, friends and family stood on the grass and held up signs that Allie could see from her room. There was an endless stream of food deliveries for the family: Chick-fil-A, chili from Wendy’s, seafood pasta from Biaggi’s.

“Everybody in Allie’s world knew about this — softball, school, church — it was on our doorstep,” said LeAnn. “People had known adults who had gotten sick and been in the hospital, but not sick like Allie. I think it was like, ‘Wow, this is real and this happened to her.’ They know how strong and athletic [she is]. She’s a power hitter.”

At Copiah Academy, Allie’s absence registered with growing fear. “Parents began to get scared,” said Rita Henley, a school administrator. The school had taken precautions, sanitizing classrooms, requiring students to wear masks and to physically distance. Students who tested positive for covid and those who shared classrooms or sports teams had to quarantine at home. “Some of the parents embraced it and some didn’t,” said Henley. “It reflected the differences in opinion that we have right now in our country.”

As Allie came in and out of consciousness at the hospital, she fretted about her grades and missing the remainder of basketball season and the upcoming softball season.

“Allie is a very aggressive athlete, always ready to practice and play hard,” said Caroline Young, LeAnn’s friend whose daughter plays on the same travel softball team as Allie. “That was the most poignant thing about the illness — we saw a really strong teammate become weak.”

On Feb. 7, LeAnn drove her daughter home to the cheers and open arms of a loving gaggle of friends and family. “I started crying, she started crying, everyone started crying,” said Allie’s cousin Erin.

LeAnn shared her family’s ordeal with a local television station. “I immediately went to the media and said, ‘This is something else covid can do. This happened to my 13-year-old. We need to look out for this.’”

Allie returned to school for a few hours each day and grew stronger. On occasion, she was overcome by seizures, passing out once in the bathroom at home and once on her way to her bedroom. One night, Allie woke and couldn’t feel her legs. “I was screaming,” LeAnn said, whose usual unflappable disposition had finally caved. By spring break, in mid-March, after neurology appointments and brain scans and heart scans, Allie started coming back to herself. She and her family got the vaccines when they became available.

At school, the questions overwhelmed her. “We had a little joke. I said I had a bad haircut and couldn’t come to school,” Allie said. But she didn’t feel the urge to proselytize about the dangers of covid. “I don’t like to go public about personal stuff.”

She suited up for a softball scrimmage and could barely hoist the bat above her shoulder. “It was very difficult because I couldn’t do what I could do before,” said Allie. She told her mom, “I just suck at this.” The crowd of softball dads teared up when Allie tried to swing the bat. “It’s amazing that she’s out there,” LeAnn said they told her.

***

Students returned to Copiah Academy in early August. Masks are not required, nor is the covid vaccine for those eligible. “Our internal conversation is that we do not feel we can require the vaccine unless the state requires it,” said Henley. But “because of Allie, people — without question — know that this is a real thing.”

Still, the shifting nature of the pandemic — the arrival of the delta variant, the news that vaccinated people can spread covid — has brewed confusion. “I truly think that we see too much back-and-forth on the news. I think it hurts people,” said Henley, who is vaccinated. “People don’t know what to believe.”

Federal health officials say millions of Americans have been safely vaccinated, and vaccination reduces the risk of severe complications from covid.

Pastor Hall is reluctant to direct his parishioners to get vaccinated. “We believe in healing, we believe in the power of God, and we also know God gives wisdom,” he said. “If the CDC is saying things we need to abide by, we need to really listen.” He added, “Allie’s story has helped a lot of people really understand, ‘Hey, this is not a pick-and-choose kind of deal. It can hit home anywhere.’”

At the hair salon in Clinton, McClure shares more openly now about her cousin’s illness with her clients. “I’ll say my little cousin had it and we get to talking about it,” said McClure. But she doesn’t push it. “When clients come in, we want it to be about them. We ask, ‘Are you going on vacation?’ We focus on them to make them feel good.”

But she notices those around her have dropped their guard. “They take everything for granted. ‘Oh, we’re good. We’re fine. We don’t have to sanitize,’” she said. “Even now at the salon we try to make people sanitize, and they’re like, ‘Ugh.’”

McClure had a mild covid infection last Thanksgiving — headache and nausea — but it passed. Even now, she’s in no rush to get vaccinated. “Even with the vaccine, you can still get it. Every day I feel like something about it is changing, there’s a new strand,” she said.

Erin, Allie’s 16-year-old cousin, isn’t sure when — or if — she’ll get vaccinated. She’s nervous about the side effects and wants to wait and see. In her view, the pandemic has “died down” and she’s unfamiliar with the delta variant. “I’d rather read about it and see it myself,” she said.

“I know she has a different perspective,” Allie said about her cousin Erin. “I would have a different perspective if it hadn’t happened to me. I just know some people are like, ‘My body, my choice.’ Everything these days is about politics and nobody likes to be wrong. It’s very confusing for my part. I want people to get vaccinated because I know what it feels like.”

Some of her closest friends have gotten the vaccine. Was it because of what happened to her? Allie responded, “Yes, ma’am.”

PBS NewsHour producer Jason Kane 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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V-Safe: How Everyday People Help the CDC Track Covid Vaccine Safety With Their Phones

Tue, 09/07/2021 - 5:00am

Of the 203 million people who have received at least one dose of a covid-19 vaccine, more than 9 million have enrolled in a program to share information about their health since getting the shot.

The initiative was created for the covid-19 vaccines to complement the Centers for Disease Control and Prevention’s vaccine safety monitoring system. Known as v-safe, the registry lets inoculated people report their experiences, including serious suspected side effects, directly to the CDC through smartphones, adding to the data gathered from clinical trials and other safety monitoring systems.

So how does v-safe strengthen the nation’s existing safety checks and how well is it working?

Going in, some public health experts expressed doubts about its effectiveness. But since the tool’s Dec. 13 release, reviews have mostly been positive.

“It’s a really good way to make everybody part of the process,” said Dr. Kathryn Edwards, founder of the Vanderbilt Vaccine Research Program and principal investigator for the CDC-funded Clinical Immunization Safety Assessment Network.

“There never has been so much scrutiny of vaccines and so much reporting and so much tailored information,” she added.

How Is Vaccine Safety Traditionally Monitored?

The federal government has various systems to monitor the safety of vaccines as well as other pharmaceutical products once they reach the marketplace. For starters, the Vaccine Adverse Event Reporting System, jointly run by the CDC and the Food and Drug Administration, since 1990 has served as a repository for reports on health problems that may be side effects of vaccines. Health care providers are required by federal law to report certain adverse events, but patients, their family members or caregivers can also submit a report online.

VAERS receives tens of thousands of reports each year, which are stripped of personal identifiers and publicly shared in an online database. These reports, which frequently lack details and sometimes contain errors, are not enough to establish a causal relationship between the vaccine and an adverse event, but they offer the agencies, along with scientists and researchers, a chance to identify and investigate unusual patterns.

VAERS helped spot unexpected cases of rare blood clots in several people who received the Johnson & Johnson vaccine. After studying the VAERS reports, the CDC listed what experts later identified as thrombosis with thrombocytopenia syndrome as a serious but rare health problem associated with the J&J vaccine.

Then there’s the Vaccine Safety Datalink, which uses electronic health data from nine large health care organizations across the country, including various Kaiser Permanente systems on the West Coast and Harvard Pilgrim Health Care in Massachusetts. According to Minnesota-based HealthPartners, another participating organization, the VSD network looks at data for 3% of the U.S. population, or roughly 12 million people — everything from medical and pharmacy claims to vital records. National Geographic reported that analyses are done weekly so signals of adverse events are quickly noted.

What Does V-Safe Add to the Mix?

Launched the day before covid vaccines were first available to the public, v-safe allows the CDC to track people over time to see how they fare.

Some vaccine safety experts have criticized the U.S. for leaning too heavily on a “passive” system that relies on people reporting issues that may or may not be related to the shots as opposed to “active” surveillance that scans large volumes of electronic health data and compares adverse events in people who receive the vaccine to those who didn’t.

V-safe requires individuals to opt in, with no control group for comparison. But some still view the tool as a step forward.

“It is a little bit more of a proactive monitoring system,” said Andrea Carcelén, an assistant scientist at the International Vaccine Access Center at Johns Hopkins Bloomberg School of Public Health.

Here’s how it works: People register with the v-safe program on their smartphone or computer after receiving their first vaccine dose. The CDC then sends them daily text messages the first week, and weekly ones for six weeks after that. Additional follow-up texts are sent at the three-, six- and 12-month marks.

Every message includes a brief health survey, always asking: “How are you feeling today?” The first week, participants are asked whether they have experienced symptoms — chills, headache, joint pain or something not listed. They are also asked if they were unable to work or attend school or perform “normal daily activities,” or if they sought a physician’s care.

Over time, the check-ins focus on new or worsening symptoms or health conditions and compare participants’ health before and after vaccination. Participants are also asked whether they have tested positive for covid since the previous survey.

CDC scientists then study responses, looking for patterns of problems that go beyond what the clinical trials predicted. And the data may provide a fuller snapshot of vaccine outcomes because it reflects not only reports of side effects but also of people who had no complaints, said Carcelén.

Even as these investigations proceed, people who reported a problem may not ever hear directly from the CDC, and v-safe is not intended to offer medical advice. The CDC requests and reviews medical records, death certificates and autopsy reports only for serious adverse events, said Martha Sharan, a CDC spokesperson. “If a report is a hoax, it is quickly caught,” she said.

And what has v-safe shown so far? “The findings in normal, regular people that got the vaccine were pretty reflective of what you saw in the clinical trials,” said Vanderbilt’s Edwards. Edwards also served on an independent safety data monitoring committee for the Pfizer-BioNTech vaccine, now branded as Comirnaty.

How Is the V-Safe Data Used?

Unlike VAERS, v-safe data is not published without context. Meaning, no one can just sort through the database and interpret the numbers as they please, as many do with VAERS data. It is, however, publicly shared through CDC studies and presentations given during meetings held by the CDC’s independent panel of experts, the Advisory Committee on Immunization Practices.

And like VAERS reports, v-safe data is susceptible to misinterpretation. One post that circulated on social media inaccurately said “3,150 persons were paralyzed” based on an ACIP presentation slide. Reuters debunked the post, saying it is a “misinterpretation of the CDC health events.”

Information gleaned from v-safe has been used in several safety analyses, including one focused on adolescents. That analysis, published Aug. 6, found that serious adverse events are rare among adolescents, partly based on v-safe surveys from tens of thousands of people ages 12 to 17. The analysis also found that a minority reported being unable to perform “normal daily activities” the day after receiving a second dose.

V-safe has perhaps been most helpful at providing real-world evidence that the covid-19 vaccines are safe during pregnancy. This is important because there was little information on how the vaccines affected pregnancy when they were first authorized, said Dr. Dana Meaney-Delman, a member of the CDC’s vaccine task force, in a recent call with clinicians.

Pregnant women were excluded from the initial clinical trials that led to the emergency use authorization of the Pfizer, Moderna and J&J vaccines, and misinformation was rampant.

Because pregnant health care workers got vaccinated and enrolled in v-safe, Meaney-Delman said, there is more evidence that indicates the benefits of getting vaccinated during pregnancy outweigh any potential risks. Following the publication of an analysis that leaned on v-safe’s vaccine pregnancy registry, the CDC recommended on Aug. 11 that people who are pregnant, lactating or trying to become pregnant get vaccinated against covid.

Currently, uptake is low — as of mid-August, 23% of pregnant people ages 18 to 49 are at least partially vaccinated.

Who Is Participating in V-Safe?

More than 9.2 million people have enrolled in v-safe as of Aug. 9, or roughly 5% of the U.S. population who received at least one dose of a covid vaccine. This seemingly low participation rate is often linked to weak advertising and public education programs about v-safe. Also, a segment of the vaccinated public likely considered it tedious or had privacy concerns. The number also excludes people who do not have smartphones.

Dr. Matthew Laurens, a vaccine researcher at the University of Maryland School of Medicine, considers this an important gap in reporting. Roughly a quarter of adults who earn below $30,000 per year — or an estimated 16% of U.S. households — say they do not own a smartphone.

People who line up for an additional vaccine dose — often referred to as a booster but representing the same formula as previously administered — will have another opportunity to sign up for v-safe.

Meanwhile, as nationwide vaccination efforts continue, some v-safe participants said they joined the effort because they wanted to help.

John Beeler, 44, of Atlanta, considered it a “public good.” He reported experiencing tinnitus — a condition that was part of his medical history — after receiving his first Moderna dose. He was never contacted but hopes his report proved helpful. Still, he appreciated being checked on, even via automation.

“Dr. Fauci is not reading my response. But the feeling is there,” said Beeler.

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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Watch: Same Providers, Similar Surgeries, But Different Bills

Sat, 09/04/2021 - 5:00am

Ely Bair had similar surgeries, at the same hospital, with the same insurer. But he received very different big medical bills. KHN Editor-in-Chief Elisabeth Rosenthal joins “CBS This Morning” to break down how this could happen to you and what you can do to avoid it. 

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, delta y tu deporte favorito, ¿es seguro ir a un estadio?

Fri, 09/03/2021 - 8:34am

La temporada de fútbol americano universitario está precalentando, la de la Liga Nacional de Fútbol Americano comienza el 9 de septiembre. Béisbol, fútbol, basketball. Por primera vez desde 2019, casi todos los estadios y canchas estarán completamente abiertos para los fanáticos.

Antes de la era COVID, sentarse hombro con hombro en un estadio con decenas de miles de espectadores gritando, después de unas horas de charla previa al partido, era lo que más esperaban los fans en el otoño.

Pero con los casos de covid-19, y las hospitalizaciones y las muertes disparándose por la variante delta, muchos fanáticos se preguntan si esa es una buena idea.

KHN habló con siete expertos en salud para conocer sus opiniones.

1. ¿Es seguro ir a un estadio lleno, incluso si la persona está vacunada?

Seis de los siete expertos en salud pública con los que habló KHN fueron contundentes: de ninguna manera. Ahora no.

“Soy fanático de los deportes”, dijo Jason Salemi, profesor asociado de epidemiología en la Universidad del Sur de Florida en Tampa. “Pero yo no iría a esos eventos en este momento”.

Salemi dijo que con los casos de covid en su nivel más alto desde fines de enero, con el recuento promedio de casos aumentando a poco más de 149,000 al lunes 30 de agosto, y los hospitales colmados de nuevo en todo el país, hay demasiado riesgo incluso para las personas completamente vacunadas contra covid.

Si bien es menos probable que en los eventos al aire libre las personas se infecten porque la circulación de aire es mayor, sentarse a unos pocos pies de 10 o 20 fanáticos que gritan viendo fútbol, ​​béisbol, fútbol americano o una carrera de autos reduce ese margen de seguridad, agregó.

Las vacunas bajan en gran medida el riesgo de hospitalización o muerte por covid, pero el avance de la más transmisible variante delta está provocando un número creciente de infecciones en personas vacunadas, algunas de las cuales causan síntomas incómodos. La infección también aumenta la probabilidad de transmitir el virus a personas no inmunizadas, que podrían enfermarse gravemente.

Incluso algunos fanáticos vacunados, en especial aquellos que son mayores y frágiles, o personas con afecciones médicas crónicas, también deben darse cuenta de que enfrentan un mayor riesgo de contraer una infección.

Los Centros para el Control y Prevención de Enfermedades (CDC) no tienen una guía específica sobre eventos deportivos, pero recomiendan que cualquier persona que asista a grandes reuniones en áreas con un alto número de casos de covid “considere usar máscara en lugares al aire libre con mucha gente y para actividades con contacto cercano”.

“Ahora, un estadio de fútbol lleno no es una buena idea”, dijo el doctor Olveen Carrasquillo, profesor de medicina y ciencias de la salud pública en la Escuela de Medicina de la Universidad de Miami. “Cuando hay muchos gritos sin máscaras, significa que se está esparciendo el virus”.

Los estadios de fútbol americano, ​​que generalmente se encuentran entre los recintos deportivos más grandes del país, generalmente están llenos de fanáticos vitoreando y aplaudiendo, saludándose con la mano, lo que hace que sea imposible distanciarse físicamente de las personas que pueden no estar vacunadas. Lo mismo ocurre en los pasillos y baños.

El doctor Robert Siegel, profesor de microbiología e inmunología en la Universidad de Stanford, dijo que si bien el riesgo de morir o terminar en cuidados intensivos por covid después de vacunarse es “extremadamente pequeño”, lo mejor es no enfermarse, hay que evitar una infección por leve que sea, para no preocuparse por las consecuencias a largo plazo de la enfermedad.

2. ¿Qué puedo hacer para reducir mi riesgo en un juego?

La primera línea de defensa es la vacunación completa.

Si no estás vacunado, no vayas al juego, dicen los siete expertos enfáticamente.

Algunas universidades, como la Universidad Estatal de Louisiana, requieren que los fanáticos se vacunen o muestren una prueba de covid negativa para asistir a un juego, y muchos jugadores de los equipos están vacunados para reducir su riesgo y no perderse juegos. Pero muchos estadios no tendrán estos requisitos.

Usa un cubrebocas, salvo cuando estés comiendo o bebiendo.

Los mandatos de máscaras varían según el lugar tanto para los equipos universitarios como para los de la NFL. Incluso si otras personas a tu alrededor no están usándola, tu máscara te brindará un nivel de protección contra la inhalación del virus.

“Es mejor si todas las partes usan una máscara, pero usar una máscara es mejor que no usarla”, dijo la doctora Nasia Safdar, especialista en enfermedades infecciosas de la Escuela de Medicina y Salud Pública de la Universidad de Wisconsin.

El doctor Dale Bratzler, director de covid de la Universidad de Oklahoma, dijo que no le diría a las personas vacunadas que eviten ir a los partidos. Sin embargo, recomienda fuertemente que los fanáticos consideren usar doble máscara.

Si quieres proteger a los demás, considera realizar una prueba de covid en casa el día del juego. Si los resultados de la prueba son positivos, o si tienes algún síntoma, incluso secreción nasal, dolor de cabeza leve o tos, no vayas al juego, dijo Safdar.

Y los expertos dijeron que prestes atención al nivel de casos de covid en cualquier ciudad a la que viajes. La incidencia podría ser alta y eso debería influir en tu decisión de asistir a un juego.

3. ¿Qué hay de encontrarse con amigos antes del juego?

La mayoría de los expertos estuvieron de acuerdo en que estar con algunos amigos al aire libre es una parte menos riesgosa de la experiencia deportiva. Pero solo si sabes que las personas con las que estás comiendo y bebiendo están vacunadas.

“Es ese ambiente festivo, donde la gente generalmente no está en posición de usar una máscara y estás parado cerca de otros”, dijo Safdar. “Sigue siendo un riesgo”.

4. Millones de personas han estado yendo a juegos de béisbol, fútbol y otros eventos deportivos durante todo el verano, sin muchos brotes. ¿Por qué preocuparse ahora por los partidos de fútbol?

Ha habido informes raros de brotes en los estadios de béisbol de las grandes ligas, que a menudo reúnen a más de 40,000 fanáticos. Pero eso también podría estar cambiando, porque la variante delta más transmisible se ha generalizado solo desde julio.

Además, dijeron los expertos, es difícil rastrear cuántos fanáticos se enferman porque el período de incubación puede durar una semana o más. Es probable que las personas no relacionen su enfermedad con el juego, especialmente si asumen que las actividades al aire libre son seguras.

“Delta cambió toda la ecuación de cómo consideramos el riesgo”, dijo el doctor William Schaffner, experto en enfermedades infecciosas de la Escuela de Medicina de la Universidad de Vanderbilt en Nashville. “Creo que habrá transmisión en los estadios”.

Los expertos en salud ponen como ejemplo al Sturgis Motorcycle Rally en Dakota del Sur en agosto, que se ha relacionado con más de 100 infecciones.

5. ¿Puedo reunirme con otros amigos y familiares vacunados?

Incluso con la variante delta en auge, expertos en salud dicen que las personas que están completamente inmunizadas pueden reunirse sin máscaras con quienes saben que también lo están.

“Si sabes con seguridad que alguien está vacunado, puedes reunirte para cenar y realizar otras actividades”, dijo el doctor Joseph Gastaldo, especialista en enfermedades infecciosas de Ohio Health, un gran sistema de múltiples hospitales con sede en Columbus.

Y el riesgo de propagación se puede minimizar en eventos como una boda al aire libre si los organizadores incluyen requisitos para las vacunas, el uso de máscaras y el distanciamiento físico para los asistentes vulnerables, apuntan expertos.

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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