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What Missouri Learned the Hard Way About Rapid Covid Testing in Schools

Thu, 08/26/2021 - 5:00am

Early in the tumultuous 2020-21 school year, Missouri officials made a big gamble: set aside roughly 1 million rapid covid tests for the state’s K-12 schools in hopes of quickly identifying sick students or staff members.

The Trump administration had spent $760 million to procure 150 million rapid-response antigen tests from Abbott Laboratories, including 1.75 million allotted for Missouri, telling states to use them as they saw fit. Nearly 400 Missouri charter, private and public school districts applied. Given supply constraints, each was offered one test per person, according to interviews with school officials and documents KHN obtained in response to a public records request.

What began as an ambitious plan landed with a thud. Few of the tests were used; according to state data updated in early June, schools reported using just 32,300.

Missouri’s effort provides a window into the complexities of covid testing at K-12 schools, even before the highly transmissible delta variant surged through. Delta’s spread has mired communities in emotional fights about how to safely send children — who are mostly unvaccinated — back to classrooms, particularly in states like Missouri, bedeviled by a high aversion to mask mandates and low vaccination rates. As classes begin, once again schools must weigh testing and other strategies to limit covid’s spread — potentially without a deep supply of test kits available.

Missouri educators described the testing that began last October as a blessing, for rooting out infected people and giving teachers peace of mind. But its logistical challenges quickly became clear, according to interviews and documents obtained by KHN. Dozens of schools or districts that applied for rapid tests listed just one health care professional to administer them. The rapid tests initially were set to expire after six months, so officials were reluctant to order too many. And some worried the tests would deliver inaccurate results or that on-site testing of someone with covid symptoms might spread infection.

“We were nervous” about sick kids being on campus, said Kelly Garrett, executive director of KIPP St. Louis, a charter school with 2,800 students and 300 staffers. Elementary students returned in November. It reserved its 120 tests for “emergency” situations.

“Schools that don’t have a nurse on-site or any kind of medical staff on-site, it’s just not as simple,” said Robert Milner, principal of Hope Leadership Academy, a charter school in Kansas City that shipped dozens of tests back to the state. Milner said his school was able to mitigate covid with measures like temperature checks, a mask requirement, physical distancing and even getting rid of air dryers in bathrooms. Plus, “I have other options that I can send my families to” in the community for testing.

“We have no plans, nor is it our job, to administer this test to everyone,” Lyndel Whittle, a public school superintendent, wrote in one district’s application for tests. The district, Iberia R-V, requested 100 rapid tests in its October application, enough to provide one to each staff member.

“We’re a school, not a healthcare provider,” Whittle wrote.

‘We Weren’t Shutting Down’

As the limits of remote learning became clear last year, officials pressed for a return to school. Gov. Mike Parson at one point said children would inevitably contract the virus at school, but “they’re going to get over it.” Now, even as childhood covid cases rise because of the delta variant, districts nationwide are increasingly under pressure to return to full-time classroom instruction.

Testing in K-12 schools generally has been limited, according to experts, despite the huge investment in rapid antigen tests. More recently, the Biden administration distributed $10 billion through the American Rescue Plan Act to increase routine covid screening in schools, including $185 million for Missouri.

Missouri is establishing a program for K-12 schools to regularly test people without symptoms, relying on a contract with Ginkgo Bioworks, in which the biotech company provides testing materials, training and staffing. As of mid-August, only 19 institutions had expressed interest, said Lisa Cox, state Department of Health and Senior Services spokesperson.

Unlike covid tests that use a polymerase chain reaction technique, which could take days to deliver results, rapid antigen tests return results within minutes. The trade-off: Studies have shown they are less accurate.

Still, for Halley Russell, president of the Missouri State Teachers Association and a high school teacher in Jackson, Missouri, it was a relief to have rapid tests and she wished they’d had them sooner. Her district, Jackson R-2, applied in December and began using them in January, months after schools reopened.

“The timeline was just hard: We couldn’t rapid-test students we thought could have [covid],” she said. “Some of them just quarantined.”

“Ultimately, I think, there was a level of anxiety the entire time because we were face-to-face, we weren’t shutting down,” said Russell, whose classroom required masks. “Testing just gives you some control over things you can’t control.”

Allison Dolak, principal of Immanuel Lutheran Church & School in Wentzville, Missouri, said her small parochial school had the means to use rapid covid tests for students and staffers — but it took ingenuity.

Dolak said applying for tests was a “no-brainer” to help keep their doors open. “There would have been so many kids that had to online-learn had we not had those tests,” she said. At times, the suburban St. Louis school had to call on parents who were nurses to administer them. Dolak even performed a few herself in the parking lot. State data as of early June shows the school received 200 tests and used 132. It did not require masking.

Many schools indicated they intended to test only staff members, applications obtained by KHN show. Missouri directed schools at first to use Abbott’s rapid tests on symptomatic people, which further limited testing.

Arguably, some of the reasons limited testing occurred aren’t bad — in interviews, educators said they curbed infections by screening for symptoms and requiring masks. Currently, Missouri authorizes testing on symptomatic and asymptomatic people.

“In the K-12 space, there really has not been that much testing,” said Dr. Tina Tan, a professor of pediatrics at Northwestern University’s Feinberg School of Medicine. “It really has been more that kids have symptoms screened before they’ve gone to school, and if they become symptomatic then they’re tested.”

At least 64 schools and districts that received tests hadn’t administered a single one, according to state dashboard data that schools self-report, as of early June.

Others that applied didn’t follow through on their orders or decided against administering tests, according to interviews and documents obtained by KHN.

One was the Maplewood Richmond Heights district in St. Louis County, which directed people away from schools for testing.

“While the antigen test is decent, there were some false negatives,” Vince Estrada, director of student services, said by email. “For example, if a student had been exposed to someone with COVID-19, and tested negative with the antigen test at school, we would still require them to get a PCR test.” Space for testing and nurse availability were also issues, he added.

“Many of our school districts don’t have capacity to store the tests, to manage the testing,” said Molly Ticknor, executive director of the Show-Me School-Based Health Alliance of Missouri, which focuses on access to health services at school.

‘A Lot’ of Tests Returned Unused

Sherry Weldon, administrator of the Livingston County Health Center in northwestern Missouri, said the public health agency ran tests for personnel in county schools, both public and private. “None of the schools want to take that on themselves,” she said. “They just were like, oh, God, no.”

When the school year was over, Weldon, a registered nurse, said she shipped back “a lot” of unused tests, although she has since reordered to offer rapid testing to the public.

Cox, the DHSS spokesperson, said as of mid-August the state had recouped 139,000 unused tests from K-12 schools.

Recouped tests would be redistributed — the shelf life of Abbott’s rapid antigen test has been extended to one year — but officials aren’t tracking how many have been, Cox said. Schools are not required to report expired antigen test quantities to the state.

Mallory McGowin, spokesperson for Missouri’s Department of Elementary and Secondary Education, said “absolutely there have been tests that have expired.”

Health officials also sent rapid tests to long-term care facilities, hospitals and jails, among other locations. As of mid-August, the state had distributed 1.5 million of the 1.75 million antigen tests it received from the federal government. After accounting for tests K-12 schools didn’t use, the state had shipped them 131,800 tests as of Aug. 17. “It quickly became clear,” Cox said, “the tests we had pushed out were not being fully utilized.”

When asked whether schools were equipped to handle testing, McGowin said having such resources was a “real opportunity” but also “a real challenge.” But “at the local level, there’s only so many people,” she said, “to help with covid protocols.”

School covid testing could “make a big difference,” said Dr. Yvonne Maldonado, chief of Stanford University’s pediatric infectious diseases division. However, the more important strategies to limit spread are masking, increased ventilation and getting more people vaccinated.

“Testing is more icing on the cake,” 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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New Montana Law Sows Confusion, Defiance Over School Quarantines

Thu, 08/26/2021 - 5:00am

As classes get underway this week and next, Montana school and county health officials are grappling with how a new state law that bans vaccine discrimination should apply to quarantine orders for students and staffers exposed to covid-19.

It’s the latest fallout from the law that says businesses and governmental entities can’t treat people differently based on vaccination status. The law makes Montana the only state that prohibits both public and private employers — including hospitals — from requiring workers to get vaccinated against covid.

Some state and county officials also interpret the law to mean that unvaccinated people can’t be ordered to quarantine over a covid exposure unless vaccinated people are, too. That interpretation goes against the Centers for Disease Control and Prevention’s recommendations for only unvaccinated people to quarantine in the event of a covid exposure.

The state law worries school officials who had planned to lean on the CDC guidelines to keep closures and disruptions to a minimum this fall after last school year’s fluctuating in-person, remote and hybrid classes.

Micah Hill, superintendent of Kalispell Public Schools, said he received guidance from Republican Gov. Greg Gianforte’s office that confirmed the law means quarantine protocols must be the same for the vaccinated and unvaccinated alike.

Hill described that interpretation as a “game changer” for schools as the highly transmissible delta variant of the virus races through the state. Kalispell’s Flathead County has among the highest number of active covid cases with just 41% of the eligible population fully vaccinated. Only 1 in 4 children eligible for a covid vaccine are vaccinated, according to county health officials. Hill estimates about two-thirds of his staff are vaccinated.

“If everybody is getting quarantined with a more contagious variant, you could see a lot of people out of school, staff and students, and [that] really threatens the ability of schools to stay open,” Hill said.

As a result of the law, some Montana county health and school officials have decided to drop quarantine orders. Instead, they are making quarantining an option for exposed students.

But at least one county has decided to defy the law. The Missoula City-County Board of Health unanimously voted this week for a policy requiring the unvaccinated to quarantine, but not the vaccinated. The board held the vote after being advised by a representative from the county attorney’s office that the policy could lead to a lawsuit.

The stance by Missoula health officials is the latest in a string of defiant acts by schools and local governments against state laws and policies that ban covid-prevention measures. In Florida, for example, a handful of counties have said they will require students to wear masks despite Republican Gov. Ron DeSantis’ ban on mask mandates.

In Texas, some school districts have defied a similar executive order by Republican Gov. Greg Abbott, while one county has sued the governor to overturn the order.

Anna Conley, Missoula’s chief civil deputy county attorney, said that although she can’t promise the county will be successful in court, the county might have a good argument to overturn the state law if it winds up being litigated. The law may conflict with other state health laws that require health boards and health officers to prevent the spread of infectious diseases, she said.

Montana legislators passed House Bill 702 this spring amid a backlash against covid-prevention protocols such as a mask mandate under former Democratic Gov. Steve Bullock, and after a Great Falls hospital announced plans to require its employees to get vaccinated against covid.

“Your health care decisions are private; they are protected by the constitution of the state of Montana,” said bill sponsor state Rep. Jennifer Carlson (R-Manhattan) during the legislative session. “Your privacy is protected, and your religious rights are protected.”

Brooke Stroyke, a spokesperson for Gianforte, said it’s up to county officials to interpret how HB 702 affects quarantine orders in schools. However, an adviser in the governor’s office has instructed districts that the law presents an all-or-none option for county health departments when it comes to quarantine orders.

“HB 702 would allow for quarantine protocols as long as they are applied to everyone equally and are not based on COVID vaccination status,” Gianforte education and workforce policy adviser Dylan Klapmeier wrote in an email.

Lance Melton, CEO of the Montana School Boards Association, said that interpretation erases the advantage vaccines could provide in schools, where vaccinated teachers and students 12 and older would not have to quarantine following an exposure under CDC guidance.

Aside from Missoula, many county health departments are still deciding what to do. Gallatin and Lewis and Clark counties both say they will drop quarantine orders, making it optional for people to follow CDC guidance.

Flathead County is leaning toward the same approach. Flathead County Health Officer Joe Russell said that would allow vaccinated students, teachers and county residents to return to school and work as long as they aren’t showing covid symptoms. Russell said the county can still order covid-positive people to isolate.

“I don’t think it’s fair to punish someone that’s fully vaccinated and tell them that they have to … stay home for eight to 10 days. How fair is that?” Russell said.

That means relying on unvaccinated people to do the right thing and stay home after they’ve been identified as a close contact.

The prospect terrifies Rebecca Miller, who has two children in the Bigfork School District in Flathead County, where masks won’t be required in schools. Miller doesn’t think parents who are desperate to keep their kids in school so they can keep working will follow the Flathead City-County Health Department’s advice.

“Yeah, I think they’re going to send them to school,” she said.

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

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

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Pandemia revela una creciente crisis de suicidios en comunidades de color

Wed, 08/25/2021 - 1:23pm

Rafiah Maxie ha sido trabajadora social clínica en el área de Chicago durante una década. En todo ese tiempo, vio al suicidio como un problema más frecuente entre los hombres caucásicos de mediana edad.

Hasta el 27 de mayo de 2020.

Ese día, su hijo de 19 años, Jamal Clay, a quien le encantaba tocar la trompeta y hacer teatro, el que la ayudaba a descargar las compras del auto y a recaudar fondos para March of Dimes, se suicidó en su garage.

“Ahora no puedo parpadear sin ver a mi hijo colgado”, dijo Maxie, quien es negra.

La muerte de Clay, junto con los suicidios de más de 100 residentes negros en Illinois el año pasado, ha llevado a los mismos vecinos a pedir nuevos esfuerzos de prevención enfocados en las comunidades negras.

En 2020, durante el primer año de la pandemia, los suicidios entre los residentes caucásicos disminuyeron en comparación con años anteriores, mientras que aumentaron entre los residentes negros, según datos estatales.

Pero este no es un problema local. Y tampoco se limita a la pandemia.

Entrevistas con una docena de investigadores del suicidio, datos recopilados de todos los estados, y una revisión de décadas de investigación revelaron que el suicidio es una crisis creciente para las comunidades de color, que ya estaba impactando antes de la pandemia, y que se ha agravado desde entonces.

Las tasas generales de suicidio en los Estados Unidos disminuyeron en 2019 y 2020. Estudios nacionales y locales atribuyen la tendencia a una caída entre los estadounidenses blancos no hispanos, que constituyen la mayoría de las muertes por suicidio. Mientras tanto, las tasas de afroamericanos, hispanos y asiático-americanos, aunque más bajas que las de sus pares caucásicos, continuaron aumentando en muchos estados. (Las tasas de suicidio han sido consistentemente altas para los nativos americanos).

“Covid creó más transparencia con respecto a lo que ya sabíamos que estaba sucediendo”, dijo Sonyia Richardson, trabajadora social clínica que atiende a personas de color, y profesora asistente en la Universidad de Carolina del Norte-Charlotte, donde investiga el tema del suicidio.

Cuando pones las tasas de suicidio de todas las comunidades en un solo paquete, “esa imagen dice que está mejorando y que lo que estamos haciendo está funcionando”, dijo. “Pero ese no es el caso en las comunidades de color”.

Perdiendo generaciones

Aunque la tasa de suicidios es más alta entre los hombres blancos no hispanos de mediana edad, los jóvenes de color están surgiendo como un grupo particularmente en riesgo.

Las investigaciones muestran que los niños negros menores de 13 años mueren por suicidio en una tasa que es casi el doble que la de los niños blancos y, con el tiempo, sus tasas de suicidio han aumentado a pesar de que han bajado para los niños blancos.

Entre los adolescentes y los adultos jóvenes, las muertes por suicidio han aumentado más del 45% entre los afroamericanos y aproximadamente el 40% para los asiático-americanos en los siete años que terminaron en 2019.

Otras tendencias preocupantes en los intentos de suicidio se remontan a los años 90.

“Estamos perdiendo generaciones”, dijo Sean Joe, experto en suicidios entre afroamericanos y profesor de la Universidad de Washington en St. Louis. “Tenemos que prestar atención ahora porque si estás saliendo de tu primera década de vida y piensas que no vale la pena seguir viviendo, eso es una señal de que algo está realmente mal”.

Estas estadísticas también refutan las ideas tradicionales de que el suicidio no ocurre en ciertas poblaciones étnicas o minoritarias porque están “protegidas” y “son resilientes” o son la “minoría modelo”, dijo Kiara Alvarez, investigadora y psicóloga del Hospital General de Massachusetts que se enfoca en el suicidio entre las poblaciones hispanas e inmigrantes.

Aunque estos grupos pueden haber tenido históricamente bajas tasas de suicidio, eso está cambiando, dijo Alvarez.

Paul Chin perdió a su hermano de 17 años, Chris, por suicidio, en 2009. Un poema que Chris escribió sobre sus orígenes en la escuela secundaria hizo que Chin se preguntara si a su hermano, ocho años menor que él, le costó ser aceptado en los Estados Unidos, a pesar de haber nacido y crecido en Nueva York.

Al crecer, los estadounidenses de origen asiático no estaban representados en las lecciones de la escuela o en la cultura pop, dijo Chin, que ahora tiene 37 años. Incluso en la investigación clínica sobre el suicidio y otros temas de salud, los niños como Chris están subrepresentados, con menos del 1% de financiación de la investigación centrada en los estadounidenses de origen asiático.

No fue hasta la pandemia y el aumento de los crímenes de odio contra los asiático-estadounidenses, que Chin vio la atención nacional sobre la salud mental de la comunidad. Espera que el interés no sea efímero. El suicidio es la principal causa de muerte entre los estadounidenses de origen asiático de entre 15 y 24 años, pero “eso no recibe suficiente atención”, dijo Chin. “Es importante seguir compartiendo estas historias”.

Kathy Williams, quien es negra, ha estado en una misión similar desde que su hijo de 15 años, Torian Graves, murió por suicidio en 1996. En aquellos días, la gente no hablaba de suicidio en la comunidad negra, dijo. Entonces, ella comenzó a plantear el tema en su iglesia en Durham, Carolina del Norte, y en las escuelas locales. Quería que las familias negras conocieran las señales de advertencia, y que la sociedad en general reconociera la gravedad del problema.

La pandemia puede haber puesto de relieve esto, dijo Williams, pero “siempre ha sucedido. Siempre”.

Pandemia arroja luz sobre los desencadenantes

Identificar las causas fundamentales del aumento de suicidios en de las comunidades de color ha resultado difícil. ¿Cuánto proviene de una enfermedad mental? ¿Cuánto de los cambios socioeconómicos como la pérdida de empleo o el aislamiento social? Ahora, covid puede ofrecer algunas pistas.

Las últimas décadas han estado marcadas por una creciente inestabilidad económica, una brecha racial en la distribución de la riqueza cada vez mayor y una mayor atención pública sobre los asesinatos de personas de color desarmadas por parte de la policía, dijo Michael Lindsey, director ejecutivo del Instituto McSilver de Política e Investigación sobre la Pobreza de la Universidad de Nueva York.

Con las redes sociales, los jóvenes enfrentan el racismo en más frentes que sus padres, dijo Leslie Adams, profesora asistente en el departamento de salud mental de la Escuela de Salud Pública Bloomberg de la Universidad Johns Hopkins.

Cada uno de estos factores impacta en el riesgo de suicidio. Por ejemplo, experimentar el racismo y el sexismo juntos está relacionado con un aumento de tres veces en los pensamientos suicidas de las mujeres asiático-americanas, dijo Brian Keum, profesor asistente de UCLA, basándose en los hallazgos preliminares de la investigación.

Covid intensificó estas dificultades entre las comunidades de color, con un número desproporcionado de seres queridos perdidos, trabajos perdidos y viviendas perdidas.

El asesinato de George Floyd provocó un malestar racial generalizado y los estadounidenses de origen asiático vieron un aumento en los crímenes de odio. Al mismo tiempo, estudios en Connecticut y Maryland encontraron que las tasas de suicidio aumentaron en estas poblaciones y disminuyeron entre sus contrapartes blancas.

“No se trata solo de un problema interno de una persona, sino de problemas sociales que deben abordarse”, dijo Shari Jager-Hyman, profesora asistente de psiquiatría en la escuela de medicina de la Universidad de Pennsylvania.

Lecciones desde Texas

En Texas, el covid golpeó especialmente a los hispanos. A julio de 2021, representaban el 45% de todas las muertes por covid y la pérdida desproporcionada de empleos. Las personas indocumentadas no son elegibles para recibir beneficios de desempleo o cheques de estímulo federal.

Durante este tiempo, las muertes por suicidio entre los hispanos tejanos aumentaron de 847 en 2019 a 962 en 2020, según datos preliminares estatales. Las muertes por suicidio aumentaron para los tejanos negros y los residentes clasificados como “otras” razas o etnias, pero disminuyeron para los tejanos blancos.

Los números no sorprendieron a Marc Mendiola. El joven de 20 años creció en una comunidad de mayoría hispana en el área sur de San Antonio. Incluso antes de la pandemia, a menudo escuchaba a sus compañeros decir que tenían pensamientos suicidas.

Muchos enfrentaban problemas económicos en sus casas, a veces viviendo sin electricidad, comida o agua. Aquellos que buscaban tratamiento de salud mental generalmente se topaban con servicios costosísimos o inaccesibles porque no se ofrecían en español.

“Estas son condiciones en las que la comunidad siempre ha estado”, dijo Mendiola. “Pero con la pandemia, es aún peor”. Hace cuatro años, Mendiola y sus compañeros de clase en South San High School comenzaron a abogar por servicios de salud mental. A fines de 2019, solo unos meses antes de que llegara covid, su visión se hizo realidad. Seis agencias comunitarias se asociaron para ofrecer servicios gratuitos a los estudiantes y sus familias en tres distritos escolares.

Richard Davidson, director de operaciones de Family Service, uno de los grupos de esta alianza, dijo que la cantidad de estudiantes que discuten los factores económicos estresantes ha aumentado desde abril de 2020. Más del 90% de los estudiantes que recibieron servicios en la primera mitad de 2021 eran hispanos, y casi el 10% informó pensamientos suicidas o de autolesión, según muestran los datos del programa.

Ninguno murió por suicidio. Muchos estudiantes están tan preocupados por la cena del día siguiente que no pueden ver un futuro más allá de eso, dijo Davidson. Es entonces cuando el suicidio puede parecer una opción viable. “Una de las cosas que hacemos es ayudarlos a ver que, a pesar de esta situación ahora, pueden crear una visión para su futuro”, dijo Davidson.

Un buen futuro

Investigadores dicen que la promesa de un buen futuro a menudo se pasa por alto en la prevención del suicidio, tal vez porque alcanzarlo es un gran desafío. Requiere crecimiento económico y social, y romper barreras sistémicas.

Tevis Simon trabaja para abordar todos esos frentes. Cuando era niña en West Baltimore, Simon, quien es negra, enfrentó la pobreza y el trauma. De adulta, intentó suicidarse tres veces. Pero ahora comparte su historia con jóvenes de toda la ciudad para inspirarlos a superar los desafíos.

También habla con políticos, agencias del orden y funcionarios sobre sus responsabilidades. “No podemos no hablar de raza”, dijo Simon, de 43 años. “No podemos no hablar de opresión sistemática. No podemos dejar de hablar de estas condiciones que afectan nuestro bienestar mental y nuestro sentimiento y deseo de vivir”.

Para Jamal Clay en Illinois, las barreras sistémicas comenzaron temprano. Antes de su suicidio el año pasado, había tratado de hacerse daño a sí mismo cuando tenía 12 años y fue víctima de acoso. En ese momento, fue hospitalizado durante unos días y se le dijo que siguiera con la terapia ambulatoria, contó su madre, Maxie.

Pero fue difícil encontrar terapeutas que aceptaran Medicaid, agregó. Cuando Maxie finalmente encontró uno, hubo una espera de 60 días. Otros terapeutas cancelaron las citas, dijo. “Así que trabajamos por nuestra cuenta”, dijo Maxie, confiando en la iglesia y la comunidad. Su hijo pareció mejorar. “Pensamos que habíamos cerrado ese capítulo de nuestras vidas”.

Pero cuando llegó la pandemia, todo empeoró. Clay volvió a casa de la universidad y trabajó en un depósito de Amazon. En los viajes hacia y desde el trabajo, la policía lo detenía con frecuencia. Dejó de usar gorras para que los oficiales lo consideraran menos intimidante, dijo Maxie.

“Se sentía incómodo estando en la calle”, dijo. Maxie todavía está tratando de encontrarle sentido a lo que sucedió el día en que murió Clay. Pero ha encontrado un propósito fundando una organización sin fines de lucro llamada Soul Survivors of Chicago.

A través de la entidad, proporciona educación, becas y zapatos, incluidos los viejos de Jamal, a las personas afectadas por la violencia, el suicidio y el trauma. “Mi hijo no podrá tener una primera entrevista en [esos] zapatos. No podrá ir a la iglesia o incluso conocer a su esposa”, dijo Maxie. Pero espera que sus zapatos lleven a alguien más hacia un buen futuro.

La corresponsal de KHN JoNel Aleccia colaboró con esta historia.

Si tú o alguien que conoces tiene una crisis, llama a la Línea Nacional de Prevención del Suicidio, al 1-800-273-8255 o textea HOME a la línea 741741

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

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From Uber Vouchers to Patient Advocates: What It Takes to Increase ER Addiction Treatment

Wed, 08/25/2021 - 5:00am

For years, Kayla West watched the opioid epidemic tear through her eastern Tennessee community. As a psychiatric nurse practitioner, she treated people with mental illness but felt she needed to do more to address addiction.

So in 2020, when the state created a position to help hospitals improve addiction care in the emergency room, West jumped at the opportunity.

She knew that many people with substance use disorders land in the ER, and that starting medications for opioid use — like buprenorphine (often known by the brand name Suboxone) — could double a person’s chance of staying in treatment a month later.

Yet she also knew that providing the medication was far from standard practice.

A recent report from the Legal Action Center and the Bloomberg American Health Initiative found that despite widespread consensus on the importance of addiction treatment in the ER and an unprecedented rise in overdose deaths, many hospitals fail to screen for substance use, offer medications to treat opioid use disorder or connect patients to follow-up care.

Many patients who don’t receive those services die shortly after discharge or within a year of their ER visit, the report said.

But a growing number of emergency rooms and health professionals are trying to change that by developing new approaches to address the missed treatment opportunity in ERs.

“We know it’s possible because others have done it,” said Sika Yeboah-Sampong, an attorney with Legal Action Center and co-author of the report. “You have a combination of levers and kinds of structures of how different cities, counties, states and even independent hospitals adopt these practices.”

These models have already been put in place in some big hospitals and small hospitals, rural areas and urban centers, those with ample resources and those on tight budgets, she said.

In Tennessee, West looked to several of them for helpful guidance as she developed a pilot program with one hospital she advises. “It’s like looking at a smorgasbord of options of where you can implement change,” she said. Here are just a few of the different strategies emerging from ERs across the United States:

Advocating for the Patient in California

Daniel Browne started drinking alcohol and using prescription opioids at age 14. By the time he was 24, he was on the verge of losing his job, his car and his apartment.

“I didn’t know where else to go to get treatment other than the ER,” he said.

In May 2020, Browne drove 15 minutes from his home to Adventist Health Howard Memorial Hospital in Willits, California, where he was immediately met by Mary Anne Cox Gould. At the time, Cox Gould was a substance use navigator for a program called CA Bridge. She championed addiction treatment in the hospital and helped connect patients from the ER to clinics in the community. (Cox Gould is now a supervisor of other navigators in Adventist Health hospitals.)

“She met me in the parking lot even before I went into the ER,” Browne recalled.

She stayed with him as he received his first dose of buprenorphine, which provided immediate relief from withdrawal symptoms. “Once you’re not facing the crippling detoxification, it’s much easier to not relapse,” Browne said.

Cox Gould then walked him over to the hospital’s outpatient clinic and helped him schedule recurring appointments. When Browne ran into obstacles filling his buprenorphine prescription at a local pharmacy, she made all the necessary arrangements for him to get it from the hospital.

Now more than a year into recovery, Browne said he’s become a more reliable employee and has reconnected with his parents and younger brother — successes he credits partly to the medication and consistent support he’s received.

Those are hallmarks of the CA Bridge program, said executive director Serena Clayton. Medication is considered a key element of treatment. Connecting patients with a navigator helps them in long-term recovery. And having navigators in the ER creates a more welcoming environment for patients, and gives ER staff a chance to learn more about addiction, she said.

The model is currently used by about 130 hospitals in California, and the state has allotted $40 million to expand the program to more than 100 others. The funds cover the salaries of substance use navigators, training for ER staff on prescribing buprenorphine and other technical assistance.

“This doesn’t have to be a one-off story about a really special hospital,” Clayton said. “It can happen at scale.”

Removing Obstacles for Patients and Doctors in New York

Patients with addiction face many barriers to recovery, said Dr. Joshua Lynch, an associate professor of emergency medicine at the University at Buffalo. But doctors who want to help them also encounter hurdles, he said.

ER physicians are short on time, often lack training for addiction-related issues and don’t know where to refer the patients for follow-up care. To improve the situation, both sets of barriers — for patients and for doctors — must be addressed, Lynch said.

That was his goal in creating New York MATTERS, a program that gives patients access to buprenorphine and links them to addiction clinics to continue treatment. It also provides pharmacy vouchers that cover 14 days of medication and Uber vouchers to cover transportation to the clinic — all through an electronic referral system.

“Being able to offer all of this without having to make any phone calls is probably what makes the doctors most likely to use it,” Lynch said.

The program, partially funded by the state Department of Health, includes 38 hospitals and 94 clinics across New York that are vetted to ensure they provide buprenorphine to those who want it and accept patients regardless of insurance status. Providers in any participating ER can bring up a map of the clinics on a tablet and let patients choose where they’d like to be referred.

“This patient population is used to being told ‘no’ or ‘that’s not possible’ or ‘you have to go to this place,’” Lynch said. “We want to inspire them by giving them these choices.”

Most patients pick a clinic close to home or where they know a friend had a good experience, Lynch said.

He estimated about 55% of patients in the program make it to their first appointment, where they can receive medication and therapy. National figures suggest fewer than 10% of patients addicted to opioids receive similar treatment.

Lynch said the cost for any hospital or clinic to join the program is minimal, since it mostly leverages existing resources, and the state hosts the data for the referral platform. Expanding the program to facilities across the entire state would cost less than $4 million a year, he said.

Training Everyone in North Carolina

Dr. Blake Fagan is chief education officer at the Mountain Area Health Education Center in Asheville, North Carolina. For years, when he approached hospital ERs to offer addiction training, he heard a common refrain.

“We don’t have any place to send patients afterwards,” he said doctors told him.

Without a clear place for patients to continue treatment, the doctors were reluctant to even start medications for opioid use. That’s when Fagan and his colleagues realized their training had to extend beyond hospitals.

They reached out to federally qualified health centers, which treat people regardless of insurance status. In a state without Medicaid expansion and with large rural expanses, these centers serve many people with addiction.

Using just over $1 million in grant funding from two foundations, the Mountain Area Health Education Center trained 11 health centers and two local health departments over the past year and a half to provide medications for opioid use disorder. From March 2020 to May 2021, those centers treated more than 400 patients with the disorder.

Dr. Shuchin Shukla, who heads the program alongside partners at the University of North Carolina- Chapel Hill, said the centers have become obvious referral spots for doctors who start patients on medication in the ER.

“We consider ourselves a model for how to do this in a Medicaid non-expansion state,” Shukla said.

North Carolina also has programs to train medical students, residents, nurse practitioners and physician assistants in addiction care.

Dr. Sara McEwen, executive director of the nonprofit Governor’s Institute, which has helped to incorporate the training into medical school curricula, said students who see addiction prevention and treatment as a routine part of medicine will naturally apply that when they reach the ER or other clinical settings.

In fact, a recent study at Wake Forest School of Medicine found 60% of medical students who received the education reported using it during their internships.

“The learning is coming from med students to residents, up the chain,” said Paige Estave, a co-author of the study and a doctor of medicine/Ph.D. candidate at the school. “Students bringing it up will cause doctors to start thinking, talking and finding resources. … Hopefully, those little pieces of change will add up cumulatively to something more.”

Measuring Success

Across these varied models, one essential question remains: Do they work?

Unfortunately, it’s also one of the most challenging to answer, according to addiction researchers and those who run the programs. Many projects are still in the early phases and won’t be able to measure success for another few years. Others are struggling to gather long-term data that’s necessary for evaluation.

In North Carolina, for instance, McEwen knows more than 500 medical students receive the addiction training each year, but until they complete residency and practice on their own, it’s difficult to gauge how many will prescribe buprenorphine to their patients. In New York, Lynch can estimate how many patients make it to their first appointment at a clinic, and a recent study of the CA Bridge program tracked how many patients were given buprenorphine across 52 hospitals. But those numbers don’t indicate how many patients achieved long-term recovery. That would require tracking patients for months and years.

In the meantime, people like West who are looking to these models as guideposts must operate with a level of uncertainty. But she said she’d rather get started now than wait for the perfect solution.

“Any movement on this is a step in the right direction,” West said. “I’ve learned that no matter how varied your resources are, there are options for change in your ER.”

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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Microbiome Startups Promise to Improve Your Gut Health, but Is the Science Solid?

Wed, 08/25/2021 - 5:00am

After Russell Jordan sent a stool sample through the mail to the microbiome company Viome, his idea of what he should eat shifted. The gym owner in Sacramento, California, had always consumed large quantities of leafy greens. But the results from the test — which sequenced and analyzed the microbes in a pea-sized stool sample — recommended he steer clear of spinach, kale and broccoli.

“Things I’ve been eating for the better part of 30 years,” said Jordan, 31. “And it worked.” Soon, his mild indigestion subsided. He recommended the product to his girlfriend.

She took the test in late February, when the company — which sells its “Gut Intelligence” test for $129 and a more extensive “Health Intelligence” test, which requires a blood sample, for $199 — began experiencing hiccups. Viome had promised results within four weeks once the sample arrived at a testing facility, but Jordan said his girlfriend has been waiting more than five months and has submitted fresh blood and stool samples — twice.

Other Viome customers have flocked to social media to complain about similar problems: stool samples lost in the mail, months-long waits with no communication from the company, samples being rejected because of shipping or lab processing snafus. (I, too, have a stool sample lost in transit, which I mailed after a first vial was rejected because it “leaked.”) The company’s CEO, Naveen Jain, took to Facebook to apologize in late July.

Viome’s troubles provide a cautionary tale for consumers in the wild west of microbiome startups, which have been alternately hailed for health breakthroughs and indicted for fraud.

The nascent industry offers individualized diet regimens based on analyzing gut bacteria — collectively known as the gut microbiome. Consumers pay hundreds of dollars for tests not covered by insurance, hoping to get answers to health problems ranging from irritable bowel syndrome to obesity.

Venture capitalists pumped $1 billion into these kinds of startups from 2015 to 2020, according to Crunchbase, buoyed by promising research and consumers’ embrace of at-home testing. PitchBook has identified more than a dozen direct-to-consumer gut health providers.

But not all the startups are equal. Some are supported by peer-reviewed studies. Others are peddling murky science — and not just because poop samples are getting lost in the mail.

“A lot of companies are interested in the space, but they don’t have the research to show that it’s actually working,” said Christopher Lynch, acting director of the National Institutes of Health Office of Nutrition. “And the research is really expensive.”

With nearly $160 million in government funding, the NIH Common Fund’s Nutrition for Precision Health research program, expected to launch by early next year, seeks to enroll 1 million people to study the interactions among diet, the microbiome, genes, metabolism and other factors.

The gut microbiome is a complex community of trillions of bacteria. Research over the past 15 years has determined that these microbes, both good and bad, are an integral part of human biology, and that altering a person’s gut microbes can fundamentally change their metabolism, immune function — and, potentially, cure diseases, explained Justin Sonnenburg, a microbiology and immunology associate professor at Stanford University.

Metagenomic sequencing, which identifies the unique set of bugs in someone’s gut (similar to what 23andMe does with its saliva test), has also improved dramatically, making the process cheaper for companies to reproduce.

“It’s seen as one of the exciting areas of precision health,” said Sonnenburg, who recently co-authored a study that found a fermented food diet increases microbiome diversity — which is considered positive — and reduces markers of inflammation. That includes foods like yogurt, kefir and kimchi.

“The difficulty for the consumer is to differentiate which of these companies is based on solid science versus over-reaching the current limits of the field,” he added via email. “And for those companies based on solid science, what are the limits of what they should be recommending?”

San Francisco-based uBiome, founded in 2012, was one of the first to offer fecal sample testing.

But as uBiome began marketing its tests as “clinical” — and seeking reimbursement from insurers for up to nearly $3,000 — its business tactics came under scrutiny. The company was raided by the FBI and later filed for bankruptcy. Earlier this year, its co-founders were indicted for defrauding insurers into paying for tests that “were not validated and not medically necessary” in order to please investors, the Department of Justice alleges.

But for Tim Spector, a professor of genetic epidemiology at King’s College London and co-founder of the startup Zoe, being associated with uBiome is insulting.

Zoe has spent more than two years conducting trials, which have included dietary assessments, standardized meals, testing glycemic responses and gut microbiome profiling on thousands of participants. In January, the findings were published in Nature Medicine.

The company offers a $354 test that requires a stool sample, a completed questionnaire, and then a blood sample after eating muffins designed to test blood fat and sugar levels. Customers can also opt in to a two-week, continuous glucose monitoring test.

The results are run through the company’s algorithm to create a customized library of foods and meals — and how customers are likely to respond to those foods.

DayTwo, a Walnut Creek, California, company that recently raised $37 million to expand its precision nutrition program, focuses on people with prediabetes or diabetes. It sells to large employers — and, soon, to health insurance plans — rather than directly to consumers, charging “a few thousand dollars” per person, said Dr. Jan Berger, chief clinical strategist.

Based on a decade of research, DayTwo has worked with nearly 75,000 people. It sends participants a testing kit and survey, and arranges for them to chat with a dietitian while their stool sample is processing. Then, when the results come in, it makes recommendations, Berger said.

“I can still eat two scoops of ice cream, but I need to add walnuts in it to regulate my blood sugar,” she offered as an example.

Viome says it has tested more than 200,000 customers and has published its methodology for analyzing stool samples, which is different from other gut health companies. But the paper does not address Viome’s larger claims of connecting the microbiome to dietary advice, and researcher Elisabeth Bik called the claims “far-fetched” in a 2019 review of the preprint version.

Viome makes additional money by selling supplements, probiotics and prebiotics based on consumers’ test results. It has also rebranded as Viome Life Sciences, expanding into precision diagnostics and therapeutics, such as saliva tests to detect throat cancer. Meanwhile, its gut health program has been mired in logistical missteps.

One customer who posted on Facebook tracked her sample through the U.S. Postal Service as it boomeranged between Los Alamos, New Mexico, and Bothell, Washington, where it was supposed to be picked up. Another fought for a refund after waiting six weeks to hear her sample was not viable and learning a second attempt had expired after spending too long in transit. The company’s expected lab processing time jumped from four weeks in February, when Jordan said his girlfriend took her first test, to six in summer. (Three weeks after I mailed my second sample in July, it still hadn’t made it to the lab, so I called it quits and asked for a refund.)

In CEO Jain’s July apology posted to the private Facebook group for Viome users, he said the company recently moved its lab from New Mexico to Washington state, close to its headquarters, which prompted a mail-forwarding fiasco. It bought new robotics that “refused to cooperate,” he wrote. “Many things didn’t go as planned during the move.”

Spokesperson Kendall Donohue said Viome has been working on the problems but laid much of the blame on the Postal Service.

She also said Viome has been notifying customers — even though many (including myself) had not been contacted.

It is Viome’s “top priority right now to ensure complete customer satisfaction, but unfortunately USPS needs to sort the issue internally for further action to be taken,” she said.

She also offered me a free “Health Intelligence” test. I declined.

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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These Governors Push Experimental Antibody Therapy — But Shun Vaccine and Mask Mandates

Wed, 08/25/2021 - 5:00am

For months, Joelle Ruppert was among the millions of Americans who are covid vaccine holdouts. Her reluctance, she said, was not so much that she opposed the new vaccines but that she never felt “compelled” by the evidence supporting their experimental use.

Nonetheless, after she fell ill with covid last month, Ruppert, a Florida preschool teacher, found herself desperate to try an experimental product that promised to ease her symptoms: infusion with a potent laboratory-produced treatment known as monoclonal antibody therapy.

“I was in bed; I was feeling so badly, like the longest flu I ever had in my life,” said Ruppert, 54, of Gainesville. “I was, like, whatever, give me whatever.”

Ruppert and her husband, Michael, 61, who also contracted covid-19, are among thousands of people in the U.S. who in recent weeks have rushed to receive infusions of the powerful antibody cocktails shown to reduce hospitalizations by 70% when given promptly to high-risk patients.

The rush has been fueled in no small part by governors in Southern states, where vaccinations lag and hospitalizations are soaring with delta-variant infections. Republican Govs. Ron DeSantis of Florida and Greg Abbott of Texas are among leaders touting the antibody treatments even as they downplay vaccination and other measures that health officials say can prevent illness in the first place.

Together, they have opened dozens of state-sponsored sites where monoclonal antibody therapy is offered, holding regular news conferences to endorse the potentially lifesaving benefits, while continuing to resist wider public health measures such as mask mandates and vaccine passports.

“Anyone that has a better-than-average risk with covid, if you do get infected, this is something you can do early and potentially really make a difference,” DeSantis said Saturday at the opening of a monoclonal antibody infusion site in Manatee County.

Since mid-July, delivery of the antibody cocktail made by Regeneron Pharmaceuticals has soared from 25,000 doses to 125,000 doses per week, with about half shipped to four states: Florida, Texas, Mississippi and Alabama, said Alexandra Bowie, a company spokesperson. The treatments use laboratory-produced molecules to replace, enhance or mimic the body’s natural antibodies that fight infection.

The sudden spotlight on the antibody treatments has whipsawed some public health experts, who have struggled for months to create and sustain sites capable of offering the therapy. The treatment is delivered primarily through a one-dose intravenous infusion that takes about 25 minutes, followed by an hour of observation for reactions.

Antibody cocktails, which must be given within 10 days of covid infection or exposure, are effective for many patients, but “this is not a substitute for vaccine, by any means,” said Dr. Christian Ramers, chief of population health and an infectious disease specialist at Family Health Centers of San Diego.

“It’s a backwards strategy,” said Ramers. “It’s so much better to prevent a disease than to use an expensive, cumbersome and difficult-to-use therapy. It does not make any medical sense to lean into monoclonals to the detriment of vaccines. It’s like playing defense with no offense.”

The cost of Regeneron infusions: about $1,250 a dose. For now, the federal government is covering the cost.

The federal government is also covering the costs of covid vaccination, at about $20 a dose.

Hospitals and infusion centers also charge for the time- and resource-intensive administration of monoclonal antibody treatment. Medicare has agreed to pay providers between $310 and $450 for performing it in health care settings — and $750 for treatment in a patient’s home.

Some patients who receive the treatment may be charged similar amounts for copays and administration fees, depending on what a hospital charges and what their insurance covers. DeSantis has emphasized that the treatment is provided at no cost to patients at Florida’s state-run sites.

The Food and Drug Administration authorized two monoclonal antibody treatments for emergency use for covid in November, weeks after President Donald Trump credited Regeneron’s product for curing his infection. Since then, use of a cocktail made by Eli Lilly has been halted because it wasn’t effective against some covid variants. In May, sotrovimab, a monoclonal antibody made by the pharmaceutical firm GlaxoSmithKline, also received emergency authorization.

The treatment is authorized for people newly infected with covid at high risk of hospitalization and for high-risk patients who have been exposed to the virus. Those eligible include a wide swath of the American public: people who are overweight or obese; those who have diabetes, heart disease or other illnesses; and those with compromised immune systems.

The covid vaccines also were authorized under emergency-use protocol. This week, the Pfizer-BioNTech vaccine was granted full approval for use in people 16 and older.

Christina Pushaw, a DeSantis spokesperson, said criticism of efforts to promote monoclonal antibody therapy amounts to “a false choice.”

“Prevention and treatment are not mutually exclusive,” she said in an email. “Both monoclonals and vaccines save lives. The difference is that vaccines are preventative and cannot help someone who is already infected with covid-19.”

Some health officials welcomed the attention to monoclonal antibody therapy generated by DeSantis and others, saying the treatment has been undervalued and underused. The federal government has shipped more than 1.3 million doses of monoclonal products to nearly 6,300 sites, according to the Department of Health and Human Services. So, far, about 637,000 doses — or fewer than half — have been used.

“It’s not about vaccination. It’s about a treatment for covid that can keep patients out of the hospital,” said Connie Sullivan, president and chief executive of the trade group National Home Infusion Association. “This isn’t about politics. This is about patients at risk.”

Still, some unvaccinated people appear to view the antibody treatments as a backup plan if they get sick, several health officials said.

At Memorial Hospital Pembroke in South Florida, Chief Nursing Officer David Starnes has overseen treatment of more than 2,000 patients with antibody cocktails since December. At least 90% of the patients have been unvaccinated — and the numbers keep climbing.

“What’s amazing to me is that a vaccine we’ve been working on for 10 years, they are deathly afraid of,” Starnes said. “But this highly experimental cocktail? They’re willing to run in there the minute that they’re sick to get this infused into their bodies.”

Even those confounded by the emphasis on monoclonals over vaccination in some states say this new attention to the treatment has helped counter a basic public relations problem: Until recently, awareness of monoclonal treatments, often called mAbs, was low, leaving patients in danger of missing the 10-day window for treatment.

Utah, where fewer than half of residents are vaccinated, is among the states hosting an intensive, coordinated effort to reach people in time. Officials at the Intermountain Healthcare system, based in Utah, pulled together a team of volunteer medical professionals, dubbed “the mAb squad,” who scan lists of newly positive covid patients and call those who meet eligibility criteria to connect them with the treatment.

Dr. Curt Andersen, a family medicine physician and an associate medical director with Intermountain Healthcare, said he’s seeing lists of 70 to 80 patients every day because of the delta surge. “I talked to this one gentleman who got treated. Then his wife got treated. Then his mother, who was at very high risk,” Andersen said. “On the phone, he broke down in tears because we had this resource and he was so grateful.”

Ruppert, the Gainesville preschool teacher, said she, too, was grateful. She and her husband both felt better within days of being treated at UF Health Shands Hospital. The experience has caused her to rethink how to protect herself and her family from covid.

“Now that I’ve been there, I have a completely different perspective on this,” said Ruppert, who will be eligible for vaccination in mid-October, 90 days after the antibody infusion. “I most likely will be vaccinated.”

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

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‘An Arm and a Leg’: Meet the Mississippi Lawyer Who Helped Start the Fight for Charity Care

Tue, 08/24/2021 - 5:00am

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

Richard “Dickie” Scruggs, famous for taking on Big Tobacco in the ’90s and winning, worked on a series of ill-fated national lawsuits against nonprofit hospitals. The goal? Get nonprofit — or “charity” — hospitals to actually provide charity care instead of price-gouging and dunning low-income patients. 

Scruggs didn’t exactly score a total victory — some hospitals kept behaving shamefully. And he lost big, eventually.

But he did help start important changes.

For instance: We’ve been following the work of Jared Walker, who went viral on TikTok, spreading the word that nonprofit hospitals are legally obligated to provide charity care. That obligation didn’t exist when Scruggs launched those lawsuits.

For the next few episodes, we’ll tell some of the stories about how that change happened — it’s a wild ride, and Scruggs wasn’t the only player (or the most effective) — and how folks today are pushing that work forward. 

This episode relies on audio from The Kindling Group documentary “Do No Harm.”

And researchers with the Innovation for Justice Program at the University of Arizona are looking at hospitals’ debt collection practices, and how laws or regulations could do a better job protecting people. They’re looking to talk to people who have been sued over medical bills. If that’s you, or someone you know, here’s a link to get in touch: bit.ly/talkmeddebt. It’s a 30-minute interview, and it is all anonymous.

Here’s a transcript of 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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Mission and Money Clash in Nonprofit Hospitals’ Venture Capital Ambitions

Tue, 08/24/2021 - 5:00am

Cone Health, a small not-for-profit health care network in North Carolina, spent several years developing a smartphone-based system called Wellsmith to help people manage their diabetes. But after investing $12 million, the network disclosed last year it was shutting down the company even though initial results were promising, with users losing weight and recording lower blood sugar levels.

The reason did not have to do with the program’s potential benefit to Cone’s patients, but rather the harm to its bottom line. Although Cone executives had banked on selling or licensing Wellsmith, Cone concluded that too many competing products had crowded the digital health marketplace to make a dent.

“They did us a tremendous favor in funding us, but the one thing we needed them to be was a customer and they couldn’t figure out how to do it,” said Jeanne Teshler, an Austin, Texas-based entrepreneur who developed Wellsmith and was its CEO.

Eager to find new sources of revenue, hospital systems of all sizes have been experimenting as venture capitalists for health care startups, a role that until recent years only a dozen or so giant hospital systems engaged in. Health system officials assert many of these investments are dually beneficial to their nonprofit missions, providing extra income and better care through new medical devices, software and other innovations, including ones their hospitals use.

But the gamble at times has been harder to pull off than expected. Health systems have gotten rattled by long-term investments when their hospitals hit a budgetary bump or underwent a corporate reorganization. Some health system executives have belatedly discovered a project they underwrote was not as distinctive as they had thought. Certain devices or apps sponsored by hospital systems have failed to be embraced by their own clinicians, out of either skepticism or habit.

“Even the best health care investors can’t reliably get their health systems to adopt technologies or new innovations,” said James Stanford, managing director and co-founder of Fitzroy Health, a health care investment company.

Some systems have found the business case for using their own innovations is weaker than anticipated. Wellsmith, for instance, was premised on a shift in insurance payments from a fee for each service to reimbursements that would reward Cone for keeping patients healthy. That change did not come as fast as hoped.

“The financial models are so much based on how many patients you see, how many procedures you do,” said Dr. Jim Weinstein, who championed a health initiative similar to Cone’s when he was CEO of the Dartmouth-Hitchcock health system in New Hampshire. “It makes it hard to run a business that is financially successful if you’re altruistic.”

Though their tax-exempt status is predicated on charitable efforts, nonprofit health systems rarely put humanitarian goals first when selecting investments, even when sitting on portfolios worth hundreds of millions of dollars or more, according to a KHN analysis of IRS filings. Together, nonprofit hospital systems held more than $283 billion in stocks, hedge funds, private equity, venture funds and other investment assets in 2019, the analysis found. Of that, nonprofit hospitals classified only $19 billion, or 7%, of their total investments as principally devoted to their nonprofit missions rather than producing income, the KHN analysis found.

Venture capital funds are a potentially lucrative but risky form of investment most associated with funding Silicon Valley startup companies. Because investors seek out companies in their early stages of development, a long-term horizon and tolerance for failure are critical to success. Venture capitalists often bank on a runaway success that ends up on a stock exchange or in a sale to a larger company to counterbalance their losses. As an asset class, venture capital funds assets annually return between 10% and 15% depending on the time frame, according to PitchBook.

While they lack the experience of longtime venture capitalists, health systems posit that they have advantages because they can invent, incubate, test and fine-tune a startup’s creations. Children’s Hospital of Philadelphia, for instance, parlayed a $50 million investment into a return of more than $514 million after it spun off its gene therapy startup Spark Therapeutics.

Many hospital-system venture capital funds, both established and new entrants, have grown rapidly. The largest, run by the Catholic hospital chain Ascension, has been in business for two decades and this year topped $1 billion, including contributions from 13 other nonprofit health systems eager to capture a piece of the returns.

Providence, a Catholic health system with hospitals in seven Western states, launched its venture capital fund in 2014 with $150 million and now has $300 million.

Cleveland-based University Hospitals launched its own fund, UH Ventures, in 2018. “We were candidly late to the game,” said David Sylvan, president of UH Ventures.

UH Ventures yielded $64 million in profits in 2020, Sylvan said, which pushed University Hospitals’ net operating revenue from the red to $31 million. Sylvan said the largest income contributor from UH Ventures was its specialty pharmacy, UH Meds, which provides medications to people with complex chronic conditions and helps them manage their ailments.

Another UH-supported startup, RiskLD, uses algorithms to monitor women and their babies during delivery to alert clinicians of sudden changes in conditions. It is used in UH’s labor and delivery units. Sylvan said it is being marketed to other systems. UH Ventures’ webpage touts the financial advantages for avoiding lawsuits, calling RiskLD “the first and only labor and delivery risk management tool designed to address birth malpractice losses.”

But sustained commitment is harder when the return on investment is not clear or immediate. In 2016, Dartmouth-Hitchcock, which operates New Hampshire’s only academic medical center, tested its remote monitoring technology, ImagineCare, on 2,894 employee volunteers. ImagineCare linked a mobile app and Bluetooth-enabled devices to a health system support center staffed by nurses and other Dartmouth-Hitchcock workers. The app tracked about two dozen measurements, including activity, sleep and, for those with chronic conditions, key indicators like weight and blood sugar levels. Worrisome results triggered contact and behavioral coaching from the Dartmouth-Hitchcock staff.

Dartmouth-Hitchcock found health care expenditures for the people with chronic conditions dropped by 15% more than matched controls. Nonetheless, in 2017, with the product facing unexpected technology challenges and the health system saddled with a short-term deficit, Dartmouth-Hitchcock scrapped the experiment and sold the technology to a Swedish company in return for potential royalties.

“We didn’t have the capital as a small health system,” said Weinstein, now senior vice president of innovation and health equity for Microsoft. “It wasn’t a venture investment to make money; in fact, we probably would have lost revenues on admissions. But it was the right thing to do.”

ImagineCare has found a more receptive home in Sweden. Two regions of the public health care system as well as a private health care organization have decided to deploy it as their remote monitoring service, according to ImagineCare’s CEO, Annette Brodin Rampe. The company expects to have 10,000 patients enrolled by year’s end.

Wellsmith, Cone Heath’s diabetes platform, suffered an even rockier trajectory. The concepts were similar, but Wellsmith was initially tailored to people with Type 2 diabetes. Data on weight, activity, blood sugar and patients’ compliance on taking medication was uploaded manually or through Bluetooth-enabled devices and sent to a small team of nurses and health coaches at Cone, who would contact those with disquieting signs.

Cone tested Wellsmith on 350 employees with Type 2 diabetes and reported encouraging results in 2018. Users’ physical exercise had increased on average by 24% and their A1c levels, which measure the percentage of red blood cells with sugar-coated hemoglobin, had dropped by 1 point on average. “We believe that the future will be carried by those who can invest in and create models of care like Wellsmith,” said Terry Akin, Cone’s CEO at the time.

But Cone grew apprehensive about Wellsmith’s commercial prospects, especially when other companies started pitching similar products. In its 2018 financial statement, Cone wrote that “management has determined that the existing technology will not be marketed for sale and licensing.” In October 2020, Cone decided to end its relationship with Wellsmith and shut it down this year, according to its financial statement.

Cone declined requests for interviews. In an email, Cone spokesperson Doug Allred wrote: “Unfortunately, a number of well-funded competitors established similar platforms. This has made it difficult to scale our platform to more customers and develop more partnerships. Due to these factors we made the difficult decision to sunset the Wellsmith platform.”

In interviews, Teshler said Cone had originally viewed the product as complementary to its efforts to move away from a traditional fee-for-service payment system. But she said alternative models — such as those in which insurers pay a set fee for each patient, providing doctors and hospitals with an incentive to keep spending low — remained the arrangement for a minority of Cone’s patients: those enrolled in Cone’s Medicare Advantage plans and accountable care organizations.

“The problem with these kinds of solutions — not just us — is it requires people to have digital devices that aren’t normally covered by health insurance,” she said.

Wellsmith’s business plan was to charge a per-member monthly fee to organizations using it. Teshler said Cone did not want to pay Wellsmith a fee when it had already lent it millions, since it couldn’t bill insurers for the service.

Other obstacles arose as well, according to Teshler. She said Wellsmith’s development was delayed when the second version of the software was a “dismal failure” and needed to be revamped. To further complicate matters, Cone began entertaining a merger with another health system, making the long-term financial commitment to Wellsmith uncertain. “And then we hit covid and it was game over,” Teshler said.

Teshler said she is still developing her concept, though, under her contract with Cone, Wellsmith’s software had to be destroyed when they split ways. She wants to market Wellsmith’s successor to primary care medical practices that contract directly with employers — groups that benefit when medical claims are reduced. She does not see other hospital systems as viable customers.

“It’s very simple for their attention to be diverted by the fact that their job is to keep people alive,” she said. Also, unless an innovation is unique, she said, “everybody’s got a fund, and nobody is going to buy anyone else’s product.”

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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Headed Away to School? Here’s What Students With Health Issues Need to Know

Tue, 08/24/2021 - 5:00am

College is a time of transition, but for those managing chronic medical conditions, it may also be the first time they will be wholly responsible for their own health: setting appointments, securing supplies and pharmaceuticals, and monitoring symptoms.

For those heading to schools far from home, it can be especially tricky navigating the complex world of insurance to pay for such crucial care. Coverage networks from back home might not cover a patient’s new doctors or a trip to an urgent care clinic. New plans may not cover the same medicines or procedures.

“Insurance doesn’t make sense to even people in health care,” said Jenna Riemenschneider, director of advocacy and special projects at the Asthma and Allergy Foundation of America.

Ensuring continuity of care and having medical support at school allow students to better pursue their studies and enjoy the college experience, health experts said. They recommend students and their families study up before heading to campus. Make calls to local or university health center providers and secure appropriate insurance to help make a smooth transition.

“You have to do some real due diligence to make sure you have the right protections,” said Erika Emerson, executive director of the Diabetes Leadership Council. “There are some things that are OK to whiff on, like if some things don’t happen and you learn a hard lesson, fine. Health care isn’t one of those things where there is a whole lot of forgiveness for mistakes that can be costly in terms of health outcomes and, certainly, financially.”

Income-Based Plans

Sam Grover was turning 26 around the time he headed from Utah to New York City for a medical school program. Per federal law, he would no longer be eligible to remain on his parents’ insurance after his birthday.

Grover, who has Type 1 diabetes, needed to be able to pay for his medical supplies, including a continuous glucose monitor, pump and insulin that keep his blood sugar levels in a safe range. After exploring his options, he enrolled in Medicaid, the federal-state health insurance program for low-income Americans.

“Growing up, I never saw myself as someone who would be in need, but then times changed, and I got diabetes, and I turned 26, and I didn’t have a job,” said Grover, who has one year left in medical school before beginning his residency. He said he hopes his work as a doctor will help make good on the help he received as a student from the government-sponsored health program.

Medicaid coverage varies by state. Grover found that Medicaid in Utah didn’t cover continuous glucose monitoring, for example, but he said New York’s program covers all his medical needs.

“It’s been the biggest blessing,” he said, adding that the cost of equipment and supplies to manage diabetes is expensive. “Just knowing that I am able to manage my diabetes while I am a student alleviates a lot of stress and anxiety that comes with having diabetes.”

Medicaid benefits are typically valid only in the state where the plan originates, and not all states have expanded coverage to more adults under the Affordable Care Act. If Medicaid isn’t an option, experts said, individual coverage through ACA insurance exchanges can be good options for students, especially if they can use federal tax credits and subsidies to make those plans more affordable.

As with most insurance options, students must clearly understand whether coverage extends beyond the location of their university, and if it covers specialist care and required medications. They also need to be aware of which ongoing out-of-pocket costs they’re responsible for.

A Parent’s Insurance

For many students younger than 26, remaining on a parent’s or guardian’s insurance might be the best option. Experts said it is imperative to read the fine print to be certain coverage is comprehensive and extends to where they attend school.

Both of Kathy Przywara’s children have asthma, and one has food allergies. Both left California to attend schools in rural Pennsylvania. After doing research, the family kept both on their existing insurance policy, but they still had to find in-network providers near the two schools.

While they were able to transfer one student’s prescriptions to a national chain pharmacy, that was not an option for the other. Przywara, who is also senior community director for the Asthma and Allergy Foundation of America, worked with a local pharmacy to ensure prescriptions were filled. The pharmacy already had a delivery program in place to the school’s health center, making it easier for students to obtain medications.

Przywara said mail-order pharmaceuticals, if covered by insurance, might also be an option for students. Some insurance covers prescriptions for multiple months of medication.

“Know what’s in your policy and make sure that the things you are going to need are covered,” Przywara said. “It’s important to keep your condition managed. That means access to your physicians and to your medication, or else the financial burden gets worse.”

Despite one’s best efforts, Pryzwara and others cautioned, emergencies can happen. Therefore, it is important for students to determine whether urgent and emergency care centers nearest them are in their network. Under the Affordable Care Act, initial emergency care should be covered but other services might not be.

University-Sponsored Insurance

Many schools require students to have health insurance and offer university-sponsored plans, said Jake Baggott, a past president of the American College Health Association and an associate vice chancellor of student affairs at the University of Wisconsin-Madison. He said that while some university health programs are equipped to deal with more complex medical issues or diagnostics, others are not. Students need to be clear on the details, such as whether their policy covers off-campus care.

Shay Webb, 22, a University of North Carolina-Wilmington graduate student earning a master’s in clinical research and product development, thought she was covering her bases when she purchased a university-sponsored policy in 2017 as an undergrad. She got the policy to help offset the out-of-pocket expenses for her Type 1 diabetes not covered by a parent’s insurance policy.

After moving onto campus, Webb was diagnosed with rheumatoid arthritis. She believed the student policy would help cover her increasing medical expenses.

Several months later, she learned her claims weren’t being processed. The insurer told her it would not pay the claims because she was not attending class in person even though she had remained a full-time student, lived on campus and had no say in whether classes were online or in person. The online program was part of the university’s effort to simulate the real-world experience of professionals in her field.

“I was just in shock,” Webb said. “No one had ever told me.”

Webb and her family were left with thousands of dollars in unexpected medical bills.

“Unexpected health costs are a tremendous burden,” Baggott said, adding that for students who may be taking on tuition debt, unexpected health costs can make things much more difficult to manage. Baggott and others said students should seek assistance from campus staff members, advocacy organizations or other experts should any issues occur.

The Bottom Line: Know the Details Before Signing

Before someone commits to an insurance plan, it is important to understand the specific type of plan, which entity is offering it and exactly how coverage works. If problems arise, students should be sure they can switch plans as needed.

The Partnership to Protect Coverage, a consortium of patient advocacy organizations, issued a report stating that insurance rules implemented during the Trump administration have allowed for the proliferation of plans that do not comply with the Affordable Care Act. These plans, such as short-term insurance options and health care sharing ministries, expose enrollees to financial risk, especially people with preexisting and chronic medical conditions.

“Exhaustively look through all of your options. Look through benefit plans. Call providers. Call the insurance company,” said Erin Hemlin, director of health policy and advocacy at Young Invincibles, a group based in Washington, D.C., that focuses on improving the economic security of young adults. “Double- and triple-check to ensure your child is going to be in a plan that is going to be there when they need 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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Temperaturas extremas aumentan los riesgos de salud de los trabajadores agrícolas

Mon, 08/23/2021 - 5:01am

COACHELLA, California. — Leoncio Antonio Trejo Galdamez, de 58 años, murió en brazos de su hijo el 29 de junio después de pasar el día colocando tuberías de riego en el Valle de Coachella, en California. Otra víctima de un negocio peligroso, la noticia de su muerte resonó en la comunidad mayoritariamente latina cerca de las fronteras de México y Arizona.

“Los trabajadores agrícolas están en la primera línea del cambio climático. Y, en algunos casos, estamos viendo una tormenta perfecta azotando a nuestros trabajadores: covid-19, humo y el calor de los incendios forestales”, dijo Leydy Rangel, vocera de la United Farm Workers Foundation (UFW).

Para trabajadores como Trejo Galdamez, que realizan sus tareas al aire libre, unos pocos grados pueden significar la diferencia entre la vida y la muerte. Aquí, los trabajadores agrícolas usan camisas de manga larga, jeans gruesos, botas pesadas y sombreros de ala ancha para protegerse del calor. Aun así, con frecuencia hay que llamar a la ambulancia.

“El calor se siente horrible”, dijo Jaime Isidoro, de 36 años. “Empiezas a trabajar, empiezas a sudar y la camiseta se empapa”.

Nacido en Puebla, México, Isidoro ha estado recolectando cultivos durante dos décadas en el Valle de Coachella. La región tiene una de las temporadas de cultivo más largas del país y proporciona la mayoría de las hortalizas de invierno de los Estados Unidos. También alberga cientos de granjas de dátiles, que crecen en el clima cálido y seco.

Aquí, el calor es un hecho.

“Hace unos años, me empezó a doler la cabeza. Empecé a tener escalofríos. Fui a la clínica y me pusieron un par de inyecciones”, contó Isidoro. “Me dijeron que era un golpe de calor. No conoces los síntomas. No sabía que era eso hasta que lo tuve”.

Y las temperaturas son cada vez más extremas.

El 4 de agosto, tres de las comunidades desérticas de la región superaron sus récords diarios registrados, alcanzando los 122 grados Fahrenheit en Palm Springs y Thermal, y los 120 en Indio. Thermal estableció un récord para su temperatura más alta en agosto, cuando se elevó a 121 grados. California registró los meses de junio y julio más calurosos.

El calor es la principal causa de muerte relacionada con el clima en los Estados Unidos. Entre 1992 y 2017, el estrés por calor mató a 815 trabajadores estadounidenses y lesionó gravemente a más de 70,000, según la Oficina de Estadísticas Laborales.

En California, las visitas a las salas de emergencia relacionadas con el calor aumentaron un 35% entre 2005 y 2015, el último año para el que hay datos disponibles, con aumentos desproporcionados entre las comunidades negras no hispanas, latinas y asiático-americanas.

El personal médico del Valle de Coachella dice que ha estado tratando a un número creciente de pacientes que sufren de agotamiento por calor o insolación en los últimos años.

En 2018, California registró 6,152 visitas a salas de emergencias debido a enfermedades relacionadas con el calor. El condado de Riverside, que incluye Coachella, Indio y Palm Springs, tiene una de las tasas más altas de visitas a emergencias vinculadas al calor en el estado.

“Si comenzamos a ver más de 120 grados en cualquier capacidad normal, realmente estamos en un territorio desconocido. El cuerpo humano no está diseñado para existir en ese tipo de calor”, dijo el doctor Andrew Kassinove, médico del departamento de emergencias y jefe de personal del JFK Memorial Hospital en Indio.

El hospital trata regularmente a las personas que trabajan al aire libre por agotamiento por calor, que se caracteriza por náuseas, aturdimiento, fatiga, calambres musculares y mareos. Con menos frecuencia ven insolación, una condición más peligrosa cuyos síntomas incluyen dolor de cabeza, confusión, vómitos, frecuencia cardíaca rápida, desmayos y falta de sudoración.

“Las temperaturas corporales basales que son realmente elevadas requieren ser tratadas con medidas para salvar vidas”, dijo Kassinove. A medida que las temperaturas se elevan por encima de la temperatura humana típica de 98,6 grados Fahrenheit, el cuerpo lucha por disipar el calor.

California tiene algunas de las protecciones laborales más estrictas contra el agotamiento por calor. Una norma adoptada por los funcionarios de seguridad laboral en 2006 fue la primera en el país en aplicarse a todos los trabajos al aire libre, obligando a las empresas a proporcionar a los trabajadores espacios con sombra, tiempo de descanso y agua adecuados.

Después que una histórica ola de calor azotara el noroeste del Pacífico en junio, Oregon y Washington adoptaron protecciones similares. Algunos miembros del Congreso han presentado un proyecto de ley similar y quieren que el Departamento de Trabajo establezca estándares federales.

Pero los grupos de derechos de los trabajadores dicen que las reglas no siempre se hacen cumplir. Y los trabajadores agrícolas, que están desesperados por el dinero y a menudo se les paga por pieza durante la cosecha, muchas veces pasan por alto su propia seguridad, dicen.

“Es poco probable que los trabajadores agrícolas presenten quejas”, dijo Rangel de la UFW. Sin asistencia federal durante la pandemia, “no tenían otra opción, tenían que seguir presentándose al trabajo si querían alimentar a su familia”.

Los latinos, que representan la mayoría de los trabajadores agrícolas de California, son como grupo más propensos a tener afecciones que pueden agravarse por el calor, como presión arterial alta y enfermedad renal.

Los trabajadores de salud enfatizan la importancia de la hidratación e instan a los trabajadores a consumir menos refrescos, café y alcohol que son deshidratantes, dijo el enfermero José Banuelos del Central Neighborhood Health Foundation, de Coachella. “No puedes cambiar tu trabajo si es al aire libre. Pero le digo a la gente que use protector solar y una capa protectora”.

El calor también puede afectar el uso de medicamentos. Los antipsicóticos y antidepresivos, por ejemplo, pueden reducir la sed y, por lo tanto, causar deshidratación, al igual que los diuréticos, que a veces se toman para la hinchazón.

Isidoro, quien dijo que está buscando otros trabajos, a menudo ve a sus compañeros de tareas luchando en los campos. Si se sienten mareados, pueden sentarse a la sombra o subirse a un camión cercano para que le pongan aire acondicionado, o llamar al 911 si los síntomas persisten.

Pero es un motivo de orgullo no mostrar que el calor te está afectando, dijo, y las llamadas para descansar a menudo se reciben con risas.

Alrededor de Bakersfield, mientras se recogen uvas durante la cosecha de verano y otoño, las ambulancias son un espectáculo habitual, dijo Isidoro. “Todos los días se escucha: ‘Aquí viene la ambulancia’ o ‘Fulano de tal se fue temprano porque se sintió enfermo’”.

Pero muchos trabajadores ignoran las señales de advertencia, dijo Aguileo Rangel Rojas, otro trabajador agrícola. “Están bien arriesgando su salud, sin pensar en eso, para asegurarse de que pueden ganar un salario”.

Rangel Rojas conoce demasiado bien los riesgos. En 2005, su hijo de 15 años, Cruz, sufrió un golpe de calor mientras recogía uvas. Pasó 15 días en el hospital y la familia no estaba segura si sobreviviría. Los ojos de Rojas se llenaron de lágrimas al recordarlo.

“No teníamos dinero. No hablábamos inglés. Sin auto. Sin nada”, dijo. “No conocíamos nuestros derechos. Puede arrancarte el corazón”.

Después de la emergencia, Cruz dejó de recolectar y volvió a la escuela secundaria; ahora es un empleado de UFW. Su padre, ahora de 53 años, todavía trabaja en el campo con su esposa.

En agosto, Rangel Rojas comenzó a trabajar por las noches, cuando las temperaturas bajan a los 80 grados. Pero incluso sin calor extremo, existen riesgos. La evaporación de los cultivos se mantiene espesa en el aire, creando una humedad que puede provocar tormentas eléctricas e inundaciones repentinas.

Un relámpago brilló a su alrededor mientras estaba cortando apio en un tractor en un amanecer reciente.

“Nos puede alcanzar un rayo en cualquier momento y todos podríamos morir”, dijo. “Debería poder ocurrir que esté lloviendo y los jefes nos pidan que dejemos de trabajar, pero no lo hacen. No podemos darnos el lujo de sentarnos detrás de un escritorio”.

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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Pandemic Unveils Growing Suicide Crisis for Communities of Color

Mon, 08/23/2021 - 5:00am

This story is a collaboration between KHN and “Science Friday.” Listen to the conversation between KHN national correspondent Aneri Pattani and John Dankosky, Science Friday’s director of news and radio projects.

Rafiah Maxie has been a licensed clinical social worker in the Chicago area for a decade. Throughout that time, she’d viewed suicide as a problem most prevalent among middle-aged white men.

Until May 27, 2020.

That day, Maxie’s 19-year-old son, Jamal Clay — who loved playing the trumpet and participating in theater, who would help her unload groceries from the car and raise funds for the March of the Dimes — killed himself in their garage.

“Now I cannot blink without seeing my son hanging,” said Maxie, who is Black.

Clay’s death, along with the suicides of more than 100 other Black residents in Illinois last year, has led locals to call for new prevention efforts focused on Black communities. In 2020, during the pandemic’s first year, suicides among white residents decreased compared with previous years, while they increased among Black residents, according to state data.

But this is not a local problem. Nor is it limited to the pandemic.

If you or someone you know is in crisis, call the National Suicide Prevention Lifeline at 1-800-273-8255 or text HOME to the Crisis Text Line at 741741.

Interviews with a dozen suicide researchers, data collected from states across the country and a review of decades of research revealed that suicide is a growing crisis for communities of color — one that plagued them well before the pandemic and has only been exacerbated since.

Overall suicide rates in the U.S. decreased in 2019 and 2020. National and local studies attribute the trend to a drop among white Americans, who make up the majority of suicide deaths. Meanwhile, rates for Black, Hispanic and Asian Americans — though lower than their white peers — continued to climb in many states. (Suicide rates have been consistently high for Native Americans.)

“Covid created more transparency regarding what we already knew was happening,” said Sonyia Richardson, a licensed clinical social worker who focuses on serving people of color and an assistant professor at the University of North Carolina-Charlotte, where she researches suicide. When you put the suicide rates of all communities in one bucket, “that bucket says it’s getting better and what we’re doing is working,” she said. “But that’s not the case for communities of color.”

Losing Generations

Although the suicide rate is highest among middle-aged white men, young people of color are emerging as particularly at risk.

Research shows Black kids younger than 13 die by suicide at nearly twice the rate of white kids and, over time, their suicide rates have grown even as rates have decreased for white children. Among teenagers and young adults, suicide deaths have increased more than 45% for Black Americans and about 40% for Asian Americans in the seven years ending in 2019. Other concerning trends in suicide attempts date to the ’90s.

“We’re losing generations,” said Sean Joe, a national expert on Black suicide and a professor at Washington University in St. Louis. “We have to pay attention now because if you’re out of the first decade of life and think life is not worth pursuing, that’s a signal to say something is going really wrong.”

These statistics also refute traditional ideas that suicide doesn’t happen in certain ethnic or minority populations because they’re “protected” and “resilient” or the “model minority,” said Kiara Alvarez, a researcher and psychologist at Massachusetts General Hospital who focuses on suicide among Hispanic and immigrant populations.

Although these groups may have had low suicide rates historically, that’s changing, she said.

Paul Chin lost his 17-year-old brother, Chris, to suicide in 2009. A poem Chris wrote in high school about his heritage has left Chin, eight years his senior, wondering if his brother struggled to feel accepted in the U.S., despite being born and raised in New York.

Growing up, Asian Americans weren’t represented in lessons at school or in pop culture, said Chin, now 37. Even in clinical research on suicide as well as other health topics, kids like Chris are underrepresented, with less than 1% of federal research funding focused on Asian Americans.

It wasn’t until the pandemic, and the concurrent rise in hate crimes against Asian Americans, that Chin saw national attention on the community’s mental health. He hopes the interest is not short-lived.

Suicide is the leading cause of death for Asian Americans ages 15 to 24, yet “that doesn’t get enough attention,” Chin said. “It’s important to continue to share these stories.”

Kathy Williams, who is Black, has been on a similar mission since her 15-year-old son, Torian Graves, died by suicide in 1996. People didn’t talk about suicide in the Black community then, she said. So she started raising the topic at her church in Durham, North Carolina, and in local schools. She wanted Black families to know the warning signs and society at large to recognize the seriousness of the problem.

The pandemic may have highlighted this, Williams said, but “it has always happened. Always.”

Pandemic Sheds Light on the Triggers

Pinpointing the root causes of rising suicide within communities of color has proven difficult. How much stems from mental illness? How much from socioeconomic changes like job losses or social isolation? Now, covid may offer some clues.

Recent decades have been marked by growing economic instability, a widening racial wealth gap and more public attention on police killings of unarmed Black and brown people, said Michael Lindsey, executive director of the New York University McSilver Institute for Poverty Policy and Research.

With social media, youths face racism on more fronts than their parents did, said Leslie Adams, an assistant professor in the department of mental health at Johns Hopkins Bloomberg School of Public Health.

Each of these factors has been shown to affect suicide risk. For example, experiencing racism and sexism together is linked to a threefold increase in suicidal thoughts for Asian American women, said Brian Keum, an assistant professor at UCLA, based on preliminary research findings.

Covid intensified these hardships among communities of color, with disproportionate numbers of lost loved ones, lost jobs and lost housing. The murder of George Floyd prompted widespread racial unrest, and Asian Americans saw an increase in hate crimes.

At the same time, studies in Connecticut and Maryland found that suicide rates rose within these populations and dropped for their white counterparts.

“It’s not just a problem within the person, but societal issues that need to be addressed,” said Shari Jager-Hyman, an assistant professor of psychiatry at the University of Pennsylvania’s school of medicine.

Lessons From Texas

In Texas, covid hit Hispanics especially hard. As of July 2021, they accounted for 45% of all covid deaths and disproportionately lost jobs. Individuals living in the U.S. without authorization were generally not eligible for unemployment benefits or federal stimulus checks.

During this time, suicide deaths among Hispanic Texans climbed from 847 deaths in 2019 to 962 deaths in 2020, according to preliminary state data. Suicide deaths rose for Black Texans and residents classified as “other” races or ethnicities, but decreased for white Texans.

The numbers didn’t surprise Marc Mendiola. The 20-year-old grew up in a majority-Hispanic community on the south side of San Antonio. Even before the pandemic, he often heard classmates say they were suicidal. Many faced dire finances at home, sometimes living without electricity, food or water. Those who sought mental health treatment often found services prohibitively expensive or inaccessible because they weren’t offered in Spanish.

“These are conditions the community has always been in,” Mendiola said. “But with the pandemic, it’s even worse.”

Four years ago, Mendiola and his classmates at South San High School began advocating for mental health services. In late 2019, just months before covid struck, their vision became reality. Six community agencies partnered to offer free services to students and their families across three school districts.

Richard Davidson, chief operating officer of Family Service, one of the groups in the collaborative, said the number of students discussing economic stressors has been on the rise since April 2020. More than 90% of the students who received services in the first half of 2021 were Hispanic, and nearly 10% reported thoughts of suicide or self-harm, program data shows. None died by suicide.

Many students are so worried about what’s for dinner the next day that they’re not able to see a future beyond that, Davidson said. That’s when suicide can feel like a viable option.

“One of the things we do is help them see … that despite this situation now, you can create a vision for your future,” Davidson said.

A Good Future

Researchers say the promise of a good future is often overlooked in suicide prevention, perhaps because achieving it is so challenging. It requires economic and social growth and breaking systemic barriers.

Tevis Simon works to address all those fronts. As a child in West Baltimore, Simon, who is Black, faced poverty and trauma. As an adult, she attempted suicide three times. But now she shares her story with youths across the city to inspire them to overcome challenges. She also talks to politicians, law enforcement agencies and public policy officials about their responsibilities.

“We can’t not talk about race,” said Simon, 43. “We can’t not talk about systematic oppression. We cannot not talk about these conditions that affect our mental well-being and our feeling and desire to live.”

For Jamal Clay in Illinois, the systemic barriers started early. Before his suicide last year, he had tried to harm himself when he was 12 and the victim of bullies. At that time, he was hospitalized for a few days and told to follow up with outpatient therapy, said his mother, Maxie.

But it was difficult to find therapists who accepted Medicaid, she said. When Maxie finally found one, there was a 60-day wait. Other therapists canceled appointments, she said.

“So we worked on our own,” Maxie said, relying on church and community. Her son seemed to improve. “We thought we closed that chapter in our lives.”

But when the pandemic hit, everything got worse, she said. Clay came home from college and worked at an Amazon warehouse. On drives to and from work, he was frequently pulled over by police. He stopped wearing hats so officers would consider him less intimidating, Maxie said.

“He felt uncomfortable being out in the street,” she said.

Maxie is still trying to make sense of what happened the day Clay died. But she’s found meaning in starting a nonprofit called Soul Survivors of Chicago. Through the organization, she provides education, scholarships and shoes — including Jamal’s old ones — to those impacted by violence, suicide and trauma.

“My son won’t be able to have a first interview in [those] shoes. He won’t be able to have a nice jump shot or go to church or even meet his wife,” Maxie said.

But she hopes his shoes will carry someone else to a good future.

If you or someone you know is in crisis, call the National Suicide Prevention Lifeline at 1-800-273-8255 or text HOME to the Crisis Text Line at 741741.

KHN senior correspondent JoNel Aleccia contributed to this report.

[Editor’s note: For the purposes of this story, “people of color” or “communities of color” refers to any racial or ethnic populations whose members do not identify as white, including those who are multiracial. Hispanics can be of any race or combination of races.]

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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As Temperatures Rise, So Do the Health Risks for California’s Farmworkers

Mon, 08/23/2021 - 5:00am

COACHELLA, Calif. — Leoncio Antonio Trejo Galdamez, 58, died in his son’s arms on June 29 after spending the day laying irrigation pipes in California’s Coachella Valley. News of his death reverberated through the largely Latino community near the Mexican and Arizona borders — another casualty in a dangerous business.

“Farmworkers are at the front lines of climate change. And, in some instances, we’re seeing a perfect storm battering our workers: covid-19, wildfire smoke and heat,” said Leydy Rangel, a spokesperson for the United Farm Workers Foundation.

For workers like Trejo Galdamez, whose jobs depend on outdoor work, a few degrees can mean the difference between life and death. Farmworkers here wear long shirts, thick jeans, heavy boots and wide-brimmed hats to guard against the heat. Even so, ambulances are frequently called to the fields, and heat-related illness appears to be increasing in the area.

“The heat feels awful,” said Jaime Isidoro, 36. “You start to work, you start to sweat, and the shirt underneath gets drenched.”

Born in Puebla, Mexico, Isidoro has been picking crops for two decades in the Coachella Valley. The region has one of the country’s longest growing seasons, providing most of America’s winter vegetables. It’s also home to hundreds of date farms, which thrive in the hot, dry climate.

Heat is a given here.

“A few years ago, my head started hurting. I started to get chills. I went to the clinic and they gave me a couple of shots,” said Isidoro. “They told me it was a heatstroke. You don’t know the symptoms. I didn’t know it was that until I had it.”

And the temperatures are getting more extreme.

On Aug. 4, three of the desert communities in the region surpassed their daily recorded highs, hitting 122 degrees Fahrenheit in Palm Springs and Thermal, and 120 in Indio. Thermal set a record for its hottest temperature ever for August at 121 degrees. California registered its hottest June and July.

Heat is the leading weather-related cause of death in the United States. Heat stress killed 815 U.S. workers and seriously injured more than 70,000 workers from 1992 through 2017, according to the Bureau of Labor Statistics. In California, heat-related emergency room visits increased by 35% from 2005 to 2015, the latest year for which data was readily available, with disproportionate increases among Black, Latino and Asian American communities.

Medical staffers in the Coachella Valley say they’ve treated a rising number of patients suffering from heat exhaustion or heatstroke in recent years. California in 2018 saw 6,152 emergency room visits due to heat-related illness. Riverside County, which includes Coachella, Indio and Palm Springs, has among the highest rates of heat-related ER visits in the state.

“If we start seeing above 120 degrees in any regular capacity, we’re really in uncharted territory. The human body is not designed to exist in that kind of heat,” said Dr. Andrew Kassinove, emergency department physician and chief of staff at JFK Memorial Hospital in Indio.

The hospital regularly treats people who work outside for heat exhaustion, characterized by nausea, lightheadedness, fatigue, muscle cramping and dizziness. Less frequently they see heatstroke, a more dangerous condition whose symptoms include headache, confusion, vomiting, rapid heart rate, fainting and a failure to sweat.

JFK Memorial has treated 129 heat-related cases already this year, compared with 85 in all of 2020 and 75 in 2019, said hospital spokesperson Todd Burke.

“Core body temperatures that are really elevated require lifesaving measures to treat them,” Kassinove said. As temperatures rise above the typical human temperature of 98.6 degrees Fahrenheit, the body struggles to dissipate the heat.

California has some of the strictest worker protections for heat exhaustion. A standard adopted by occupational safety officials in 2006 was the first in the country to apply to all outdoor jobs, mandating companies to provide workers with adequate shade, downtime and water. After a historic heat wave hit the Pacific Northwest this June, Oregon and Washington adopted similar protections. Some members of Congress have introduced a similar bill and want the Labor Department to establish federal standards.

But workers’ rights groups say the rules are not always enforced. And farmworkers, who are desperate for the money and often get paid per piece during harvests, often overlook their own safety, they say.

“Farmworkers are less likely to file complaints,” said the UFW’s Rangel. With no federal assistance during the pandemic, “they had no option; they had to keep showing up to work if they wanted to feed their family.”

Latinos, who represent the majority of California farmworkers, are as a group more likely to have conditions that can be exacerbated by the heat, like high blood pressure and kidney disease.

Health workers stress the importance of hydration and urge the workers to consume less dehydrating soda, coffee and alcohol, said nurse practitioner Jose Banuelos at Coachella’s Central Neighborhood Health Foundation. “You can’t change your job if your job is outside. But I tell people to wear sunscreen and a protective coating.”

The heat may also affect a patient’s use of medicines. Antipsychotics and antidepressants, for example, can reduce thirst and thus cause dehydration, as do diuretics, sometimes taken for swelling.

Isidoro, who said he’s looking for other jobs, often sees fellow workers struggling in the fields. If they feel faint, they can sit in the shade, or jump in a nearby truck for air conditioning — or call 911 if symptoms persist. But it’s a point of pride not to show the heat is getting to you, he said — and calls to slow down are often met with snickers.

Around Bakersfield, while picking table grapes during the summer and fall harvest, ambulances are a regular sight, Isidoro said. “Daily you would hear: ‘Here comes the ambulance’ or ‘So-and-so left early because he felt ill.’”

But many workers ignore the warning signs, said Aguileo Rangel Rojas, another farmworker. “They are OK risking their health, not thinking about it, to make sure they can make a wage.”

Rangel Rojas knows the risks all too well. In 2005, his 15-year-old son, Cruz, suffered heatstroke while picking grapes. He spent 15 days in the hospital and the family wasn’t sure he would survive. His father teared up at the memory.

“We didn’t have money. We didn’t speak English. Without cars. Without anything,” he said. “We didn’t know our rights. It can rip your heart out.”

Cruz stopped picking after that and went back to high school; he’s now a UFW employee. His father, now 53, still works in the fields with his wife.

In August, Rangel Rojas began working nights, when temperatures go down to the low 80s. But even without extreme heat, there are risks. Evaporation from the crops hangs thick in the air, creating humidity that can bring on thunderstorms and flash floods. Lightning flashed around him while he was out cutting celery on a tractor on a recent predawn morning.

“We can get hit by lightning at any moment and we could all die,” he said. “There should be an instance when it’s raining and the bosses have us stop working, but they don’t. We don’t have the luxury of sitting behind a desk.”

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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Readers and Tweeters Ponder Vaccines and Points of Fairness

Mon, 08/23/2021 - 5:00am

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

Higher Insurance Rates for the Unvaccinated? Snuff Out That Idea

This is about Dr. Elisabeth Rosenthal’s comments on “All In With Chris Hayes” (“Analysis: Don’t Want a Vaccine? Be Prepared to Pay More for Insurance,” Aug. 4). It is extraordinary that anyone would suggest higher health insurance premiums for those who remain unvaccinated for covid. Already health insurers receive a bonanza from all the costs paid by the government, e.g., free vaccinations (to us).

Once the covid vaccines get full approval, those not vaccinated can be excluded from restaurants, markets, theaters, sports events, etc. We will need proof of vaccination because unvaccinated people cannot be trusted to be truthful.

Insurance premium surcharges are not the answer, because surcharges can also act as inflationary drivers on the health insurance rates for everyone. I would not trust companies with health insurance surcharges. A very bad precedent, even for smokers.

— Dimitri Papanastassiou, Pasadena, California

Why should (unvaccinated) patients be kept financially unharmed from what is now a preventable hospitalization?'#COVID19 #covidvacccine2021 https://t.co/UkZZEUKwKG

— Barbara Katz-Chobert (@KatzChobert) August 15, 2021

— Barbara Katz-Chobert, Philadelphia

Unvaccinated But Still Protected?

You claim to believe in science, then why are you ignoring naturally acquired immunity to covid-19 (“If the Unvaccinated Want to Work, They Face a Series of Hurdles,” Aug. 19)? There should be a waiver for folks who have documented tests that prove they are immune. I had covid in March 2020 and was tested for antibodies last month. I have IgG & IgM antibodies that are tested at 70 times the amount needed for prevention of infection. And my infection was over a year and a half ago.

We could be closer to herd immunity if the number of folks with naturally acquired immunity was calculated into those who are immune. The medical community is wasting shots on people who don’t really need them. If I were to go to get an MMR, chickenpox or tuberculosis titer test, all I have to prove is that I am immune. I am not required to get a vaccine. 

— Rebecca Vichitnand, Arlington, Washington

Fantastic news that 90% of U.S. adults 65+ are vaccinated against coronavirus–but I'd love to see those numbers for everyone 12+ who is eligible for a vaccine. https://t.co/RFpdFY52ZN

— Amanda Davis (@amandad_dc) August 5, 2021

— Amanda Davis, Washington, D.C.

Can’t Hold a Candle to the ‘Birthday Rule’ for Fairness

The birthday rule was a fair way for insurers to cover claims so that “good” insurers don’t get lopsided or tilted toward paying all of the claims (“Bye-Bye to Health Insurance ‘Birthday Rule’? Kansas Lawmaker Floats Fix,” July 27). If Company A has a “Cadillac” plan, they shouldn’t have the burden of paying all the claims for children. Company B may have a lesser plan, thereby not having to pay claims for children. Parents covered by two companies both should enroll in each plan, and the birthday rule would dictate which insurer pays first. If both plans were elected, the bottom-line out-of-pocket for the family will be the same. The benefits would coordinate.

This rule is fair because many large companies (such as GM or Walmart) are self-funded, which means they pay the claims out of their pockets. An insurance company is hired to pay claims but the money is the employers’. If the birthday rule is removed, large companies would pay more than what is fair to other companies.

Just because employees or Congress members do not understand, nor read the information about enrolling, does not mean the rule in place is a bad rule. Parents have 30 days from birth to enroll a child. Especially if the child has high claims, it would be advantageous to enroll in both plans. Not all rules are evil or trying to take advantage of not paying claims. There is a reason for this rule: fairness.

— Kathleen Gallagher, Wilmington, North Carolina

The public health department keeps track of things like mosquito borne illnesses and sexually transmitted disease. Behind the scenes but important work. Maybe they need more Snapchat channels to be noticed in this day and age. https://t.co/PbPSmLtH6K

— Emily Deans MD (@evolutionarypsy) August 6, 2021

— Dr. Emily Deans, Norwood, Massachusetts

Heeding Hard Lessons

This is a very important topic for tax-cutting and emergency managers in Michigan (“Hard Lessons From a City That Tried to Privatize Public Health,” Aug. 6). Former Gov. John Engler cut Michigan’s flat tax in steps, beyond his term, and forced massive cuts in Michigan’s cities and then emergency managers. This also helped lead to Flint’s water crisis. Please, KHN, do more follow-up. Twelve deaths in Flint at least. Probably many more in Detroit from covid-19. This is a very important health-planning cause.

— Dave McAninch, South Haven, Michigan

Katrina. Zika. Ebola. Sandy. Flint Water Crisis. COVID.When we underinvest in public health, particularly at the local level, bad things happen during crises. When we will stop repeating these mistakes? https://t.co/UJDaHQKaDM

— Dr. Chris Friese, RN (@ChrisFriese_RN) August 6, 2021

— Chris Friese, Ann Arbor, Michigan

Thank you so much for the recent story about the history and current status of public health services in Detroit. I hope it is read by many public health officials, and that the lessons from Detroit are heeded.

I am a recently retired neonatal nurse practitioner and have been licensed in 12 states, and therefore have seen the importance of public health issues in several regions over the years. Many of my patients were dependent on public health resources after their discharge from the neonatal intensive care unit.

Families are in desperate need of public health services, and these services are so important for maintaining the health of communities in the U.S. It seems there are always new public health issues to be addressed. Again, thank you!

— Patricia Basto, Tucson, Arizona

I would love to see a medical home like this for our refugees and immigrants in Missoula https://t.co/g14Qm6TgpV

— Doug Odegaard (@dodegaard) July 30, 2021

— Doug Odegaard, Missoula, Montana

Good News for a Change

Your story “How a Doctor Breaks Norms to Treat Refugees and Recent Immigrants” (July 27) by Markian Hawryluk is one of the most inspiring articles I’ve ever read. Thank you so much!

— Jan McDermott, San Francisco

I just came across this story and had to share it! What an awesome human! He's also a great doctor. I know because I feel better just reading about him. I mean, I'm all teary-eyed, but I feel better.https://t.co/c6emcya5Ae

— Loretta Sue Ross ⚖ (@lorettasueross) July 27, 2021

— Loretta Sue Ross, Clinton, Missouri

Developing a Tolerance for Outrageous Drug Prices?

This was a good story (“Women Say California Insurer Makes It Too Hard to Get Drug for Postpartum Depression,” July 28), although Massachusetts already requires insurers to “conform to generally accepted standards of care, including scientific literature and expert consensus, when making decisions about mental health treatment” as well as medical treatment (California is not necessarily in the vanguard there). I agree that the Kaiser Permanente criteria are well beyond the pale of acceptable medical management of postpartum depression; in effect, they have declared that they will not pay for this agent, ever. Since it appears to work relatively well, while it’s reasonable to require a trial of one or two less intensive agents first, four drugs and electroconvulsive therapy are an unacceptable response to medically managing the use of this drug.

My question is this: Why is there not more outrage about the price of the agent? $34,000?! That is simply indefensible. The reason insurers react in this way is because the prices are outrageous, especially because they cannot be planned for when making budgets. I recognize that the company that makes it has costs to recoup, but in the age of 1,000+% markups and generic takeovers raising the price of drugs that have been around since before I was a physician, this is simply not reasonable. To paraphrase Uwe Reinhardt (when explaining why U.S. health care is so expensive): It’s the prices, stupid. And it is the prices. Insurers do underwriting so that they can plan how much money to set aside for medical expenses. This kind of price increase shocks both the conscience and the budget, and provokes the kind of backlash seen here.

I will also draw your attention to some efforts here in Massachusetts to cushion the price shock, involving amortization of high-cost, single-use agents like this one over time, with a clause basically saying that if it was not effective, the insurer slides out of the “mortgage.” This was first proposed for the CAR-T class of biologic agents. Look up the FoCUS Project at the MIT Center for Biomedical Innovation/NEWDIGS.

— Dr. Thomas A. Amoroso, Concord, Massachusetts

This story is heartbreaking.

— Jessica Wakeman (@JessicaWakeman) July 30, 2021

— Jessica Wakeman, Asheville, North Carolina

Ice-Filled Drill: Been There, Done That

This is not a unique idea (“A Chilling Cure: Facing Killer Heat, ERs Use Body Bags to Save Lives,” July 22). As an intern in 1969, I worked with Dr. Brian Dawson at the Mayo Clinic. On occasion, he would conduct an emergency drill in the operating room to simulate care of a hyperthermic patient under anesthesia. He would yell, “Dawson dinghy drill!” Staff members would rush in a rubber dinghy, quickly inflate it and fill it with ice, in which to immerse a patient replica, while Dawson timed the drill on his stopwatch.

— Dr. Frederic Grannis, Duarte, California

We bodybaggin' ATs were ahead of our time! #CoolFirstTransportSecond #CWIforEHShttps://t.co/hZ9jUMNDSv

— Caitlin Place (@CaitrATC) July 23, 2021

Caitlin Place, Jackson, Minnesota

Great idea for heatstroke. We had the luxury of ice-filled tubs for heatstroke recruits at Parris Island’s Marine Corps Recruit Depot in the early ’70s. With an average temperature of victims over 106 degrees Fahrenheit, after immersion in ice and vigorous rubbing, all temps fell under 101 in less than 20 minutes. No renal failure, etc. All returned to active duty within a week. I can’t believe that was almost 50 years ago! Good luck and Godspeed.

— Anthony Costrini, Savannah, Georgia

Rural maternity care access is important. If you've ever had a baby and you live in an urban area or close to a hospital, take a minute to think about this….. Can you imagine? https://t.co/fAbjVH4jKK

— Katy Backes Kozhimannil, PhD, MPA (@katybkoz) August 2, 2021

— Katy Backes Kozhimannil, Minneapolis

Nurses Needed to Shore Up Care

The most informative angle was not covered in your story about maternity care deserts: the registered nurses who choose not to work there (“12,000 Square Miles Without Obstetrics? It’s a Possibility in West Texas,” Aug. 2). Interview them. Health systems and hospitals that respect registered nurses usually do not have recruitment and retention issues. Read about me and my colleagues in “The Nurses: A Year of Secrets, Drama and Miracles With the Heroes of the Hospital” by Alexandra Robbins.

— Jan Marty, Vancouver, Washington

My novel is on this topic; what happens if there are no hospitals around? Well, our for-profit healthcare system does not guarantee there will be. Obstetrics is actually a big money loser for a hospital btw — that and ER (h/t @meganranney )#medtwitter https://t.co/8l1RNidS7T pic.twitter.com/WNKdcCUAyJ

— Ashley Madison Cawthorn (@MarieMyungOkLee) August 2, 2021

— Marie Myung-Ok Lee, New York City

The Benefit of Home Health Care

As KHN recently pointed out, expanding Medicare benefits to meet seniors’ changing health care needs is tremendously popular among older Americans and their families (“Why Doesn’t Medicare Cover Services So Many Seniors Need?” Aug. 11). While Congress is discussing plans to add benefits to Medicare, efforts to expand senior access to home-based care following hospitalization are also picking up steam.

The program is called Choose Home, and it would create a cost-effective, patient-centered additional option for Medicare beneficiaries to safely recover at home after being discharged from the hospital. As the covid-19 pandemic has shown us, the ability to receive health care at home is more important than ever. If passed, the bipartisan Choose Home Care Act of 2021 (S. 2562) would empower more eligible seniors to receive skilled nursing, therapy services and additional personal care and support with activities of daily living in the comfort and safety of their own homes upon a physician recommendation. In addition, Choose Home would train and educate family caregivers to provide continued support for their loved ones.

By providing add-on payments for additional services such as continuous remote patient monitoring, meals and nonemergency transportation, Choose Home would help improve patient outcomes and save the Medicare program an estimated $144 million-$247 million per year, according to an expert analysis. By all accounts, Choose Home is a win-win for seniors and America’s health care system at large. Further, efforts to improve patient choice when it comes to post-hospital care are broadly supported by American voters.

To meet the needs of America’s growing senior population more safely — while saving precious taxpayer dollars — I urge lawmakers in Congress to support the bipartisan Choose Home Care Act.

— Joanne Cunningham, executive director, Partnership for Quality Home Healthcare, Washington, D.C.

Don’t be fooled: Medicare has been taken over by for-profit #Medicare Advantage private plans. The entitlement part is really, really slim. Americans deserve better. Expand #Medicare to everyone, cover all needed services, and pay providers a fair rate. https://t.co/DkkaISvcKn

— Barbara DiPietro (@BarbaraDiPietro) August 11, 2021

— Barbara DiPietro, Baltimore

Making the Podcast Accessible

I am not commenting on a particular podcast, but rather about the presentation of your “What the Health?” podcast. I have looked for written transcripts (very important for hearing-impaired persons to have access to a transcript) but was unable to find one. Was I looking in the wrong place, or do you not provide accessibility to your podcasts for those with hearing impairments?

— Dr. Katherine Phaneuf, Westford, Massachusetts

[Editor’s note: We are in the process of making transcripts available for future “What the Health?” podcasts. Please keep your eyes peeled.]

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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¿Escuela o “ruleta rusa”? Entre delta y no exigir máscaras, algunos padres no ven ninguna diferencia

Sat, 08/21/2021 - 2:29pm

El niño acababa de empezar el jardín de infantes. O, como lo llamaba su madre, “la ruleta rusa”. Eso se debe a que su distrito escolar en Grand Junction, Colorado, experimentó uno de los primeros brotes de la variante delta en la nación la primavera pasada, y ahora las autoridades escolares han relajado las reglas destinadas a proteger contra covid-19.

La madre, Venessa, que pidió no ser identificada con su nombre completo por temor a las repercusiones que pudiera tener para su familia, es parte de un grupo de padres, abuelos, profesionales médicos y miembros de la comunidad que se reunieron en las últimas semanas para tratar de cambiar estas nuevas normas.

El grupo se llama a sí mismo “S.O.S.”, que significa Supporters for Open and Safe Schools (“Partidarios de escuelas abiertas y seguras”, usando el acrónimo que se utiliza para pedir ayuda).

Está formado por republicanos y demócratas, cristianos y ateos. Su principal pedido: exigir máscaras.

Venessa dijo que el concepto no es complicado para su hijo de 5 años. “Simplemente se la pongo, como le pongo sus zapatos”.

A apenas dos semanas del inicio de este año escolar, 30 aulas ya han presentado informes de exposición a estudiantes positivos para covid, dijo la vocera del distrito Emily Shockley. Y tres salones más fueron puestos en cuarentena porque tenían al menos tres estudiantes que dieron positivo.

Las máscaras todavía no son un requisito universal.

Aunque los Centros para el Control y la Prevención de Enfermedades (CDC) recomiendan el “usar máscara en interiores” en las escuelas, independientemente del estatus de vacunación, las escuelas de todo el país no están adoptando los requisitos de cubrebocas, incluso para los estudiantes menores de 12 años que aún no son elegibles para las vacunas protectoras.

El condado de Mesa, donde vive Venessa, fue uno de los lugares donde llegó la variante delta antes de que terminara la escuela de verano. Un informe publicado a principios de agosto por los CDC encontró que desde finales de abril hasta fines de junio, cuando la variante delta se extendió allí, las escuelas fueron el escenario más común de brotes, además de las instalaciones de cuidado residencial, a pesar de que se requerían máscaras en las escuelas para estudiantes de 11 años y más.

Las escuelas fueron más centros infecciosos que las cárceles.

Susan Hassig, epidemióloga de enfermedades infecciosas de la Universidad de Tulane en Nueva Orleans, ve el informe sobre el condado de Mesa como una advertencia de lo que está por venir: muestra una alta propagación de la variante entre los escolares.

Las suposiciones anteriores de que los niños no tenían probabilidades de contraer o propagar el virus ya no se aplica, dijo: los niños han vuelto a sus actividades habituales en persona, con una variante altamente transmisible circulando. “Tenemos muchos más niños que están expuestos, y con delta, muchos más niños se infectan”, dijo Hassig este mes. “Y ahora tenemos aquí en Louisiana hospitales infantiles colmados”.

Políticos de ocho estados, incluidos Texas y Florida, han prohibido los mandatos de máscaras en las escuelas públicas, pero algunos distritos escolares, incluso en grandes ciudades como Dallas, Houston, Austin y Fort Lauderdale, y pequeñas como París, Texas, se están rebelando contra esta norma, exigiendo el uso de máscaras, a pesar de la amenaza de recibir multas.

La administración Biden ha apoyado a las jurisdicciones locales rebeldes, con la oferta de pagar los salarios de los miembros de la junta escolar de Florida en contra de su gobernador. La administración también está considerando investigaciones en estados y distritos por, potencialmente, violar los derechos civiles que garantizan el acceso a la educación.

“No nos vamos a quedar sentados mientras los gobernadores intentan bloquear e intimidar a los educadores para que no protejan a nuestros niños”, dijo el presidente Joe Biden.

La doctora Jyoti Kapur, pediatra de Schoolhouse Pediatrics en Austin, Texas, y madre de dos niños menores de 12 años, fue parte de un grupo que persuadió a su distrito escolar para que promulgara un mandato de máscara. Kapur dijo que sus hijos están “encantados” por volver a la escuela en persona. “Queremos que todos los superintendentes escolares y sus juntas directivas sepan en todas partes de Texas, y en todo el país, que los expertos están con ustedes”, agregó. “Hagamos nuestro mejor esfuerzo. Si no funciona, sabremos hicimos todo lo posible para proteger a nuestros hijos “.

En Louisiana, Hassig señaló las tasas de casos “casi verticales” y las tasas de hospitalización como evidencia de cuán seriamente las escuelas deberían tomar el virus este año. Como abuela, quiere que su nieta pueda asistir al segundo grado en persona. Como epidemióloga, se preocupa no solo por los efectos inmediatos de la variante delta en los hospitales y las economías, sino también por la oportunidad que brinda su propagación para la aparición de nuevas cepas que pueden ser aún más contagiosas o capaces de evadir las vacunas.

Para Hassig, las máscaras son parte del conjunto de herramientas que podrían calmar ambos temores. “Lo que pudo haber sido suficiente para reducir los problemas generalizados la primavera pasada no necesariamente va a funcionar con delta, porque delta es diferente”, dijo Hassig. “Hay que estar preparado para llevarlo a un nivel superior”.

Sin embargo, el Distrito Escolar 51 del Valle del condado de Mesa está reduciendo un poco las medidas, a pesar de su experiencia la primavera pasada con brotes. Sin un mandato estatal de máscaras este año escolar, la decisión fue impuesta a los funcionarios de salud pública del condado y a los distritos escolares individuales. Y el distrito escolar del condado de Mesa no exige máscaras para los estudiantes o el personal.

Venessa, la madre del niño de jardín de infantes, dijo que había asumido que las pautas serían más estrictas este año escolar que el anterior debido a la omnipresencia de la variante delta. “¿Por qué no empezar con cautela?”, se preguntó. “No abriéndole las puertas al virus para luego intentar atraparlo”.

Las pautas federales sobre el transporte público significan que los estudiantes deben usar máscaras en los autobuses escolares, pero cuando llegan a la escuela, pueden sacárselas. Según Joel Sholtes, miembro del grupo S.O.S. y padre de un niño de segundo grado, eso es exactamente lo que está sucediendo desde que comenzaron las clases el 9 de agosto.

“Los niños sin máscaras les están diciendo a nuestros niños con máscaras que no necesitan usarlas y que deben quitárselas. Algunos niños lo hacen porque no quieren sobresalir”, dijo Sholtes, quien, como ingeniero civil, cree que es tan importante que las escuelas se adapten a la recomendación de salud pública como lo es para él la orientación de expertos sobre cómo diseñar un puente de manera segura.

“No es sobre quién puede hablar más fuerte en una reunión pública. Hay algunas cosas sobre las que necesitamos la opinión de expertos y tenemos que seguirlas”, dijo. “La salud pública no debería ser diferente”.

La policía escoltó a los miembros de la junta escolar a sus autos después de una reunión pública el martes 17 de agosto porque se sintieron amenazados por algunos padres que querían más tiempo para expresar sus preocupaciones contra las máscaras y las vacunas, según el Grand Junction Daily Sentinel.

Brian Hill, asistente del superintendente del distrito del condado de Mesa, dijo que el sistema escolar “recomienda encarecidamente” el uso de máscaras en interiores. Dijo que vio una combinación de estudiantes con y sin cubrebocas en sus rondas durante la primera semana de clases.

“También apoyaremos a los estudiantes y al personal dentro de nuestras escuelas, con cualquier decisión que tomen al respecto”, dijo. “Ya sea que tomen la decisión de usar una máscara o no, vamos a apoyar eso en los campus, no queremos que los estudiantes se sientan intimidados o juzgados por la decisión que están tomando”.

Hill señaló las cifras del año escolar pasado que muestran que los miembros de la familia, y no las interacciones de la escuela, fueron los principales culpables de transmitir covid a los 1,293 estudiantes que dieron positivo entre los 21,000 estudiantes del distrito.

“Es un porcentaje muy pequeño, similar a cualquier tipo de transmisión en la escuela”, dijo. “Entonces, realmente no estábamos viendo transmisión en nuestras escuelas. Estaba sucediendo en la comunidad”. Durante el último año escolar, aproximadamente el 7% de los menores de 18 años que dieron positivo por covid en el condado tuvieron exposición a través de una instalación institucional como una escuela o un lugar de cuidado infantil, según una presentación del distrito.

A fines de julio, aproximadamente dos semanas antes de que comenzara el año escolar, menos del 60% del personal del distrito escolar estaba completamente vacunado y menos del 23% de los estudiantes elegibles estaban completamente vacunados, según la presentación.

 El gobernador demócrata Jared Polis envió una carta a los superintendentes de distrito pidiéndoles que adoptaran estrategias como los requisitos de máscaras, aunque ha evitado imponer una orden estatal. Polis también anunció recientemente que Colorado está ofreciendo pruebas rápidas semanales, considerada una herramienta de detección útil cuando se realiza con frecuencia, a todas las escuelas del estado, e incluso podría pagar a los estudiantes entre $5 y $25 por hacerse la prueba, aunque necesitarían el consentimiento de un padre.

Hill dijo que es demasiado pronto para decir si su distrito participará.

Blythe Rusling enseñó quinto grado en una de la docena de escuelas en el condado de Mesa que tuvo un brote la primavera pasada. Eso fue cuando los estudiantes de 11 años o más debían usar máscaras. “Los niños pueden quejarse un poco por usar una máscara, pero al final del día entendieron que era algo que podíamos hacer para mantenernos sanos unos a otros”, dijo Rusling, quien este año escolar trabaja como intervencionista en lectura.

Ahora, sin embargo, dijo, notó que el tono había cambiado entre los adultos. Mientras el personal se preparaba para la escuela, dijo que fue uno de los pocos en usar una máscara. “Es como si no fueras popular si usas máscara”, dijo.

Sin embargo, dos mensajes iluminaron su visión del futuro. Fueron de ex alumnos que ya habían cumplido 12 años y estaban ansiosos por contarle la noticia: se habían vacunado contra covid.

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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Journalists Investigate Vaccine Mandates and Health Worker Burnout

Sat, 08/21/2021 - 5:00am

KHN Midwest correspondent Lauren Weber discussed how public health workers are struggling to deal with the pandemic on the “Healthy You: Surviving a Pandemic” podcast on Aug. 12. She also spoke about covid-19 news on WAMU’s “1A” on Aug. 13.

KHN chief Washington correspondent Julie Rovner talked about the misunderstandings of the Health Insurance Portability and Accountability Act (HIPAA) on Wisconsin Public Radio’s “Central Time” on Aug. 9.

KHN Editor-in-Chief Elisabeth Rosenthal discussed vaccine mandates and financial penalties for the unvaccinated with CNN’s “Smerconish” on Aug. 7. She also spoke about whether unvaccinated people should pay more for health insurance on Syndicated’s “Michael Medved Show” on August 5.

KHN Montana correspondent Katheryn Houghton spoke about Montana’s prohibition of vaccine mandates on Montana Public Radio on Monday.

KHN senior correspondent Phil Galewitz discussed burnout among home health care workers on WAMU’s “1A” on Wednesday.

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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School or ‘Russian Roulette’? Amid Delta Variant and Lax Mask Rules, Some Parents See No Difference

Fri, 08/20/2021 - 5:00am

The child had just started kindergarten. Or, as her mother called it, “Russian roulette.” That’s because her school district in Grand Junction, Colorado, experienced one of the nation’s first delta-variant outbreaks last spring, and now school officials have loosened the rules meant to protect against covid-19.

The mother, Venessa, who asked not to be named in full for fear of repercussions for her family, is part of a group of parents, grandparents, medical professionals and community members who assembled in the past few weeks to push back.

The group calls itself “S.O.S.,” which stands for “Supporters for Open and Safe Schools,” while nodding to the international signal for urgent help. It’s made up of Republicans and Democrats, Christians and atheists, and its main request: Require masks.

Venessa said the concept is not complicated for her 5-year-old. “She just puts it on, like her shoes.”

But just two weeks into this school year, 30 classrooms already have reports of exposure to covid-positive students, district spokesperson Emily Shockley said. And three more classrooms were quarantined because they’d had at least three students in them test positive. Masks are still not universally required.

Even though the Centers for Disease Control and Prevention recommends “universal indoor masking” in schools regardless of vaccination status, schools across the country are not embracing mask requirements, including for students under 12 who aren’t yet eligible for protective vaccines.

Mesa County, where Venessa lives, was one of the places where the variant arrived before school let out for summer. A report published in early August by the CDC found that from late April through late June, as the delta variant spread there, schools were the most common setting for outbreaks aside from residential care facilities, even though masks were required in schools for students age 11 and older. Schools were bigger virus hubs than correctional facilities.

Susan Hassig, an infectious disease epidemiologist at Tulane University in New Orleans, views the report on Mesa County as a warning shot of what’s to come, showing high spread of the variant among schoolchildren.

Prior assumptions that kids weren’t likely to get or spread the virus no longer apply, she said: Kids are back to their regular in-person activities, and with a highly transmissible variant circulating to boot. “We’ve got a lot more kids that are getting exposed, and with delta, a lot more kids getting infected,” Hassig said this month. “And now we’ve got full children’s hospitals here in Louisiana.”

Politicians in eight states, including Texas and Florida, have prohibited mask mandates in public schools, but some school districts — including in big cities such as Dallas, Houston, Austin and Fort Lauderdale and small ones such as Paris, Texas — are rebelling against those orders and mandating masks anyway, despite the threat of fines.

The Biden administration has supported those local jurisdictions that have gone rogue, with offers to pay the salaries of Florida school board members going against their governor. The administration is also considering investigations into states and districts for potentially violating civil rights that guarantee access to education.

“We’re not going to sit by as governors try to block and intimidate educators from protecting our children,” said President Joe Biden.

Dr. Jyoti Kapur, a pediatrician with Schoolhouse Pediatrics in Austin, Texas, and mother of two children under 12, was part of a group that persuaded the school district there to enact a mask mandate. Kapur said her kids are “ecstatic” about starting school again in person.

“We want all the school superintendents and their boards of trustees to know everywhere in Texas — and in the country — that the experts are with you,” said Kapur. “Let’s do our best. If it doesn’t work, we will go down knowing we did our best to protect our children.”

In Louisiana, Hassig pointed to the “nearly vertical” case rates and hospitalization rates in her state as evidence of how seriously schools should take the virus this year.

As a grandmother, she wants her granddaughter to be able to attend second grade in person. As an epidemiologist, she worries about not just the immediate effects of the delta variant on hospitals and economies, but also the opportunity its spread gives to the emergence of new strains that may be even more contagious, or able to evade vaccines. To Hassig, masks are part of the toolkit that could assuage both fears.

“What may have been sufficient to reduce widespread problems last spring is not necessarily going to work with delta, because delta is different,” Hassig said. “Be ready to take it up a notch.”

However, the Mesa County Valley School District 51 is ratcheting measures down a notch — despite its experience last spring with outbreaks. Without a state mask mandate in place this school year, the decision was punted to county public health officials and individual school districts. And the school district in Mesa County is not requiring masks for students or staffers.

Venessa, the mom of the kindergartner, said she had assumed guidelines would be more stringent this school year than last because of the delta variant’s pervasiveness. “Why not start with the horse on a lead rope?” she said. “Not just open the corral, let it run out, and then try to go catch it?”

Federal guidelines around public transportation mean students do have to wear masks on school buses, but when they get to school, those masks can come off. According to Joel Sholtes, a member of the S.O.S. group and the father of a second grader, that’s exactly what’s happening since school started for his kid on Aug. 9.

“Unmasked kids are telling our masked kids that they don’t need to mask and should take them off. Some kids are because they don’t want to stand out,” said Sholtes, who, as a civil engineer, believes it’s as important for schools to hew to public health guidance as it is for him to hew to expert guidance on how to safely design a bridge.

“It’s not who can be loudest at a public meeting. There’s some things that we need expert opinion on, and we have to follow those,” he said. “Public health shouldn’t be different.”

Police escorted school board members to their cars after a public meeting Tuesday because they felt threatened by some parents who wanted more time to voice anti-mask and anti-vaccine concerns, according to the Grand Junction Daily Sentinel.

Brian Hill, the Mesa County district’s assistant superintendent, said the school system is “highly recommending” indoor masking. He said he saw a mixture of masked and unmasked students in his rounds of campuses during the first week of class.

“We’ll also support students and staff within our schools, with whatever decision they make around that,” he said. “Whether they make the decision to wear a mask or not, we’re going to support that in the campuses in a way that we don’t want students to feel bullied or feel judged for the decision that they’re making.”

Hill pointed to numbers from last school year showing that family members — and not school interactions — were the primary culprits in passing covid on to the 1,293 students who tested positive out of the district’s 21,000 students.

“It’s a very tiny, tiny percentage that were traced back to any sort of in-school transmission,” he said. “So, we weren’t really seeing transmission in our schools. It was happening out in the community.”

During the past school year, about 7% of those age 18 and under who tested positive for covid in the county had exposure through an institutional facility like a school or child care site, according to a district presentation.

As of late July, about two weeks before the school year started, fewer than 60% of school district staffers were fully vaccinated, and fewer than 23% of eligible students were fully vaccinated, the presentation said.

Democratic Gov. Jared Polis sent a letter to district superintendents imploring them to adopt strategies such as mask requirements, though he has avoided imposing a statewide order. Polis also recently announced that Colorado is offering weekly rapid testing — considered a useful screening tool when done frequently — to all schools in the state, and might even pay students between $5 and $25 to take the tests, though they’d need consent from a parent. Hill said it’s too early to say if his district will opt in.

Blythe Rusling taught fifth grade at one of about a dozen schools in Mesa County that had an outbreak last spring. That was back when students 11 and older were required to wear masks.

“The kids might grouse a bit about wearing a mask, but at the end of the day they understood that it was something we could do to keep each other healthy,” said Rusling, who is working as a reading interventionist this school year.

Now, though, she said, she noticed the tenor had changed among the adults. As staffers prepped for school, she said, she was one of the few to wear a mask. “It almost feels like you’re not the cool kid when you’re wearing a mask,” she said.

Still, two messages brightened her view of the future. They were from former students who had turned 12 and couldn’t wait to tell her the news: They’d gotten covid vaccines.

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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‘We Sent a Terrible Message’: Scientists Say Biden Jumped the Gun With Vaccine Booster Plan

Fri, 08/20/2021 - 5:00am

The Biden administration’s plans to make covid-19 booster shots available next month has drawn a collective scream of protest from the scientific community.

As some scientists see it, the announcement is rash and based on weak evidence, and they worry it could undercut confidence in vaccines with no clear benefit of controlling the pandemic. Meanwhile, more information is needed on potential side effects or adverse effects from a booster shot, they say.

Perhaps even worse, the announcement has fueled deeper confusion about what Americans need to do to protect themselves from covid.

“I think we’ve scared people,” said Dr. Paul Offit, director of the Vaccine Education Center at Children’s Hospital of Philadelphia and an adviser to the National Institutes of Health and the Food and Drug Administration.

“We sent a terrible message,” he said. “We just sent a message out there that people who consider themselves fully vaccinated were not fully vaccinated. And that’s the wrong message, because you are protected against serious illness.”

As of Thursday, 51% of the U.S. population was fully vaccinated, Centers for Disease Control and Prevention data shows. Biden administration officials ― citing data from Israel, a study from the Mayo Clinic that is not yet peer-reviewed and new CDC studies ― say it’s necessary to plan for boosters to prevent a worsening of the pandemic as the delta variant powers a surge in cases and overwhelms hospital intensive care units.

In essence, officials are caught between a rock and a hard place ― trying to be prepared while simultaneously not undermining messaging about how well the existing vaccines work.

Officials must weigh two unknowns: the risks of moving ahead aggressively with booster shots versus the risks of waiting to learn much more about the virus and the power of the vaccines. The government’s normal path to regulatory approval is, by design, slow and deliberate. The virus has its own schedule, fast and unpredictable.

“Arguably, I think that the federal government is simply trying to stay ahead of the curve,” said Dr. Joshua Barocas, associate professor of medicine at the University of Colorado. But, he said, “I have not seen robust data yet to suggest that it is better to boost Americans who have gotten two vaccines than invest resources and time in getting unvaccinated people across the world vaccinated.”

Beginning in late September, boosters would be made available to adults (age 18 and up) eight months after they received the second dose of a Pfizer-BioNTech or Moderna covid vaccine, President Joe Biden said. But his plan comes with big caveats: It does not yet have the blessing of a CDC advisory panel, and the FDA has not authorized boosters for all adults.

The urgent question is whether the vaccines are losing their power against covid.

“We are concerned that this pattern of decline we are seeing will continue in the months ahead, which could lead to reduced protection against severe disease, hospitalization and death,” Surgeon General Vivek Murthy said.

But many scientists and public health experts say the data doesn’t demonstrate a clear benefit to the public in making booster shots widely available, and the Biden administration’s message confuses people about what the covid vaccines were designed to do.

“They’re not a force field. They don’t repel the virus from your body. They train your immune system to respond when you become infected … with the goal of keeping you out of the hospital,” said Jennifer Nuzzo, an epidemiologist and associate professor at the Johns Hopkins Bloomberg School of Public Health.

Meanwhile, questions abound. Will boosters for fully vaccinated adults make the virus less transmissible ― that is, slower or less likely to spread to others?

“I certainly hope that’s the case … but the bottom line, with full transparency, we don’t know that right now,” Dr. Anthony Fauci, Biden’s chief medical adviser, said Wednesday.

What about side effects? “It would be nice to understand what side effects people have after their third dose,” Nuzzo said.

“We don’t have any reason to believe, based on the safety profile of the vaccine itself, that we’re going to see significant adverse events with booster shots,” Barocas said. However, those things are “just now being studied.”

The concerns are real. While serious side effects from covid vaccines have been rare, some have caused alarm ― including mRNA vaccines being linked to cases of myocarditis, or inflammation of the heart.

“At the individual level, we need to know the side effect profile of a 3rd dose, especially in younger people. Until now, the benefits of vaccination have far outweighed the potential side effects,” Dr. Jeremy Faust, an emergency medicine physician at Brigham and Women’s Hospital in Boston, wrote in a blog post outlining why he was skeptical about a plan to give boosters to everyone.

Even in light of the new CDC studies published Wednesday, experts say one thing is clear: The vaccines still work very well at what they were meant to do, which is to protect people against the worst outcomes of getting infected with the virus.

One study, relying on data from 21 hospitals in 18 states, found no significant change in the vaccines’ effectiveness against hospitalization between March and July, which coincides with delta becoming the prevalent covid strain. Another, using data from New York, also found the vaccines highly effective in preventing hospitalization, even as there was a decline in effectiveness against new infections. The third, evaluating the Pfizer and Moderna vaccines in nursing home residents, saw a drop in how effective they were at preventing infection ― but the research didn’t distinguish between symptomatic and asymptomatic cases.

“It’s like we’re engaged in friendly fire against these vaccines,” Nuzzo said. “What are we trying to do here? Are we just trying to reduce overall transmission? Because there’s no evidence that this is going to do it.”

Fauci, in outlining the case for boosters, highlighted data showing that antibody levels decline over time and higher levels of antibodies are associated with higher vaccine efficacy. But antibodies are only one component of the body’s defense mechanisms against a covid infection.

When the antibodies decrease, the body compensates with a cellular immune response. “A person who has lost antibodies isn’t necessarily completely susceptible to infection, because that person has T-cell immunity that we can’t measure easily,” said Dr. Cody Meissner, a specialist in pediatric infectious diseases who sits on the FDA’s vaccine advisory panel.

John Wherry, director of the Penn Institute of Immunology at the University of Pennsylvania, recently published a study finding that the mRNA vaccines provoked a strong response by the immune system’s T cells, which researchers said could be a more durable source of protection. Wherry is working on a second study based on six months of data.

“We’re seeing very good durability for at least some components of the non-antibody responses generated by the vaccines,” he said.

For protection against serious disease, “really all you need is immunological memory, and these vaccines induce immunological memory and immunological memory tends to be longer-lived,” Offit said. Federal scientists also are studying T-cell response, Fauci said.

Pfizer and Moderna have said they think boosters for covid will be necessary. But it’s up to the government to authorize them. Federal officials say they are sifting through new data from the companies and elsewhere as it becomes available.

There’s not a deep playbook for this: Emergency use authorization, or EUA, of vaccines has been sparingly used. The FDA has already amended Pfizer’s prior EUA clearance twice, first in May to expand the vaccines to adolescents 12 to 15 years old and, again, this month to allow immunocompromised people to obtain a third dose. The FDA did not respond to questions about the process for authorizing widespread booster shots.

Pfizer announced in July that it expects $33.5 billion in covid vaccine revenue this year. Its stock has risen 33% this year, closing at $48.80 Thursday. Moderna reported sales of $5.9 billion through June 30 for 302 million doses of its vaccine. The company’s stock has skyrocketed 236% year-to-date, closing at $375.53 Thursday.

In applying for emergency authorization, the FDA requires vaccine manufacturers to submit clinical efficacy data and all safety data from phase 1 and phase 2 clinical trials as well as two months of safety data from phase 3 studies. For full approval, the FDA requires manufacturers to submit six months of data.

Pfizer this week announced it has submitted phase 1 clinical trial data to the FDA as part of an evaluation for future approval of a third dose. The company said phase 3 results are “expected shortly.”

Pfizer said its preliminary trial results showed a third dose was safe and increased antibody levels against the original virus and the delta variant. Moderna found a third dose had safety results similar to a second dose and produced a strong antibody response. 

Typically, any distribution of shots would occur after the CDC’s Advisory Committee on Immunization Practices also developed recommendations. But with the Biden administration’s announcement about boosters, public health experts worry the message suggests the outcome is preordained.

“They have completely and unfairly jammed FDA and ACIP. They’ve left them no choice. If there’s no booster program, FDA gets blamed and that’s not appropriate,” said Dr. Nicole Lurie, a former senior Health and Human Services official in the Obama administration and U.S. director of the Coalition for Epidemic Preparedness Innovations, the global epidemic vaccines partnership.

KHN senior correspondent Sarah Jane Tribble and editor Arthur Allen contributed to this report.

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

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Biden’s No-Jab-No-Job Order Creates Quandary for Nursing Homes

Fri, 08/20/2021 - 5:00am

President Joe Biden’s edict that nursing homes must ensure their workers are vaccinated against covid-19 presents a challenge for an industry struggling to entice its lowest-paid workers to get shots without driving them to seek employment elsewhere.

Although 83% of residents in the average nursing facility are vaccinated, only 61% of a home’s workers are likely to be, according to data submitted by homes and published by the Centers for Medicare & Medicaid Services as of the week ending Aug. 8. More than 602,000 staff members have contracted covid and more than 2,000 have died from it.

That led Biden to declare Wednesday that the government would require employee vaccinations as a condition for nursing homes to receive Medicare and Medicaid reimbursements, which account for most of the industry’s income.

“More than 130,000 residents in nursing homes have, sadly, over the period of this virus, passed away,” Biden told reporters. “At the same time, vaccination rates among nursing home staff significantly trail the rest of the country.”

Nursing homes in Florida and Louisiana have the lowest average staff vaccination rates among states, with 46% of workers in a facility fully vaccinated. Rates are highest in Hawaii, with an average of 87% of workers vaccinated by facility, and California, with 81% vaccinated on average, the data shows.

The American Health Care Association, a nursing home lobby, said it appreciated the order but that the mandate should apply to other health care providers as well so that workers who refuse vaccination won’t have a reason to change jobs within the industry.

“Focusing only on nursing homes will cause vaccine hesitant workers to flee to other health care providers and leave many centers without adequate staff to care for residents,” Mark Parkinson, president and CEO of the association, said in a statement. “It will make an already difficult workforce shortage even worse.”

David Grabowski, a professor of health care policy at Harvard Medical School, said that, because many nursing home aides are paid only the minimum wage or slightly higher, they would be more likely to seek out work at retail establishments. “The risk isn’t that they go to the hospital down the street — the risk is they go to Starbucks or Target,” he said in an interview. “It’s great if you want to mandate the vaccine, but you also want to make sure these workers are making a living wage.”

Jon Green, CEO of Pinewood Manor Nursing and Rehabilitation in rural Hawkinsville, Georgia, said the “vaccines are necessary for control of the virus,” but “if we would have mandated it ourselves, it would have caused [many workers] to leave.’’ His facility, which is a nonprofit home, has about 85 employees.

Just over half of nursing home workers in Georgia, on average, are vaccinated.

Some facilities have already placed vaccination requirements on employees, including PruittHealth, a large Southern nursing home chain. The company set an Oct. 1 deadline for employees to have received at least an initial dose of vaccine. About 45% of its nursing home workforce has received a shot. PruittHealth said only medical and religious exemptions to its vaccine mandate will be considered on a case-by-case basis.

Lori Smetanka, executive director of Consumer Voice, a nonprofit that advocates for people receiving long-term care services, said that if nursing homes succeed in getting more employees to accept vaccinations, it might make it easier for them to retain and recruit others who have been fearful of catching covid at the homes.

“We did see that a number of workers fairly early on in the pandemic had quit because they were worried about their own safety,” Smetanka said. “This is one opportunity to attract people who have not been willing to work in the facilities.”

CMS said it would issue an emergency rule in the coming weeks that adds staff vaccination to the requirements for nursing homes to receive Medicare and Medicaid reimbursements. That rule would presumably spell out the criteria for compliance.

In practice, nursing homes rarely are thrown out of the Medicare and Medicaid programs for violating the government’s conditions of participation. The government generally gives facilities multiple opportunities to correct violations before proposing termination, even when facilities have repeatedly flouted the rules.

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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After Pandemic Ravaged Nursing Homes, New State Laws Protect Residents

Fri, 08/20/2021 - 5:00am

When the coronavirus hit Martha Leland’s Connecticut nursing home last year, she and dozens of other residents contracted the disease while the facility was on lockdown. Twenty-eight residents died, including her roommate.

“The impact of not having friends and family come in and see us for a year was totally devastating,” she said. “And then, the staff all bound up with the masks and the shields on, that too was very difficult to accept.” She summed up the experience in one word: “scary.”

But under a law Connecticut enacted in June, nursing home residents will be able to designate an “essential support person” who can help take care of a loved one even during a public health emergency. Connecticut legislators also approved laws this year giving nursing home residents free internet access and digital devices for virtual visits and allowing video cameras in their rooms so family or friends can monitor their care.

Similar benefits are not required by the Centers for Medicare & Medicaid Services, the federal agency that oversees nursing homes and pays for most of the care they provide. But states can impose additional requirements when federal rules are insufficient or don’t exist.

And that’s exactly what many are doing, spurred by the virus that hit the frail elderly hardest. During the first 12 months of the pandemic, at least 34% of those killed by the virus were residents of nursing homes and other long-term care facilities, even though they make up fewer than 1% of the American population. The vaccine has since reduced virus-related nursing home deaths to about 1 in 4 covid-related fatalities in the United States, which have risen to more than 624,000, according to The New York Times’ coronavirus case tracker.

“Part of what the pandemic did is to expose some of the underlying problems in nursing homes,” said Nina Kohn, a professor at Syracuse University School of Law and a distinguished scholar in elder law at Yale Law School. “This may present an opportunity to correct some of the long-standing problems and reduce some of the key risk factors for neglect and mistreatment.”

According to a review of state legislation, 23 geographically and politically diverse states have passed more than 70 pandemic-related provisions affecting nursing home operations. States have set minimum staffing levels for nursing homes, expanded visitation, mandated access for residents to virtual communications, required full-time nurses at all times and infection control specialists, limited owners’ profits, increased room size, restricted room occupancy to two people and improved emergency response plans.

The states’ patchwork of protection for nursing home residents is built into the nation’s nursing home care regulatory system, said a CMS spokesperson. “CMS sets the minimum requirements that providers need to meet to participate with the Medicare/Medicaid programs,” he said. “States may implement additional requirements to address specific needs in their state — which is a long-standing practice — as long as their requirements go above and beyond, and don’t conflict with, federal requirements.”

Julie Mayberry, an Arkansas state representative, remembers a nursing home resident in her district who stopped dialysis last summer, she said, and just “gave up” because he couldn’t live “in such an isolated world.”

“I don’t think anybody would have ever dreamed that we would be telling people that they can’t have someone come in to check on them,” said Mayberry, a Republican and the lead sponsor of the “No Patient Left Alone Act,” an Arkansas law ensuring that residents have an advocate at their bedside. “This is not someone that’s just coming in to say hello or bring a get-well card,” she said.

When the pandemic hit, CMS initially banned visitors to nursing homes but allowed the facilities to permit visits during the lockdown for “compassionate care,” initially if a family member was dying and later for other emergency situations. Those rules were often misunderstood, Mayberry said.

“I was told by a lot of nursing homes that they were really scared to allow any visitor in there because they feared the state of Arkansas coming down on them, and fining them for a violation” of the federal directive, she said.

Jacqueline Collins, a Democrat who represents sections of Chicago in the Illinois State Senate, was also concerned about the effects of social isolation on nursing home residents. “The pandemic exacerbated the matter, and served to expose that vulnerability among our long-term care facilities,” said Collins, who proposed legislation to make virtual visits a permanent part of nursing home life by creating a lending library of tablets and other devices residents can borrow. Gov. J.B. Pritzker is expected to sign the measure.

To reduce the cost of the equipment, the Illinois Department of Public Health will provide grants from funds the state receives when nursing homes settle health and safety violations. Last year, Connecticut’s governor tapped the same fund in his state to buy 800 iPads for nursing home residents.

Another issue states are tackling is staffing levels. An investigation by the New York attorney general found that covid-related death rates from March to August 2020 were lower in nursing homes with higher staffing levels. Studies over the past two decades support the link between the quality of care and staffing levels, said Martha Deaver, president of Arkansas Advocates for Nursing Home Residents. “When you cut staff, you cut care,” she said.

But under a 1987 federal law, CMS requires facilities only to “have sufficient nursing staff to attain or maintain the highest practicable … well-being of each resident.” Over the years, states began to tighten up that vague standard by setting their own staffing rules.

The pandemic accelerated the pace and created “a moment for us to call attention to state legislators and demand change,” said Milly Silva, executive vice president of 1199SEIU, the union that represents 45,000 nursing home workers in New York and New Jersey.

This year states increasingly have established either a minimum number of hours of daily direct care for each resident, or a ratio of nursing staff to residents. For every eight residents, New Jersey nursing homes must now have at least one certified nursing aide during the day, with other minimums during afternoon and night work shifts. Rhode Island’s new law requires nursing homes to provide a minimum of 3.58 hours of daily care per resident, and at least one registered nurse must be on duty 24 hours a day every day. Next door in Connecticut, nursing homes must now provide at least three hours of daily direct care per resident next year, one full-time infection control specialist and one full-time social worker for every 60 residents.

To ensure that facilities are not squeezing excessive profits from the government payment they receive to care for residents, New Jersey lawmakers approved a requirement that nursing homes spend at least 90% of their revenue on direct care. New York facilities must spend 70%, including 40% to pay direct-care workers. In Massachusetts, the governor issued regulations that mandate nursing homes devote at least 75% on direct-care staffing costs and cannot have more than two people living in one room, among other requirements.

Despite the efforts to improve protections for nursing home residents, the hodgepodge of uneven state rules is “a poor substitute for comprehensive federal rules if they were rigorously enforced,” said Richard Mollot, executive director of the Long Term Care Community Coalition, an advocacy group. “The piecemeal approach leads to and exacerbates existing health care disparities,” he said. “And that puts people — no matter what their wealth, or their race or their gender — at an even greater risk of poor care and inhumane treatment.”

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?’: Booster Time

Thu, 08/19/2021 - 3:15pm

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.

As covid-19 cases in the U.S. continue to rise, the Biden administration is countering with new strategies. The latest efforts include preparing for vaccine boosters starting this fall, requiring that nursing home workers be vaccinated and pushing back against state bans on mask mandates in schools.

Meanwhile, the U.S. House is returning early from its summer break to begin work on a planned $3.5 trillion budget bill that will address a long list of health issues, including changes to Medicare and Medicaid, extending the Affordable Care Act subsidies and lowering prescription drug prices.

This week’s panelists are Julie Rovner of KHN, Alice Miranda Ollstein of Politico, Margot Sanger-Katz of The New York Times and Kimberly Leonard of Business Insider.

Among the takeaways from this week’s episode:

  • Democratic House members from the moderate and progressive wings are facing off over the fate of two key initiatives: the bipartisan infrastructure bill and the $3.5 trillion reconciliation package, which includes President Joe Biden’s priorities for health care, climate change and other matters. Moderates are pushing for the House to vote on the traditional infrastructure bill first and get it to the president’s desk, but progressives are insisting it must go forward in tandem with the more controversial reconciliation plan.
  • House Speaker Nancy Pelosi seems confident she can wrestle her caucus into moving forward without losing support from either wing.
  • The reconciliation package, while massive, is still very ambiguous. Most of the proposals and ways to pay for them are being negotiated. That makes it hard for lawmakers to endorse yet. The process is reminiscent of the difficult campaign to get the Affordable Care Act across the finish line in 2009 or the Republican effort to repeal and replace the ACA in 2017, when members of Congress did not have a lot of details about what might replace it.
  • The Biden administration’s call for booster shots for people who have been vaccinated against covid has generated some disagreement among public health experts. Some argue that the need in the U.S. is not yet great and that those shots should be sent to countries in greater need, where a new variant could develop if too many people contract covid. But the administration and its supporters argue it is better to be ahead of the virus, rather than try to tamp down a resurgence among the vaccinated later.
  • To push the nation’s inoculation efforts, Biden on Wednesday called for nursing homes to require staff members to be vaccinated or lose Medicare and Medicaid funding. Some other industries — especially those where risks are great — have already mandated vaccinations on their own.
  • The president also pushed back in his comments this week against conservative governors who insist schools may not require students to wear masks. Public health officials have said masking will help prevent kids from getting sick, especially since many are too young to get the shots and the delta variant appears to be more virulent than previous versions of the virus. In some states that start school early, thousands of children already have been forced to quarantine. The administration, educators and public health officials are concerned that rampant spread could force many schools to resume remote learning.
  • Nonetheless, some Republican state officials, including Florida Gov. Ron DeSantis and Texas Gov. Greg Abbott, are digging in their heels about mandates. It’s a tricky political issue for them because the delta variant is hitting Southern states the hardest.
  • Medicare Advantage plans have been growing in popularity, often because they offer benefits not available in traditional Medicare coverage. But if Democrats succeed in their efforts to beef up standard Medicare with dental, vision and hearing benefits, it could affect the business model of the Medicare Advantage plans.

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

Julie Rovner: KHN’s “Federal Vaccine Program Hasn’t Helped Those Whose Lives Were Altered by Covid Shot,” by Arthur Allen.

Margot Sanger-Katz: The Atlantic’s “How the Pandemic Now Ends,” by Ed Yong, and New York magazine’s “Don’t Panic, but Breakthrough Cases May Be a Bigger Problem Than You’ve Been Told,” by David Wallace-Wells.

Alice Ollstein: The New Republic’s “Here’s a Terrible New Idea: Making the Unvaccinated Pay Higher Insurance Premiums,” by Natalie Shure.

Kimberly Leonard: Business Insider’s “Amazon, Investment Banks, and Even Big Tobacco Are Spending Millions of Dollars to Try to Get Favorable Marijuana Laws,” by Kimberly Leonard and Jeremy Berke.

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.

USE OUR CONTENT

This story can be republished for free (details).

Categories: National News Content