Category: From California Healthline.org

Joe Biden ran on an expansive health care platform during his 2020 presidential campaign, with a broad array of promises such as adding a government-sponsored health plan to the Affordable Care Act and lowering prescription drug prices. Perhaps most significantly, he pledged to get control of the covid pandemic that claimed more than 400,000 American lives by Inauguration Day.

President Biden now faces major challenges in accomplishing his health care agenda; among the biggest will be bridging partisan divides in both Congress and the nation at large.

Even with the Democrats’ newfound majority in the Senate — the result of victories by the Rev. Raphael Warnock and Jon Ossoff in Georgia’s runoff elections — differences in health policy between the party’s moderate and progressive wings will persist.

“With razor-thin Democratic majorities in both the House and the Senate and many other priorities in addition to health care, Biden is unlikely to succeed in accomplishing all of his health agenda,” said Larry Levitt, executive vice president for health policy at the Kaiser Family Foundation. (KHN is an editorially independent program of KFF.)

Still, Democratic control of the Senate will allow Biden to pursue some of his health care priorities “using a two-pronged strategy of legislation and executive actions,” Levitt said.

PolitiFact and KHN teamed up to analyze Biden’s promises during the 2020 presidential campaign and will monitor his policies over the next four years to see which ones materialize. But, for now, as Biden settles into the West Wing, what are his chances of making progress on health care?

The Covid Pandemic

In his first 100 days in office, Biden has promised to get 100 million doses of covid vaccine in the arms of Americans and — if Congress provides the funds to do so — get all kids back into schools safely. He asked people to wear face masks in public for those 100 days. He also has repeatedly promised he would get the covid pandemic under control.

Other covid promises include a pledge to double the number of drive-thru testing sites and create a national pandemic testing board. He said he wants to invest $25 billion in covid vaccine distribution and to ensure that every American has access to the vaccine at no cost. He’s also promised to use the Defense Production Act to ramp up personal protective equipment supplies and restore national stockpiles.

During his first two days in office, Biden took steps to accomplish these goals, using executive orders to put in place masking mandates regarding federal buildings and interstate travel — for example, in airports and on commercial aircraft, trains, ferries and intercity bus services — and re-engaging the United States with the World Health Organization. He also issued orders to create a covid response coordinator who will lead the federal government’s efforts for providing vaccination, testing and supplies, set up a national pandemic testing board, establish international travel protocols, use the Defense Production Act to provide necessary supplies and ensure minority communities are provided resources to combat the disease. The White House released a 200-page plan on Thursday that outlines the Biden administration’s strategy to address the covid-19 pandemic.

Some members of his covid leadership team — such as Jeff Zients, tapped to coordinate the White House’s covid response, and Dr. Rochelle Walensky, who will lead the Centers for Disease Control and Prevention — don’t require Senate confirmation, meaning they can get to work right away. But Biden’s pick for Health and Human Services secretary, Xavier Becerra, will need approval by the Senate, a step that will likely be eased because of Democrats’ Georgia victories. Still, how his nomination plays out — as well as Biden’s other selections for posts that require confirmation — could be an early sign of whether the new administration will face strong partisan resistance.

While the executive orders are strong signals of what Biden hopes to accomplish, he will need Congress to fund his plans to expand testing and vaccine distribution. Biden outlined the week before his inauguration in a $1.9 trillion proposal to address covid and the economy. However, the president could face difficulty in getting bipartisan agreement on this plan, with some Republicans criticizing it as too expensive.  It took Congress seven months to pass a second covid relief bill in December.

Other limiting factors include whether the supply of vaccine is adequate to reach 100 million doses and whether organized efforts are put in place to increase testing and ramp up production, said Dr. Georges Benjamin, executive director of the American Public Health Association.

One area in which Biden could face pushback: mask-wearing. Even though he has already issued executive orders regarding mask use in federal buildings, for instance, broader mask mandates fall under individual governors’ authority, and some Republican state executives remain resistant.

Even if Biden makes inroads on that front, Americans will have to accept this step as part of their daily lives. A December KFF survey showed that while most Americans, regardless of party, wear a mask whenever they leave their house, there is still a lag among Republicans.

“I think Biden’s biggest challenges in fulfilling his covid goals are in bringing a divided country together with the bully pulpit of the presidency,” said Levitt. “If testing and the vaccine and mask-wearing are successful in only blue America, then it will be hard to succeed overall.”

Health Insurance

As Barack Obama’s vice president, Biden was instrumental in the enactment of the Affordable Care Act, which expanded health insurance coverage to millions of people but has drawn fierce Republican opposition.

Biden’s health agenda promises to expand the ACA and undo many of the steps taken by President Donald Trump to dismantle it.

“I’ll not only restore Obamacare, I’ll build on it. You can keep your private insurance. If you like it, you can choose a Medicare-like public option,” Biden said during a campaign event in Pittsburgh on Nov. 2.

Adding a government-run public option to other ACA health care plans is one of Biden’s most ambitious pledges. It’s a controversial idea even within the Democratic caucus, where some members want instead to move to a single-payer health plan like “Medicare for All.” Remember the debates during the Democratic presidential primary?

Health policy experts we consulted said implementing a public option seems extremely unlikely in the current environment. So does lowering the Medicare eligibility age from 65 to 60, another divisive idea among Democrats. But both moderates and progressives — even lawmakers across the aisle — might be able to come together on initiatives that could shore up the ACA and make coverage more affordable, such as expanding eligibility for premium subsidies.

Biden doesn’t need Congress to restore parts of the ACA that were changed via regulations issued by the Trump administration. He can instruct agencies to issue new rules that would reverse such Trump initiatives as allowing states to implement work requirements for some adults who gained Medicaid coverage in the ACA expansion of that program. Still, regulatory changes take time. And, in some cases, altering them can be complicated.

Take, for instance, the Trump administration’s rules promoting short-term or association health plans. That metaphorical cat is already out of the bag, said Joseph Antos, a health care scholar at the American Enterprise Institute.

“There are a lot of people insured through those plans and so [changing that policy is] a very tricky thing,” said Antos. “I don’t think it would be wise for him to do anything to reverse that [rule] even though there has been a lot of noise from the left.”

In Antos’ view, the main advantage in gaining Senate control will be helping speed confirmation for key nominations, “which opens the door to new thinking on regulations.”

Drug Prices

On the campaign trail, Biden made clear his intent to bring down prescription drug prices. He promised to lower costs by 60%. Among the related policy ideas he floated: repealing the law that bars Medicare from negotiating lower drug prices and allowing the importation of prescription drugs from other countries.

But details of these proposals aren’t yet available, leaving some experts to question their feasibility.

Of course, the pharmaceutical lobby won’t be enthusiastic about any drug pricing legislation and would likely mount an aggressive campaign to defeat it. And just as with any other proposal, there will be the hurdle of getting Congress to agree on what to include in a drug pricing bill. Plus, given the rapid development of covid vaccines, Capitol Hill may be more sympathetic to the drug industry.

But Stacie Dusetzina, an associate professor of health policy at Vanderbilt University, said it’s possible Biden could succeed in lowering drug prices by limiting drug price increases to the rate of inflation and capping out-of-pocket spending for seniors covered by Medicare.

Both the House and Senate included similar proposals in past drug pricing bills, she said, and “those are both things I think could legitimately move forward, if anything moves forward.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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At the last minute, President Donald Trump granted pardons to several individuals convicted in huge Medicare swindles — including a major Long Beach kickback scheme — that prosecutors alleged often harmed or endangered elderly and infirm patients while fleecing taxpayers.

“These aren’t just technical financial crimes. These were major, major crimes,” said Louis Saccoccio, chief executive officer of the National Health Care Anti-Fraud Association, an advocacy group.

The list of some 200 Trump pardons or commutations, most issued as he vacated the White House this week, included at least seven doctors or health care entrepreneurs who ran discredited health care enterprises, from nursing homes to pain clinics. One is a former doctor and California hospital owner embroiled in a massive workers’ compensation kickback scheme that prosecutors alleged prompted more than 14,000 dubious spinal surgeries. Another was in prison after prosecutors accused him of ripping off more than $1 billion from Medicare and Medicaid through nursing homes and other senior care facilities, among the largest frauds in U.S. history.

“All of us are shaking our heads with these insurance fraud criminals just walking free,” said Matthew Smith, executive director of the Coalition Against Insurance Fraud. The White House argued all deserved a second chance. One man was said to have devoted himself to prayer, while another planned to resume charity work or other community service. Others won clemency at the request of prominent Republican ex-attorneys general or others who argued their crimes were victimless or said critical errors by prosecutors had led to improper convictions.

Faustino Bernadett, a former California anesthesiologist, was among those pardoned by Trump. Bernadett had been sentenced in January 2020 to 15 months in prison in connection with a scheme that paid $30 million in kickbacks to doctors and others who referred spinal fusion surgeries to Pacific Hospital of Long Beach, which he owned, from 2008 to 2010.

Many of the spinal surgery patients “were injured workers covered by workers’ compensation insurance. Those patient-victims were often blue-collar workers who were especially vulnerable as a result of their injuries,” according to prosecutors.

The White House said the conviction “was the only major blemish” on the doctor’s record. While Bernadett failed to report the crime, “he was not part of the underlying scheme itself,” according to the White House. Another former owner of the hospital, Michael Drobot, was sentenced to five years in prison as part of the case.

The White House said Bernadett, 66, was involved in numerous charitable activities, including “helping protect his community from COVID-19.” “President Trump determined that it is in the interests of justice and Dr. Bernadett’s community that he may continue his volunteer and charitable work,” the White House pardon statement read.

Trump commuted the sentence of former nursing home magnate Philip Esformes in late December. He was serving a 20-year sentence for bilking $1 billion from Medicare and Medicaid. An FBI agent called him “a man driven by almost unbounded greed.” Prosecutors said that Esformes used proceeds from his crimes to make a series of “extravagant purchases, including luxury automobiles and a $360,000 watch.”

Esformes also bribed the basketball coach at the University of Pennsylvania “in exchange for his assistance in gaining admission for his son into the university,” according to prosecutors.

Fraud investigators had cheered the conviction. In 2019, the National Health Care Anti-Fraud Association gave its annual award to the team responsible for making the case. Saccoccio said that such cases are complex and that investigators sometimes spend years and put their “heart and soul” into them. “They get a conviction and then they see this happen. It has to be somewhat demoralizing.”

Tim McCormack, a Maine lawyer who represented a whistleblower in a 2007 kickback case involving Esformes, said these cases “are not just about stealing money.”

“This is about betraying their duty to their patients. This is about using their vulnerable, sick and trusting patients as an ATM to line their already rich pockets,” he said. He added: “These pardons send the message that if you are rich and connected and powerful enough, then you are above the law.”

The Trump White House saw things much differently.

“While in prison, Mr. Esformes, who is 52, has been devoted to prayer and repentance and is in declining health,” the White House pardon statement said.

The White House said the action was backed by former Attorneys General Edwin Meese and Michael Mukasey, while Ken Starr, one of Trump’s lawyers in his first impeachment trial, filed briefs in support of his appeal claiming prosecutorial misconduct related to violating attorney-client privilege.

Trump also commuted the sentence of Salomon Melgen, a Florida eye doctor who had served four years in federal prison for fraud. That case also ensnared U.S. Sen. Robert Menendez (D-N.J.), who was acquitted in the case and helped seek the action for his friend, according to the White House.

Prosecutors had accused Melgen of endangering patients with needless injections to treat macular degeneration and other unnecessary medical care, describing his actions as “truly horrific” and “barbaric and inhumane,” according to a court filing.

Melgen “not only defrauded the Medicare program of tens of millions of dollars, but he abused his patients — who were elderly, infirm, and often disabled — in the process,” prosecutors wrote.

Prosecutors said the scheme raked in “a staggering amount of money.” Between 2008 and 2013, Medicare paid the solo practitioner about $100 million. He took in an additional $10 million from Medicaid, the government health care program for low-income people, $62 million from private insurance, and approximately $3 million in patients’ payments, prosecutors said.

In commuting Melgen’s sentence, Trump cited support from Menendez and U.S. Rep. Mario Diaz-Balart (R-Fla.). “Numerous patients and friends testify to his generosity in treating all patients, especially those unable to pay or unable to afford healthcare insurance,” the statement said.

In a statement, Melgen, 66, thanked Trump and said his decision ended “a serious miscarriage of justice.”

“Throughout this ordeal, I have come to realize the very deep flaws in our justice system and how people are at the complete mercy of prosecutors and judges. As of today, I am committed to fighting for unjustly incarcerated people,” Melgen said. He denied harming any patients.

Others who received pardons or commutations included Sholam Weiss, who was said to have been issued the longest sentence ever for a white collar crime — 835 years. “Mr. Weiss was convicted of racketeering, wire fraud, money laundering, and obstruction of justice, for which he has already served over 18 years and paid substantial restitution. He is 66 years old and suffers from chronic health conditions,” according to the White House.

John Davis, the former CEO of Comprehensive Pain Specialists, the Tennessee-based chain of pain management clinics, had spent four months in prison. Federal prosecutors charged Davis with accepting more than $750,000 in illegal bribes and kickbacks in a scheme that billed Medicare $4.6 million for durable medical equipment.

Trump’s pardon statement cited support from country singer Luke Bryan, said to be a friend of Davis’.

These treatments “involved sticking needles in their eyes, burning their retinas with a laser, and injecting dyes into their bloodstream.”

“Notably, no one suffered financially as a result of his crime and he has no other criminal record,” the White House statement reads.

“Prior to his conviction, Mr. Davis was well known in his community as an active supporter of local charities. He is described as hardworking and deeply committed to his family and country. Mr. Davis and his wife have been married for 15 years, and he is the father of three young children.”

CPS was the subject of a November 2017 investigation by KHN that scrutinized its Medicare billings for urine drug testing. Medicare paid the company at least $11 million for urine screenings and related tests in 2014, when five of CPS’ medical professionals stood among the nation’s top such Medicare billers.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Over a month into a massive vaccination program, most older Americans report they don’t know where or when they can get inoculated for covid-19, according to a poll released Friday.

Nearly 6 in 10 people 65 and older who have not yet gotten a shot said they don’t have enough information about how to get vaccinated, according to the KFF survey. (KHN is an editorially independent program of KFF.)

Older Americans are not the only ones in the dark about  the inoculation process. About 55% of essential workers —designated by public health officials as being near the front of the line for vaccinations — also don’t know when they can get the shots, the survey found. Surprisingly, 21% of health workers said they are unsure about when they will get vaccinated.

Black and Hispanic adults, as well as those in low-income households, are among the groups struggling most to find vaccine information. Within each of those groups, at least two-thirds said they do not have enough information about when they can get vaccinated, the survey found.

The covid vaccines, which were first distributed in mid-December to health care workers and people living in nursing homes or assisted living centers, are now available for other older adults in most states, though age restrictions vary. Ohio, for example, opened up vaccinations to all residents  80 and older. In Virginia, the minimum age for the second wave of shots is 65. In Indiana, it’s 70; Maryland, 75. Some states, such as Florida and Texas, started vaccinating anyone 65 and up in December, though many states did not begin vaccinating all seniors until January.

Limited doses have left many seniors scrambling to get an inoculation appointment.

For example, at 9 a.m. Thursday, Washington, D.C., opened 2,200 covid vaccine appointment slots for people 65 and older in several hard-hit neighborhoods. Within 20 minutes, they were all filled.

To date, more than 15 million Americans have been vaccinated for covid, which has infected 24 million and killed more than 400,000. The two covid vaccines authorized for emergency use by the Food and Drug Administration require two doses either three or four weeks apart.

Despite the rocky rollout of vaccines, two-thirds of respondents were “optimistic” that things will get better.

Sixty-five percent of adults said they believe the distribution of the vaccines is being done fairly, but half of Black adults said they were concerned that the efforts are not adequately considering the needs of the Black community.

The KFF survey of 1,563 adults was conducted Jan. 11-18. The margin of sampling error is plus or minus 3 percentage points.

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President Joe Biden wasted no time getting down to work. Among the raft of executive orders he signed on Inauguration Day were several aimed at curtailing the covid crisis, including one requiring mask-wearing by federal employees and anyone on federal property for the next 100 days.

Meanwhile, with the inauguration of Vice President Kamala Harris and the swearing-in of two new Democratic senators from Georgia, Democrats took over the majority in the Senate, albeit with a 50-50 tie. That leaves Democrats in charge of both the legislative and executive branches for the first time since 2010, but with such narrow majorities it could be difficult to advance many of Biden’s top health agenda items, starting with an expansion of the Affordable Care Act.

This week’s panelists are Julie Rovner of KHN, Alice Miranda Ollstein of Politico, Tami Luhby of CNN and Sarah Karlin-Smith of the Pink Sheet.

Among the takeaways from this week’s podcast:

• Although Biden can make certain changes to the federal policies in the fight against covid-19, much of what he has detailed in his plan will require congressional action, and Senate Republicans do not appear willing to support a major legislative package just yet.
• Many of the efforts against covid that Biden has said he wants to put in place are initiatives that have been recommended by public health officials over the past year and not acted upon. But the discovery of new, more contagious variants of the coronavirus may necessitate faster efforts to distribute vaccine and other actions.
• Wearing masks and other simple public health practices can have a big impact on slowing the spread of covid, but much of the public is looking to a vaccine for help. Those supplies remain limited and it’s not clear whether Biden’s interest in using the Defense Production Act to force industry to help will increase vaccine production.
• Vaccination success is hampered by unreliable estimates of the amount of supplies states can expect to receive and a patchwork of sign-up methods and eligibility criteria.
• Among the actions Biden and a Democratic Congress could take to reverse policies instituted by the Trump administration are ramping up workplace enforcement of covid rules to help keep employees from spreading the disease, restoring a penalty for not having insurance so that the lawsuit threatening the Affordable Care Act would become moot, and overturning rules requiring reviews of federal scientists.
• The Senate has not yet scheduled a confirmation hearing for Xavier Becerra, Biden’s choice for Health and Human Services secretary. Before a mob stormed the U.S. Capitol this month, it was thought that establishing a new federal health team would be the president’s priority, but national security took precedence after the violence.
• Controlling drug prices is an issue with huge popular support, but Congress is divided over how to do it. The broad measure that passed the House in 2019 is again unlikely to fly in the Senate, but senators may try to produce a more modest proposal along the lines of a bipartisan measure offered previously by Sens. Chuck Grassley (R-Iowa) and Ron Wyden (D-Ore).
• Drugmakers have generally fought most efforts to implement price controls, but there may be growing interest within the industry to work out a bipartisan deal that they have a hand in, rather than waiting to see what Democrats can push through.

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

Julie Rovner: The Atlantic’s “Pramila Jayapal Is ‘Next-Level’ Angry,” by Elaine Godfrey

Alice Miranda Ollstein: The New York Times’ “Emerging Coronavirus Variants May Pose Challenges to Vaccines,” by Apoorva Mandavilli

Sarah Karlin-Smith: Vanity Fair’s “A Tsunami of Randoms”: How Trump’s COVID Chaos Drowned the FDA in Junk Science,” by Katherine Eban

Tami Luhby: KHN’s “Black Americans Are Getting Vaccinated at Lower Rates Than White Americans,” by Hannah Recht and Lauren Weber

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This story was produced by Kaiser Health News, an editorially independent program of the Kaiser Family Foundation.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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With the arrival of winter and the U.S. coronavirus outbreak in full swing, the restaurant industry — looking at losses of $235 billion in 2020 — is clinging to techniques for sustaining outdoor dining even through the cold and vagaries of a U.S. winter.

Yurts, greenhouses, igloos, tents and all kinds of partly open outdoor structures have popped up at restaurants around the country. Owners have turned to these as a lifeline to help fill some tables by offering the possibility at least of a safer dining experience.

“We’re trying to do everything we can to expand the outdoor dining season for as long as possible,” said Mike Whatley with the National Restaurant Association.

Dire times have forced the industry to find ways to survive. Whatley said more than 100,000 restaurants are either “completely closed or not open for business in any capacity.”

“It’s going to be a hard and tough winter,” Whatley said. “As you see outdoor dining not being feasible from a cold-weather perspective or, unfortunately, from a government regulations perspective, you are going to see more operators going out of business.”

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In recent months, many cities and states have imposed a raft of restrictions on indoor dining, given the high risk of spreading the virus in these crowded settings.

Many have capped occupancy for dine-in restaurants. Some halted indoor dining altogether, including Michigan and Illinois. Others have gone even further. Los Angeles and Baltimore have halted indoor and outdoor dining. Only carryout is allowed.

Those who can serve customers outdoors, on patios or sidewalks, are coming up with creative adaptations that can make dining possible in the frigid depths of winter.

Embrace the ‘Yurtiness’

Washington state shut down indoor dining in mid-November and has kept that ban in place as coronavirus cases continue to surge.

On a blustery December evening, servers at the high-end Seattle restaurant Canlis huddled together in the parking lot, clad in flannel and puffy vests, while their boss Mark Canlis gave a pep talk ahead of a busy night.

“The hospitality out here is exactly the same as it is in there,” Canlis said, gesturing to his restaurant, which overlooks Lake Union. “But that looks really different, so try to invite them into the ‘yurtiness’ of what we are doing.”

Canlis has erected an elaborate yurt village in the parking lot next to his family’s storied restaurant.

It includes an outdoor fireplace and wood-paneled walkways winding between small pine trees and the circular tents. The assemblage of yurts, with their open window flaps, is the Canlis family’s best effort to keep fine dining alive during the pandemic and a typically long and wet Seattle winter (referred to locally as the “Big Dark”).

Arriving guests are greeted with a forehead thermometer to take their temperature and a cup of hot cider.

“It gives us an excuse to think differently,” Canlis said of the outdoor dining restrictions.

The yurts are meant to shield diners from the elements and from infectious airborne particles that might otherwise spread from table to table.

Dining inside such structures is not risk free: Guests could still catch the virus from a dining companion as they sit near each other, without masks, for a prolonged period. But Canlis said there is no easy way to determine whether every member of a dining group is from the same household.

“I’m not the governor or the CDC,” he said. “I’m assuming if you are there at the table, you’re taking your health into your own hands.”

New rules for outdoor dining structures in Washington require Canlis to consider issues such as how to ventilate the yurts properly and sanitize the expensive furniture.

“What is the square inch of yurt volume space? What is the size of the door and the windows? How many minutes will we allow the yurt to ‘breathe?’” Canlis said.

The structures get cleaned after each dining party finishes a meal and leaves; during the meal service the waiters enter and leave quickly, wearing N95 masks.

Tim Baker, owner of Seattle’s San Fermo, holds a hot air cannon he uses inside the dining igloos ahead of each seating. After a thorough ventilation, the device warms up the interior, he says, and also helps disperse any lingering infectious particles. (Will Stone)

Igloos, Domes, Tents: Just How Safe Are They?

Another, more modern-looking take on outdoor dining involves transparent igloos and other domelike structures that have become popular with restaurant owners all over the country.

Tim Baker, who owns the Italian restaurant San Fermo in Seattle, had to order his igloos from Lithuania and assemble them with the help of his son.

His restaurant’s policy is that only two people are allowed in an igloo at a time, to cut down on the risk of those from different households gathering together.

“You’re completely enclosed in your own space with somebody in your own household. These domes protect you from all the people walking by on the sidewalk, and the server doesn’t go in with you,” he said.

Baker said he consulted with experts in airflow and decided to use an industrial hot air cannon after each party of diners leaves the igloo and before the next set enters — aiming to clear the air inside the structure of any lingering infectious particles.

“You fire this cannon up, and it just pushes the air through really aggressively,” quickly dispersing the particles, Baker said.

His restaurant’s igloos have become a big attraction.

“I’m particularly proud of anything that we can do to get people excited right now, because we need it,” he said. “We’re all getting crushed by this emotionally.”

Not all outdoor dining structures are created equally, said Richard Corsi, an air quality expert and dean of engineering and computer science at Portland State University in Oregon.

“There’s a wide spectrum,” Corsi said. “The safest that we’re talking about is no walls — a roof. And then the worst is fully enclosed — which is essentially an indoor tent — especially if it doesn’t have really good ventilation and good physical distancing.”

In fact, Corsi said, some outdoor dining structures that are enclosed and have lots of tables near each other end up being more dangerous than being indoors, because the ventilation is worse.

Dining that is truly outdoors, with no temporary shelter at all, is much safer because there are “higher air speeds, more dispersion and more mixing than indoors,” Corsi said, which means respiratory droplets harboring the virus don’t accumulate and are less concentrated when people are close to one another.

“If they have heaters, then you’re going to actually have pretty good ventilation,” Corsi said. “The air will rise up when it’s heated, and then cool air will come in.”

He said private “pods” or “domes” can be fairly safe if they are properly ventilated and cleaned between diners. That also assumes that everyone eating inside the structure lives together, so they have already been exposed to one another’s germs.

But Corsi said he is still not going out for a meal in one of the many new outdoor dining creations — “even though I know they’ve got a much lower risk” of spreading covid-19 than most indoor alternatives.

This story comes from NPR’s health reporting partnership with Kaiser Health News.

Anita Baron first noticed something was wrong in August 2018, when she began to drool. Her dentist chalked it up to a problem with her jaw. Then her speech became slurred. She managed to keep her company, which offers financing to small businesses, going, but work became increasingly difficult as her speech worsened. Finally, nine months, four neurologists and countless tests later, Baron, now 66, got a diagnosis: amyotrophic lateral sclerosis.

ALS, often called Lou Gehrig’s disease after the New York Yankees first baseman who died of it in 1941, destroys motor neurons, causing people to lose control of their limbs, their speech and, ultimately, their ability to breathe. It’s usually fatal in two to five years.

People with ALS often must quit their jobs and sometimes their spouses do, too, to provide care, leaving families in financial distress. A decade-long campaign by advocates highlighting this predicament notched a victory last month when Congress passed a bill opening key support programs earlier for ALS patients.

In late December, then-President Donald Trump signed the bill into law. It eliminates for ALS patients the required five-month waiting period to begin receiving benefits under the Social Security Disability Insurance program, which replaces at least part of a disabled worker’s income. Gaining SSDI also gives these patients immediate access to Medicare health coverage.

Advocacy groups note that the Social Security Administration still will need to set up procedures for implementing the law, before patients will see the benefits.

The Muscular Dystrophy Association, an umbrella organization for people with 43 neuromuscular conditions, partnered with other ALS groups to support the bill to eliminate the SSDI waiting period.

“We’re hopeful that it can serve as a model for other conditions that may be similarly situated,” said Brittany Johnson Hernandez, senior director of policy and advocacy at MDA.

In the weeks leading up to the passage of the bill, Sen. Mike Lee, R-Utah, sought to broaden the scope of the legislation to include other conditions. He pledged to continue to work on legislation to eliminate the SSDI waiting period for additional diseases that meet certain criteria, including those with no known cure and a life expectancy of less than five years.

Eliminating the waiting period has been a top priority for ALS advocates. There is no simple, single test or scan to confirm that someone has ALS, though symptoms can escalate rapidly. By the time people finally get the diagnosis, they are often already seriously disabled and unable to work; waiting five months longer for financial aid can be a burden, according to patients and families.

“Five months may seem like a short period of time, but for someone with ALS it matters,” said Danielle Carnival, CEO of I Am ALS, an advocacy group. “It’s a huge win and will make a huge difference for people right away.”

Eligibility for SSDI benefits generally requires people to have worked for about a quarter of their adult lives at jobs through which they paid Social Security taxes. Benefits are based on lifetime earnings; the average monthly SSDI benefit was $1,259 in June 2020, according to the Social Security Administration. (The average retirement benefit was $1,514 that month.)

The SSDI waiting period was intended to make sure the program served only people expected to have claims that would last at least a year, said Ted Norwood, chief legal officer at Integrated Benefits Inc. in Jefferson City, Missouri, who represents SSDI applicants. But it isn’t necessary, he added, because disability rules now require that people have a condition that will keep them out of work at least a year or result in death.

“The five-month waiting period serves no purpose as far as weeding out cases,” Norwood said.

Existing federal law also made special health provisions for people with ALS and end-stage renal disease. Most people with disabilities must wait two years to be eligible for Medicare, but people with either of those two diseases can qualify sooner. ALS patients are eligible as soon as SSDI benefits start.

The new law could have made a big difference for Baron, who lives in Pikesville, Maryland. She and her husband, who works part time at a funeral parlor, didn’t have comprehensive health insurance when she got sick. They were enrolled only in a supplemental medical plan that paid out limited cash benefits.

By the time she was diagnosed and her SSDI and Medicare came through, Baron and her husband had maxed out their credit cards, raided $10,000 from their IRA and gone to their family for money. They were $13,000 in debt. They sold their house and moved into a condo to save on expenses.

“It is imperative that as [people] become more and more debilitated and cannot work, that they have immediate access to SSDI,” Baron said.

Like Sen. Lee, some patient advocates say the accommodations on disability benefits and Medicare made for patients with ALS should be extended to others with similarly intractable conditions.

The Social Security Administration has identified 242 conditions that meet the agency’s standards for qualifying for disability benefits and are fast-tracked for benefit approval.

Once approved, people with these conditions still must wait five months before they receive any money. Now, under the new law, people with ALS can skip the waiting period, though no one else on the “compassionate allowances” list can.

Breast cancer advocates are hoping for similar accommodations for people with metastatic breast cancer. Legislation introduced in the House and Senate in 2019 would have eliminated the SSDI waiting period for this group, but it did not pass.

Tackling the problem one condition at a time doesn’t make sense, others argue.

“Can you imagine, one by one, people with these conditions trying to find people in the House and in the Senate to champion the bill?” said Carol Harnett, president of the Council for Disability Awareness, which represents disability insurers.

Deb McQueen-Quinn thinks it would be good if the new law sets a precedent for eliminating the SSDI waiting period. At 55, McQueen-Quinn has lived with ALS since 2009, far longer than most.

A former convenience store manager, she uses a wheelchair full time now. She knows all too well the toll of the disease. ALS runs in her family, and she’s watched several family members, including her sister, brother and a cousin die of it.

Her sister, a former quality control engineer, was diagnosed in 2006 and died the following year, a week before she would have received her first SSDI payment.

McQueen-Quinn, who lives in Wellsville, New York, with her husband, has two children in their 30s. Her son, 33, carries the familial genetic mutation that leads to ALS. So far he hasn’t developed symptoms. But it’s for people like her son and other family members that she fought for the new law.

“Now that we’ve set the precedent, I’m sure you’ll see a lot of other diseases go after this,” she said.

This story is part of a partnership that includes NPR, WLRN and KHN. It can be republished for free.

Little Havana is a neighborhood in Miami that, until the pandemic, was known for its active street life along Calle Ocho, including live music venues, ventanitas serving Cuban coffee and a historic park where men gather to play dominoes.

But during the pandemic, a group called Healthy Little Havana is zeroing in on this area with a very specific assignment: persuading residents to get a coronavirus test.

The nonprofit has lots of outreach experience. It helped with the 2020 census, for example, and because of the pandemic did most of that work by phone. But this new challenge, community leaders say, needs a face-to-face approach.

The group’s outreach workers have been heading out almost daily to walk the quiet residential streets, to persuade as many people as possible to get tested for covid-19. On a recent afternoon, a group of three — Elvis Mendes, María Elena González and Alejandro Díaz — knocked on door after door at a two-story apartment building. Many people here have jobs in the service industry, retail or construction; most of them aren’t home when visitors come calling.

Lisette Mejía did answer her door, holding a baby in her arms and flanked by two small children.

“Not everyone has easy access to the internet or the ability to look for appointments,” Mejía replied, after being asked why she hadn’t gotten a test. She added that she hasn’t had any symptoms, either.

The Healthy Little Havana team gave her some cotton masks and told her about pop-up testing planned for that weekend at an elementary school just a short walk away. They explained that people might lack symptoms but still have the virus.

Testing Is Still Too Difficult

The nonprofit organization is one of several receiving funding from the Health Foundation of South Florida. The foundation is spending $1.5 million on these outreach efforts, in part to help make coronavirus testing as accessible and convenient as possible.

A number of social and economic reasons make it difficult for some Miamians to get tested or treated, or isolate themselves if they are sick with covid. One big problem is that many people say they can’t afford to stay home when they’re sick.

“People usually rather go to work than actually treat themselves — because they have to pay rent, they have to pay school expenses, food,” said Mendes.

This part of Miami is home to many Cuban exiles, as well as people from all over Latin America. Some lack health insurance, while others are undocumented immigrants.

So Mendes and his team try to spread the word among residents here about programs like Ready Responders, a group of paramedics that now has foundation funding to give free coronavirus tests at home in areas like this one, regardless of immigration status.

“Our mission is for all these people to get tested — regardless if they have a symptom or not — so we can diminish the level of people getting covid-19,” Mendes said. According to the Centers for Disease Control and Prevention, people who are infected but presymptomatic or asymptomatic account for more than 50% of transmissions.

The Health Foundation of South Florida’s coronavirus-related grants have ranged from $35,000 to $160,000; other recipients include the South Florida chapter of the National Medical Association, Centro Campesino and the YMCA of South Florida.

The foundation is focusing on low-income neighborhoods where some residents might not have access to a car or be able to afford a coronavirus test at a pharmacy. Their focus includes residential areas near agriculture work sites. In Miami-Dade County, the foundation is working with county officials directly to increase testing. In neighboring Broward County, the foundation is collaborating with public housing authorities to bring more testing into people’s homes.

Soothing Fears, Offering Options in Spanish

It’s time-consuming to go door to door, but worthwhile: Residents respond when outreach teams speak their language and make a personal connection.

Little Havana resident Gloria Carvajal told the outreach group that she felt anxious about whether the PCR test is painful.

“What about that stick they put all the way up?” Carvajal asked, laughing nervously.

González jumped in to reassure her it’s not so bad: “I’ve done it many times, because obviously we’re out and about in public and so we have to get the test done.”

Another outreach effort is happening at Faith Community Baptist Church in Miami. The church hosted a day of free testing back in October, with help from the foundation.

“You know us. You know who we are,” said pastor Richard Dunn II. “You know we wouldn’t allow anybody to do anything to hurt you.”

Dunn spoke recently in nearby Liberty City, a historically Black neighborhood, at an outdoor memorial service for Black residents who have died of covid. To convey the magnitude of the community’s losses, hundreds of white plastic tombstones were set up behind the podium. They filled an entire field in the park.

“Thousands upon thousands have died, and so we’re saying to the Lord here today, we’re not going to let their deaths be in vain,” Dunn said.

Dunn is also helping with a newly launched effort to build trust in the covid vaccines among Black residents, by participating in online meetings during which Black church members can hear directly from Black medical experts. The message of the meetings is that the vaccines are safe and vital.

“It’s taken over 300,000 lives in the United States of America,” Dunn said at the end of the meeting. “And I believe to do nothing would be more of a tragedy than to at least try to do something to prevent it and to stop the spreading of the coronavirus.”

Churches will play a big role in the ongoing outreach efforts, and Dunn is committed to doing his part. He knows covid is an extremely contagious and serious disease — this past summer, he caught it himself.

This story comes from a reporting partnership that includes WLRN, NPR and Kaiser Health News.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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La Pequeña Habana es un barrio de Miami que, hasta la pandemia, era conocido por su activa vida en las calles, a lo largo de la Calle Ocho, en donde hay locales de música en vivo, ventanitas que sirven café cubano y un parque histórico donde los hombres se reúnen a jugar dominó.

Pero durante la pandemia, un grupo llamado Healthy Little Havana se está concentrando en esta área con una tarea muy específica: persuadir a los residentes para que se hagan una prueba de coronavirus.

La organización sin fines de lucro tiene mucha experiencia en divulgación. Ayudó con el censo de 2020 y, a causa de la pandemia, hizo la mayor parte de ese trabajo por teléfono. Pero Líderes comunitarios dicen que este nuevo desafío necesita un enfoque cara a cara.

Los trabajadores del grupo han salido casi a diario por las tranquilas calles residenciales, para persuadir a la mayor cantidad posible de personas de que se hagan la prueba de covid-19. En una tarde reciente, un grupo de tres —Elvis Mendes, María Elena González y Alejandro Díaz— tocó todas las puertas de un edificio de dos pisos.

Mucha gente aquí trabaja en la industria de servicios, en comercios minoristas o en la construcción; la mayoría de ellos no están en casa cuando los visitantes llegan.

Lisette Mejía respondió, con un bebé en brazos y flanqueada por dos niños pequeños.

“No todo el mundo tiene acceso fácil a Internet o a la posibilidad de buscar citas”, respondió Mejía a la de por qué no se había hecho una prueba. Agregó que tampoco ha tenido ningún síntoma.

El equipo de Healthy Little Havana le dio algunas mascarillas de algodón y le informó sobre las pruebas planificadas para ese fin de semana en una escuela primaria que se encuentra a poca distancia caminando. Le explicaron que las personas pueden no tener síntomas pero aún tener el virus.

Las pruebas siguen siendo demasiado difíciles

La organización sin fines de lucro es una de varias que reciben fondos de la Health Foundation of South Florida. La fundación está gastando $1.5 millones en estos esfuerzos de divulgación, en parte para ayudar a que las pruebas de coronavirus sean lo más accesibles y convenientes posible.

Varias razones sociales y económicas hacen que sea difícil para algunos residentes de Miami hacerse la prueba o recibir tratamiento, o aislarse si están enfermos de covid. Un gran problema es que muchas personas dicen que no pueden permitirse quedarse en casa cuando están enfermas.

“Tienen que pagar la renta, los gastos escolares, la comida”, dijo Mendes.

Esta parte de Miami es el hogar de muchos cubanos exiliados, así como de personas de toda América Latina. Algunos carecen de seguro médico, otros son inmigrantes indocumentados.

Mendes y su equipo intentan hacer correr la voz entre los residentes sobre programas como Ready Responders, un grupo de paramédicos que ahora tiene fondos de la fundación para realizar pruebas gratuitas de coronavirus en el hogar en áreas como ésta, independientemente del estatus migratorio de la persona.

“Nuestra misión es que todas estas personas se hagan la prueba, independientemente de si tienen un síntoma o no, para que podamos disminuir el nivel de personas que contraen covid-19”, dijo Mendes. Según los Centros para el Control y Prevención de Enfermedades (CDC), las personas infectadas pero presintomáticas o asintomáticas representan más del 50% de las transmisiones.

Las subvenciones relacionadas con el coronavirus de la Health Foundation of South Florida han oscilado entre $35,000 y $160,000; otros beneficiarios incluyen el capítulo del sur de Florida de la Asociación Médica Nacional, el Centro Campesino y el YMCA del sur de Florida.

La fundación se está enfocando en vecindarios de bajos ingresos donde algunos residentes podrían no tener acceso a un automóvil o no poder pagar una prueba de coronavirus en una farmacia.

Su enfoque incluye áreas residenciales cerca de los sitios de trabajo agrícola. En el condado de Miami-Dade, está trabajando directamente con las autoridades para aumentar las pruebas. En el vecino condado de Broward, está colaborando con las autoridades de vivienda pública para llevar más pruebas a las viviendas.

Calmar los miedos, ofrecer opciones en español

Lleva mucho tiempo ir de puerta en puerta, pero vale la pena: los residentes responden cuando los equipos hablan su idioma y establecen una conexión personal.

Gloria Carvajal, residente de la Pequeña Habana, dijo al grupo de extensión que se sentía ansiosa por saber si la prueba de PCR es dolorosa.

“¿Qué hay de ese aguja?”, preguntó Carvajal, riendo nerviosamente.

González intervino para asegurarle que no es tan mala: “He tomado el test muchas veces, porque obviamente estamos en público y tenemos que hacernos la prueba”.

Otro esfuerzo de alcance está ocurriendo en Faith Community Baptist Church en Miami. La iglesia organizó un día de pruebas gratuitas en octubre, con la ayuda de la fundación.

“Nos conoces. Sabes quiénes somos”, dijo el pastor Richard Dunn II. “Sabes que no permitiremos que nadie haga nada para lastimarte”.

Dunn habló recientemente en la cercana Liberty City, un barrio históricamente negro, en un servicio conmemorativo al aire libre para los residentes de raza negra que han muerto a causa de covid. Para transmitir la magnitud de las pérdidas de la comunidad, se colocaron cientos de lápidas de plástico blanco detrás del podio. Llenaron un campo entero en el parque.

“Miles y miles han muerto, y por eso le estamos diciendo al Señor aquí hoy que no vamos a permitir que sus muertes sean en vano”, dijo Dunn.

Dunn también está ayudando con un esfuerzo para generar confianza en las vacunas covid entre los residentes de raza negra, al participar en reuniones en línea durante las cuales los miembros de la iglesia pueden escuchar directamente a los expertos médicos de su propia raza. El mensaje de las reuniones es que las vacunas son seguras y vitales.

“Se han cobrado más de 300,000 vidas en los Estados Unidos de América”, dijo Dunn al final de la reunión. “Y creo que no hacer nada sería más una tragedia que al menos intentar hacer algo para prevenirlo y detener la propagación del coronavirus”.

Las iglesias desempeñarán un papel importante en los esfuerzos de divulgación en curso, y Dunn está comprometido a hacer su parte. Sabe que el covid es una enfermedad grave y extremadamente contagiosa; el verano pasado, él mismo lo contrajo.

Esta historia es parte de una alianza de noticias que incluye a WLRN, NPR y Kaiser Health News.

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

 

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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This story can be republished for free (details).

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Con la llegada del invierno y el brote de coronavirus en pleno apogeo en el país, la industria de los restaurantes, que espera pérdidas de $235 mil millones en 2020, se aferra a las opciones al aire libre incluso durante los gélidos meses de invierno.

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Carpas, toldos, invernaderos, hasta iglús y todo tipo de estructuras parcialmente abiertas han aparecido en restaurantes de todo el país.

Los propietarios recurren a estas opciones como un salvavidas para ayudar a llenar algunas mesas, y tener al menos la posibilidad de ofrecer una experiencia gastronómica más segura.

“Estamos tratando de hacer todo lo posible para ampliar la temporada de comidas al aire libre durante el mayor tiempo posible”, dijo Mike Whatley, de la Asociación Nacional de Restaurantes.

Tiempos nefastos han obligado a la industria a encontrar formas de sobrevivir. Whatley dijo que más de 100,000 restaurantes están “completamente cerrados”.

“Va a ser un invierno duro”, dijo Whatley. “A medida que aumenta el frío, veremos más restaurantes cerrando”.

En los últimos meses, muchas ciudades y estados han impuesto una serie de restricciones a las comidas en interiores, dado el alto riesgo de propagar el virus en entornos abarrotados.

Muchos limitaron el espacio interior. Otros cerraron por completo las comidas en interiores, como Illinois y Michigan. Otros han ido aún más lejos: Los Ángeles y Baltimore han prohibido las comidas en interiores y al aire libre. Solo se permite comida para llevar.

Aquellos que pueden atender a los clientes al aire libre, en patios o aceras, están ideando adaptaciones creativas que pueden hacer posible cenar en los gélidos días del invierno.

El estado de Washington cerró los espacos interiores a mediados de noviembre y ha mantenido esa prohibición a medida que los casos de coronavirus continúan aumentando.

El lujoso restaurante Canlis, en Seattle, ha construido un elaborado pasaje en el estacionamiento.

Incluye una chimenea al aire libre y pasillos con paneles de madera que serpentean entre pequeños pinos y tiendas circulares. El conjunto de tiendas es el esfuerzo de la familia Canlis para mantener viva la buena mesa durante la pandemia, en el invierno típicamente largo y húmedo de Seattle.

Los huéspedes que llegan son recibidos con un termómetro de frente para tomar su temperatura y una taza de sidra caliente.

Las nuevas reglas para las estructuras de comedor al aire libre en Washington requieren que Canlis considere cuestiones como por ejemplo cómo ventilar las tiendas correctamente y desinfectar los muebles costosos.

Las estructuras se limpian después de cada cena; los camareros entran y salen rápidamente, con máscaras N95.

Tim Baker, dueño del restaurante San Fermo en Seattle, sostiene un cañón de aire caliente que utiliza entre comensales. Dice que la máquina ventila, calienta el ambiente y ayuda a dispersar cualquier remanente de partículas infecciosas. (Will Stone)

Estos espacios, ¿qué tan seguros son?

Otra versión más moderna de las cenas al aire libre incluye iglús transparentes y otras estructuras en forma de domo que se han vuelto populares entre los propietarios de restaurantes de todo el país.

Tim Baker, dueño del restaurante italiano San Fermo en Seattle, tuvo que encargar sus iglús a Lituania y montarlos con la ayuda de su hijo.

La política de su restaurante es que solo se permiten dos personas en un iglú a la vez, para reducir el riesgo de que estén cerca comensales de diferentes hogares.

“Estás completamente encerrado en tu propio espacio con alguien de tu propia casa. Estos domos te protegen de todas las personas que pasan por la acera y el mozo no entra contigo”, dijo.

Baker contó que consultó con expertos en flujo de aire y decidió usar un cañón de aire caliente industrial después que cada grupo de comensales sale del iglú, y antes de que entre el siguiente grupo, para despejar el aire dentro de la estructura de cualquier partícula infecciosa persistente.

“Se dispara este cañón y empuja el aire de manera realmente agresiva, dispersando rápidamente las partículas”, dijo Baker.

Los iglús de su restaurante se han convertido en una gran atracción.

“Estoy orgulloso de cualquier cosa que podamos hacer para entusiasmar a la gente en este momento, porque lo necesitamos”, dijo. “Todos estamos siendo aplastados emocionalmente por la pandemia”.

No todas las estructuras al aire libre se construyen por igual, dijo Richard Corsi, experto en calidad del aire y decano de ingeniería e informática de la Universidad Estatal de Portland en Oregon.

“Hay un amplio espectro”, dijo Corsi. “Lo más seguro de lo que estamos hablando es sin paredes, un techo. Y luego lo peor es completamente cerrado, que es esencialmente una carpa interior, especialmente si no tiene una ventilación realmente buena y un buen distanciamiento físico”.

De hecho, dijo Corsi, algunas estructuras de comedor al aire libre que están cerradas y tienen muchas mesas juntas terminan siendo más peligrosas que estar en el interior, porque la ventilación es peor.

Comer al aire libre, sin nada, es mucho más seguro porque hay “velocidades del aire más altas, más dispersión y más mezcla que en el interior”, dijo Corsi, lo que significa que las gotas respiratorias que albergan el virus no se acumulan y son menos concentrado cuando las personas están cerca unas de otras.

“Si tienen calentadores, entonces tendrás una ventilación bastante buena”, dijo Corsi. “El aire se elevará cuando se caliente y luego entrará aire frío”.

Dijo que los domos privados pueden ser bastante seguros si se ventilan y limpian adecuadamente entre comensales. Eso también supone que todos los que comen dentro de la estructura viven juntos, por lo que ya han estado expuestos a los gérmenes de los demás.

Pero Corsi dijo que todavía no saldrá a comer a una de las muchas nuevas creaciones para cenas al aire libre, “aunque sé que tienen un riesgo mucho menor de propagar el covid-19 que la mayoría de las alternativas en interiores”.

Esta historia es parte de una alianza de noticias de salud entre NPR y Kaiser Health News.

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

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Joe Biden on Wednesday took the oath to become the 46th president of the United States, vowing to bring the nation together in the midst of an ongoing pandemic that has claimed more than 400,000 lives, enormous economic dislocation and civil unrest so serious that the U.S. Capitol steps where he took his oath were surrounded not by cheering crowds, but by tens of thousands of armed police and National Guard troops.

In his inaugural address, given outside despite concerns for his physical security, Biden emphasized unity, the driving theme of his campaign. “My whole soul is in this, bringing America together, uniting our nation,” he said. “And I ask every American to join me in this cause.”

On health care, Biden made it clear that combating the covid-19 pandemic will be his top priority. “We must set aside politics and finally face this pandemic as one nation,” he said. “We will get through this together.”

Last week, Biden unveiled a covid plan that includes using the Defense Production Act to speed the manufacture of syringes and other supplies needed to administer vaccines; creating federal vaccination centers and mobilizing the Federal Emergency Management Agency, the National Guard and others to administer the vaccines, and launching a communications campaign to convince reluctant members of the public that the vaccine is safe. Details on his vaccination plan followed his unveiling the day before of a $1.9 trillion covid emergency relief package.

Biden got a separate boost earlier in the day with the swearing in of two new Democratic senators from Georgia, fresh off their victories in a Jan. 5 runoff election. The additions of Sen. Jon Ossoff and Raphael Warnock, plus a tie-breaking vote from new Vice President Kamala Harris, gives Democrats 51 votes in the Senate and effective control of both chambers of Congress for the first time since 2010.

With such narrow majorities in the House and Senate, it seems unlikely Biden will be able to make good on some of his more sweeping health-related campaign promises, including creating a “public option” to help expand insurance coverage and lowering the Medicare eligibility age from 65 to 60.

But even the barest of control will make it substantially easier for Biden to get his appointees confirmed in the Senate, and the possibility is open to use a fast-track process called budget reconciliation to make health-related budget changes, perhaps including modifications of the Affordable Care Act that might make coverage less expensive for some families.

Beyond covid, health is likely to take a back seat in the early going of the administration as officials deal with more pressing problems like the economy, immigration and climate change.

Biden health aides are expected to begin to unwind many of the changes made by Trump that do not require legislation, such as restoring anti-discrimination protections for transgender people and reversing the Trump administration’s decision to allow some states to implement work requirements for adults covered by Medicaid. But even that could take weeks or months.