Category: From California Healthline.org

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In March, during the first week of the San Francisco Bay Area’s first-in-the-nation stay-at-home order, California Healthline spoke with emergency department physicians working on the front lines of the burgeoning COVID-19 pandemic. At the time, these doctors reported dire shortages of personal protective equipment and testing supplies. Health officials had no idea how widespread the virus was, and some experts warned hospitals would be overwhelmed by critically ill patients.

In the end, due to both the early sweeping shutdown order and a state-sponsored effort to bolster the supply chain, Bay Area hospitals were able to avert that catastrophe. The region so far has fared much better than most other U.S. metro regions when it comes to rates of COVID infection and death. Even so, with intensive care unit capacity dwindling to critical levels statewide, San Francisco on Thursday issued another drastic order, announcing a mandatory 10-day quarantine for anyone returning to the city who has spent time outside the region.

Amid this fierce second surge, we circled back last week to check in with Dr. Jeanne Noble, director of the COVID response at the University of California-San Francisco medical center emergency department, to get her reflections on the Bay Area’s experience. She explained how even as her hospital has made so many improvements, including recently launching universal testing so that everyone who comes to the emergency room is tested for COVID-19, the lockdown and burnout are wearing on her and her colleagues. The conversation has been edited for length.

Q: How are you doing at UCSF right now? 

We’re OK in terms of our numbers. We have our ICU capacity; today’s numbers are 74% occupied. Acute care is a little bit tighter; the emergency department is seeing an increase in patients. [Editor’s note: As of Sunday, ICU capacity had dropped to 13%.]

We did have a period of time before this last surge where we often had a few days with no COVID patients. That was great. That ended in late September. This morning we have 11 patients on ventilators in the ICU.

I think we’re the first hospital in the state for universal testing. Everyone who comes to the ER gets tested. I’ve been working on this for months, but it’s new this week. Now we have testing, so we don’t have to do so much guesswork.

Q: When we spoke during the week of the first stay-at-home order, back in March, you were very worried. How do things compare now?

The supply [of masks] is just much better than it was back in March. In March, we had furloughed engineers from our local museum, the Exploratorium, making us face shields, and we started a makers lab in the library across the street to make supplies. It doesn’t feel like that this time around. We have a longer horizon.

I think in terms of our COVID care and our hospital capacity, we are fine. But my own sort of perspective on all of this is: When are we going to be done with this? Because even though things are smoother — we have PPE, we have testing — it’s a tremendous amount of work and stress. Frankly, the fact that my children have not been in school since March is one of my major sources of stress.

We’re all working way more than we ever have before. And nine months into it, the adrenaline is gone and it’s just purely exhausting.

Q: Can you tell me more about that, the physical and emotional toll on the hospital staff?

We don’t allow eating in the ED anymore, so we don’t have break rooms. Especially if you’re the supervising doctor, you need to do this elaborate handoff to another doctor if you need to eat. You know, it’s 10 hours into your shift and you want a cup of coffee.

The hassles and the discomforts. Wearing an N95 day after day is really uncomfortable. A lot of us have ulcers on our noses. They become painful.

And the lack of being able to socialize with colleagues is hard. The ED has always been a pretty intense environment. That’s offset by this closeness and being a team. All of this emotional intensity, treating people day after day at these incredible junctures in their lives — a lot of the camaraderie and morale comes from being able to debrief together. When you’re not supposed to be closer than a few feet from one another and you don’t take off your masks, it’s a lot of strain.

People are much less worried about coming home to their families. It hasn’t been the fomite disease we were all worried about initially, worried we’d give our kids COVID from our shoes. But there’s still the concern. Every time you get a runny nose or a sore throat you need to get tested, and you worry about what if you infected your family.

Q: So will you and your colleagues be able to take a break over the holidays?

We’ll see what happens. We’re just now starting to feel like we’re seeing the post-Thanksgiving numbers. But I think that even without having to do extra shifts in the ED, certainly for someone like me doing COVID response, there’s always a huge number of issues to work through. We just got the monoclonal antibodies, which is great, but that’s a whole new workflow.

I think what is going to bother people the most is that we are in lockdown. Kind of longing for that relaxation and time with family that we’re all kind of craving.

Q: It sounds like things are hard, but the hospital is in a relatively good place.

I was deployed to the Navajo Nation and helped with their surge in May in Gallup, New Mexico, and that is much, much harder than what we’ve faced in the Bay Area. In Gallup, at Indian Health Service, they were incredible in just the can-do attitude with way fewer resources than we have here. As of this summer, they had had the worst per capita surge in the country. They redesigned their ED essentially by cutting every room in half, hanging plastic on hooks you would use to hang your bicycle wheel. They hung thick plastic and right there doubled their capacity of patients they could see.

Our tents at UCSF are these blue medical tents with HVAC systems, heaters, negative pressure. They are really nice. There they had what looked like beach cabanas — open walls with just a tent overhead. In March and April they were taking care of patients in the snow. In the summer, it was hot and windy. When I was there, almost every single one of my patients had COVID.

That level of intensity was not something we had to go through in the Bay Area. Not to say that it’s easy [here]; I just told you all the ways it’s hard. But everything is relative. In terms of the COVID landscape, we have been very lucky.

Q: The Bay Area was early to close and has had stricter regulations than many parts of the country. As someone directly affected, what do you think of the response?

I think that we have benefited from early closures, unquestionably, when we did our shelter-in-place in March and probably saved 80,000 lives. It was really a tremendous and a bold move.

We’ve done some things well and other things not so well. We were very late to implement closures in a targeted fashion. Restaurants and dining reopened this summer, and a lot of us couldn’t figure out why indoor dining was open. Why is indoor dining something we need to even be considering when we’ve just barely flattened our curve? It was very predictable that cases would go up when dining happened. And they did.

We need to evaluate what is more important for our society and well-being, and to say what is the risk associated with that activity. Schools are of high social value. And [the closures are] really hard for kids. We’re seeing a lot of adolescents with suicidal ideation brought to the emergency department, which is related to school closure. I would put dining and restaurants as being of minimal social importance and very high risk.

We could have done this better. Closing [down society] when numbers go up is reasonable and that saves lives. But I think we know enough that it should not be an across-the-board closing. I mean, with this latest order, they temporarily closed parks. And we’ve been telling people to go outside. It’s like, what? Are you kidding?

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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TELLURIDE, Colo. — The day after Thanksgiving, Dr. Jana Eller and Dr. Shiraz Naqvi were seated beside an outdoor fire pit at the base of Telluride Ski Resort, taking a short break from skiing.

The two physicians from Houston had driven more than 18 hours to get here for the holiday weekend, and they were staying (and preparing meals) in a rented home. They traveled with another couple and their kids, colleagues they’ve been “bubbling” with in Houston.

“We got a COVID test prior to leaving and will get another when we return,” Naqvi said.

The skiing itself doesn’t feel much different during the pandemic, Eller said, but “the après ski scene is just gone.”

In March, at the beginning of the pandemic, Colorado Gov. Jared Polis issued an executive order requiring the state’s ski resorts to close in response to COVID-19, which had hit the state’s ski towns early and hard. Now, as the resorts enter their busy season, the state has taken pains to avoid blanket closures even though cases of COVID-19 are reaching their highest levels yet.

How to stay open amid the pandemic is an issue resorts across the U.S. are facing. Mandatory face coverings have become the norm, but other COVID mitigation efforts vary by site. Vermont resorts ask skiers to certify their compliance with rules governing interstate travel during the pandemic when buying a lift ticket, and in Colorado’s Pitkin County (home to Aspen), visitors will be required to confirm they’ve had a negative COVID test result within 72 hours of travel or pledge to quarantine for 14 days after arrival or until they obtain a negative test result.

Telluride is an internationally renowned destination trying to operate safely while protecting the 8,000 or so permanent residents in the area. Located in a remote southwestern part of Colorado, its economy depends on tourism, and the resort posts as many as 6,500 visitors on its busiest days.

On Nov. 25, with its COVID case numbers skyrocketing and its positivity rate hitting 4.6%, San Miguel County, which includes Telluride, closed its bars and restricted its restaurants to takeout and outdoor dining only. Signs posted throughout the resort remind visitors of the “five commitments of containment” — wear a mask, maintain 6 feet of physical distance, minimize group size, wash hands frequently and, when you feel sick, stay home and get tested.

How bad would things have to get to close the resort? That’s hard to gauge, said Grace Franklin, public health director for the county. People are going to do what they will regardless, she said.

“If we shut down the ski resort, how many people will take to the backcountry and get injured or trigger avalanches where the impact is greater? It’s a ‘damned if you do, damned if you don’t’ situation,” Franklin said.

Instead, Franklin said, the question becomes “How do we create safer, engineered events so people have an outlet, but we minimize as much risk as possible?”

Skiing itself poses relatively little risk, said Kate Langwig, an epidemiologist at Virginia Tech. “You’re outside with a lot of airflow, you’ve got something strapped to your feet so you’re not in super close contact with other people, and most of the time you’re riding the lift with people in your group.”

Gathering in the lodge or bar is by far the biggest COVID risk associated with skiing, said Langwig, who grew up skiing in northern New York. “In my family, one of the things you do after a day of skiing is connect with friends and have a beer in the lodge,” and it’s this social aspect of skiing that’s too risky right now, she said.

In an effort to discourage tourists and residents from congregating, local governments, medical facilities and the ski resort released a co-signed letter in November urging people to cancel any plans to gather with those outside their immediate household and celebrate the holidays solely with people from their own household. Keeping the resort open will require everybody to do their part, said Lindsey Mills, COVID public information consultant for San Miguel County.

“We are not telling anybody not to come, at least not yet,” said Todd Brown, Telluride’s mayor pro tem. But local officials are broadcasting a strong message to everyone in the area — “Chill out. Don’t have the big party with five families.”

Officials aren’t worried only about coronavirus transmission; they’re also concerned about overtaxing their medical facilities. San Miguel County has an urgent care center but no hospital, and its medical center experienced a 22% staffing shortage at the end of November, mostly because so many employees are in quarantine. Hospitals in nearby Mesa County reached their ICU capacity last month, and other hospitals in the region are also pinched.

“We can’t have a situation where people break their legs on the slopes and we can’t get them care,” said Franklin.

The resort has taken steps to facilitate physical distancing among visitors. Reservations aren’t required at Telluride, but lift tickets must be purchased in advance, and the resort can restrict ticket sales if necessary, said Jeff Proteau, vice president of operations and planning at the Telluride Ski Resort. Gondolas are operating with the windows open and each load is restricted to members of the same household.

To reduce contact in and around the lifts, workers have created “ghost lines” of empty space to ensure a 6-foot distance between groups while they wait in lift lines. People from the same household can stand in line together and ride the two- to four-person lifts next to one another, Proteau said, but when riding a lift with someone from another household, guests are asked to leave a vacant seat between them.

Langwig was a children’s ski instructor for many years and worries about ski school. “You interact pretty closely with the kids,” she said, noting that runny noses are common. “You spend a lot of time getting kids bundled up and to and from the bathroom.” This could be especially challenging if indoor spaces are closed, she said. “Hot chocolate breaks are one of the ways you get kids through the day, and that’s not safe anymore.”

In anticipation of visitors needing to take breaks to warm up, the resort has installed six temporary structures around the mountain with insulated ceilings and heated panels. When the sides are rolled up, they’re considered outdoor spaces, Proteau said, but they can be closed into confined spaces with limited occupancy as needed, especially on a blustery day.

The risk for most employees on the mountain should be relatively minimal, Langwig said, at least at work. “Lift attendants are outside wearing thick gloves and a mask most of the time. Compared to someone who works in a restaurant, their risk is pretty low.”

Employees are generally assigned to work in small groups that can be quarantined, if necessary, without wiping out a whole department, Proteau said. There’s also contact tracing in place for resort employees.

Arizona native Joey Rague moved to Telluride last year and works as a ski valet on the mountain. He said there’s a huge incentive among employees to keep the resort open. With affordable housing sparse in Telluride, “all of us are struggling seasonally to be able to pay rent.”

So far, he said, most visitors have been respectful and conscientious of the rules.

“It seems as though people understand that if we want to stay open, we have to come together,” he said.

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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KHN Midwest correspondent Lauren Weber discussed how the COVID-19 backlash undermines public health on Newsy on Thursday.

• Click here to watch Weber on Newsy
• Read “Pandemic Backlash Jeopardizes Public Health Powers, Leaders” by California Healthline senior correspondent Anna Maria Barry-Jester, KHN data reporter Hannah Recht, Michelle R. Smith of The Associated Press and Weber

California Healthline editor Arthur Allen discussed COVID vaccines with KIQI 1010AM’s “Hecho en California” on Thursday.

• Click here to hear Allen on KIQI 1010AM

California Healthline correspondent Angela Hart co-moderated a panel on the future of the Affordable Care Act in California at the Sacramento Press Club on Tuesday.

• Click here to watch Hart at the Sacramento Press Club
• Read Hart’s “California Stands to Lose Big if US Supreme Court Cancels Obamacare”

KHN senior correspondent Phil Galewitz discussed COVID vaccine distribution on Newsy on Tuesday.

• Click here to watch Galewitz on Newsy
• Read “Farmworkers, Firefighters and Flight Attendants Jockey for Vaccine Priority” by California Healthline correspondent Rachel Bluth and Galewitz

KHN Editor-in-Chief Elisabeth Rosenthal discussed COVID prevention PSAs and why they should be scarier on WNYC’s “The Takeaway” on Tuesday. She also discussed COVID and President-elect Joe Biden’s health care team on WBUR’s “On Point” on Dec. 11.

• Click here to hear Rosenthal on WNYC
• Read Rosenthal’s “It’s Time to Scare People About COVID”
• Click here to hear Rosenthal on WBUR

KHN Midwest correspondent/editor Laura Ungar discussed COVID primary care closures on Minnesota Public Radio on Dec. 11.

• Click here to hear Ungar on Minnesota Public Radio
• Read Ungar’s “Thousands of Doctors’ Offices Buckle Under Financial Stress of COVID”

KHN chief Washington correspondent Julie Rovner discussed the surge in COVID cases and efforts for a relief bill in Congress with WAMU’s “1A” on Dec. 11.

• Click here to hear Rovner on WAMU

KHN senior Colorado correspondent Markian Hawryluk discussed contact tracing in a Latino immigrant community with KUNC’s “Colorado Edition” on Dec. 10.

• Click here to hear Hawryluk on KUNC
• Read Hawryluk’s “Tracking COVID’s Spread Inside a Tight-Knit Latino Community”

Like tens of millions of other parents nationwide, Jonathan and Sara Sadowski struggle to assist their four children, ages 5 to 11, with their online schooling at home. In addition, their eldest child, who has cerebral palsy and is in a wheelchair, needs special care.

So to help the kids and keep them safe — especially their oldest child — Jonathan opted to take 12 weeks of paid leave from his teaching job under a program authorized by an emergency federal law enacted in March.

“Qualifying for paid leave was a huge relief and has worked out really well,” said Jonathan, who lives in Concord, New Hampshire.

But the family has learned about a new wrinkle: The 11-year old needs surgery in January. The operation is expected to require a month or two of recovery. Unfortunately, Jonathan’s leave will be used up by then; what’s more, the emergency federal paid leave program it is based on lapses Dec. 31.

Unions and workers’ rights and consumer advocacy groups are this week waging a last-ditch effort to get Congress to extend the program into 2021. They argue that the program is a critical component helping to prevent the spread of the virus and providing financial assistance to struggling families.

They also assert that a number of unwise exemptions — plus a lack of enforcement and public awareness — have limited the program’s effectiveness.

“The emergency paid-leave provisions have been one important step in helping American families deal with this crisis,” said Sen. Kirsten Gillibrand (D-N.Y.). “Congress must extend the provision until this crisis is over. Paid leave is critical as the economy recovers.”

The program is among two dozen pandemic-related relief measures set to expire at the end of the year. Those include unemployment benefits, protections against evictions, student loan relief and payments for COVID testing.

The Democratic-controlled House twice approved bills extending most of those, including paid leave. But Republican leaders in the Senate have until this month refused to consider new relief and stimulus legislation. This week, negotiations have intensified on a compromise bill that extends some of the expiring measures. But an extension of paid sick days and paid leave is not included in that bill.

Capitol Hill staffers and workers’ rights advocates say a paid-leave extension could still be added to the relief bill or a government spending bill that Congress must pass this month.

“It’s outrageous that paid leave is not in this legislation,” said Vicki Shabo, a senior fellow for paid-leave policy and strategy at New America, a Washington think tank. “The evidence is very clear paid sick days and leave help prevent spread of the virus, and it’s a benefit families overwhelmingly want and need.” 

Neither the Trump administration nor President-elect Joe Biden responded to requests for comment, and neither has announced a position on the issue.

Paid Sick Leave ‘Is in the Public Interest’

The current law requires businesses with fewer than 500 workers to allow their employees to take up to 10 days of sick leave at full pay and up to 50 more at two-thirds pay to care for a child when schools or day care centers are closed because of COVID-19.

The federal government covers the cost via tax credits to employers. The benefit covers mandatory 14-day quarantine periods for those exposed to the virus, whether they get sick or not.

Larger firms were exempted on the theory that most already provide paid sick days and some forms of extended paid leave — and don’t need federal subsidies.

But an analysis after the law was enacted found that the exemption leaves about 70 million workers in large businesses — roughly half the nation’s workforce — without the full protections offered under the COVID law.

The law and subsequent Department of Labor rules also permit firms with 50 or fewer employees to opt out of providing paid sick days or leave if they think their business will be adversely affected.

About 34 million people work for those small businesses — and the majority offer fewer than 10 paid sick days, if any. Few have extended paid leave.

In addition, the law has no guarantee of paid sick days or leave for the nation’s 13 million health care and emergency response workers.

The justification for that when the measure was enacted: Hospitals, clinics, nursing homes and emergency response companies needed to ensure that these essential workers would show up in a time of crisis.

“This was extremely shortsighted and bad policy,” said Pronita Gupta, director of job quality at the Center for Law and Social Policy in Washington, D.C. “We have seen the harmful outcome — the high number of coronavirus cases in health care facilities, especially among low-wage nursing home workers.”

Nor does the law offer extended paid leave for people who have COVID-19 or need to care for a family member with the disease beyond 10 days. Republicans opposed a broad-based benefit beyond at-home child care, advocates for the benefit noted.

“The problem is we now know that thousands of people who have COVID are sick for more than two weeks, some for months,” said Shabo. “These people need to be able to stay home and recover; that’s in the public interest as well.”

In a letter this month, a coalition of nine national public health groups urged Congress to extend the paid-leave benefits. “Paid sick leave can reduce the spread of COVID-19 in workplaces and communities by removing the barrier to employees staying home if they might have the virus,” the groups wrote. “Even one infection can set off an outbreak.”

Business groups are sympathetic, but some still oppose extending paid leave. Chief among them is the National Federation of Independent Business, a lobbying powerhouse that represents small businesses. Beth Milito, the group’s senior executive counsel, said that while small-business owners have been “highly sensitive” to their workers’ needs during the pandemic, mandating paid sick days and extended leave puts an undue burden on them.

“Figuring out who qualifies, monitoring who takes leave and then applying for the tax credit is all too much red tape,” Milito said. “It’s the hassle factor at a time when many businesses are barely making ends meet.”

Estimates of the Program’s Costs Vary Widely

Surveys show a majority of the estimated 70 million private- and public-sector workers covered under the law — after all the exemptions and carve-outs — don’t know about their right to paid sick days or leave.

“The lack of awareness has limited the potential of this benefit,” said Dawn Huckelbridge, director of the Paid Leave for All campaign, which is supported by a coalition of unions and employees and other groups. The Department of Labor, which administers the benefit, “simply fell down on the job,” she said.

Estimates last spring of the use and cost of the benefit varied widely — from around $20 billion to $105 billion.

But more recent estimates suggest it may be less. According to a Government Accountability Office report citing IRS data, as of the end of October about 150,000 employers had filed for paid family and sick leave tax credits, totaling $1.3 billion. The report noted, however, that many employers will likely wait until filing their taxes in the spring to claim the credit and recoup their costs.

The congressional Joint Committee on Taxation last month released fresh projections on the cost of an extension of paid leave — $1.4 billion if extended for two months and $1.8 billion for three months.

Although it’s too early for any full assessment of the paid-leave program’s impact, advocates point to a key study, published online in October in the journal Health Affairs. Researchers at Cornell University and the KOF Swiss Economic Institute found that in states where workers gained the right to paid sick leave under the emergency law, 400 fewer confirmed COVID cases were reported per day.

The researchers conclude: “Our findings suggest that the U.S. emergency sick leave provision was a highly effective policy tool to flatten the curve in the short run.”

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As apprehension about the pandemic intensifies, more Americans — nearly three-quarters — say they wear masks every time they leave the house, according to a poll released Friday.

The poll from KFF also found that 68% of American adults were worried someone in their family will get sick from the coronavirus, the highest level since the nonprofit began tracking the question in February. The public was least worried in April, when 53% were concerned the infection might strike their family. Since April, fewer than half of Republicans have consistently expressed fear that a family member will be sickened by COVID-19. (KHN is an editorially independent program of KFF.)

The latest survey, conducted among 1,676 adults from Nov. 30 to Dec. 8, found that 51% of Americans believed the worst is yet to come from the pandemic, which has claimed more than 300,000 lives in the U.S. The height of optimism occurred in September, when 38% of adults expected things to get worse.

Public support has risen for consistent use of masks, which has been a highly politicized marker of partisan affiliation. The poll found 73% of people said they wear a mask every time they leave home, an increase of 21 percentage points since May due to greater compliance among all partisan and age groups. The same percentage of 73% of respondents said they believe wearing a mask is part of the communal responsibility to prevent the spread of COVID, though nearly half of Republicans view it primarily as a personal choice.

While 87% of Democrats said they always wear a mask out of the house, 71% of independents and 55% of Republicans said the same.

Seven in 10 adults said they are prepared to adhere to physical distancing guidelines for another half-year or more until vaccines are widely available. Nearly 9 in 10 Democrats said they had the wherewithal but only half of Republicans did.

Political leanings polarized people in their views about whether their states have enacted enough restrictions to limit the spread of COVID-19. Half of Republicans thought their state had too many restrictions on businesses, while only 7% of Democrats and 24% of independents did. Four of 10 Republicans thought the state had too many restrictions on individuals, while only 3% of Democrats and 19% of independents did.

About half of Americans said stress related to the coronavirus has affected their mental health. The concerns are most widespread among women, young adults, minorities and people who have lost income, either personally or via their spouse, since the start of the outbreak.

The poll’s margin of error is +/-3%.

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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Congress appears to be inching ever closer to agreement on a long-delayed COVID-19 relief bill, which would extend unemployment insurance and other emergency programs set to expire in the next several days. That bill, however, apparently will not include the top-priority items for both political parties: business liability protections supported by Republicans and aid to states and localities sought by Democrats.

The bill is likely to be part of a giant spending bill to keep the federal government funded for the rest of the fiscal year. And it might include a last-minute surprise: legislation to put an end to “surprise” medical bills sent to patients who inadvertently obtain care outside their insurance network.

This week’s panelists are Julie Rovner of Kaiser Health News, Alice Miranda Ollstein of Politico, Rebecca Adams of CQ Roll Call and Mary Agnes Carey of KHN.

Among the takeaways from this week’s podcast:

• Congress has essentially agreed on a federal spending bill for the rest of the fiscal year — which began in October. But it will likely wait as lawmakers continue squabbling over the COVID relief package, with negotiations now centering on small details.
• Republicans for months have been hesitant to move forward on a bill that would provide more relief for consumers affected by the pandemic because party leaders did not like Democrats’ insistence that it include more state and local aid. But that provision has been jettisoned, so Republicans are less opposed to the measure. Plus, they see a political downside to holding up the bill: Their two Georgia candidates for Senate — facing Democratic opponents in a special runoff election — are being hammered on the issue.
• The compromise on surprise medical bills came after supporters secured agreement among Democrats who had favored varying remedies and all the committees in the House and Senate on the bill, a consensus that was forged with major concessions by progressives.
• But doctors’ groups and other industry critics are still attacking the surprise billing proposal — even though many observers see the bill as tilted in their favor over insurers — so its passage is not guaranteed. Supporters are banking on the looming end of the congressional session to move the measure over the finish line.
• Vice President Mike Pence announced he will get vaccinated against COVID-19 in public this week in hopes of convincing anyone skeptical about the shots that they are safe. President-elect Joe Biden is planning to do the same soon. But this is a difficult stance for politicians. They don’t want to look as if they are pushing themselves ahead in line, but they also want to normalize the use of the vaccine.
• About 200 state and local public health leaders have quit or been fired because of public opposition to measures to curb the coronavirus. Although President Donald Trump has reined in his criticism of some of these officials and their efforts, the opposition is still strong. Those critics may be buttressed by fears that new restrictions imposed to control the surging virus will hurt the economy.

Also this week, Rovner interviews Elizabeth Mitchell, president and CEO of the Pacific Business Group on Health, about the future of employer-provided health insurance.

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

Julie Rovner: The Texas Monthly’s “Texas Wedding Photographers Have Seen Some $#!+,” by Emily McCullar

Alice Miranda Ollstein: The New York Times’ “‘Like a Hand Grasping’: Trump Appointees Describe the Crushing of the C.D.C.,” by Noah Weiland

Mary Agnes Carey: NPR’s “How Do We Grieve 300,000 Lives Lost?” by Will Stone

Rebecca Adams: Bloomberg News’ “White House Official Recovers From Severe Covid-19, Friend Says,” by Jennifer Jacobs

To hear all our podcasts, click here.

And subscribe to What the Health? on iTunes, Stitcher, Google Play, Spotify, or Pocket Casts.

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

This story also ran on CNN. It can be republished for free.

Imagine this: Your elderly mother, who has dementia, is in a nursing home and COVID-19 vaccines are due to arrive in a week or two.

You think she should be vaccinated, having heard the vaccine is effective in generating an immune response in older adults. Your brother disagrees. He worries that development of the vaccine was rushed and doesn’t want your mother to be among the first people to get it.

These kinds of conflicts are likely to arise as COVID vaccines are rolled out to long-term care facilities across the country.

“This is a highly politicized environment, not only with respect to vaccines but also over the existence of the virus itself,” said Michael Dark, a staff attorney with California Advocates for Nursing Home Reform. “It’s not hard to imagine disputes arising within families.”

About 3 million people — most of them elderly — live in nursing homes, assisted living centers and group homes, where more than 105,000 residents have died of COVID-19. They should be among the first Americans to receive vaccines, along with health care workers, according to recommendations from the Centers for Disease Control and Prevention and various state plans.

But long-term care residents’ participation in the fastest and most extensive vaccination effort in U.S. history is clouded by a significant complication: More than half have cognitive impairment or dementia.

This raises a number of questions. Will all older adults in long-term care understand the details of the vaccines and be able to consent to getting them? If individual consent isn’t possible, how will families and surrogate decision-makers get the information they need on a timely basis?

And what if surrogates don’t agree with the decision an elderly person has made and try to intervene?

“Imagine that the patient, who has some degree of cognitive impairment, says ‘yes’ to the vaccine but the surrogate says ‘no’ and tells the nursing home, ‘How dare you try to do this?” said Alta Charo, a professor of law and bioethics at the University of Wisconsin-Madison Law School.

Addressing these issues will occur against a backdrop of urgency. Deaths in long-term care facilities are rising dramatically, with new estimates suggesting that 19 residents die of COVID-19 every hour. With viral outbreaks increasing, already-overwhelmed staffers may not have much time to sit down with residents to answer questions or have conversations with families over the phone.

Meanwhile, CVS and Walgreens, the companies operating vaccine programs at most long-term care facilities, have aggressive timetables. Both companies have said the large-scale rollout of the Pfizer-BioNTech vaccine — the first one that the Food and Drug Administration has authorized — will begin on Dec. 21.But facilities in some states may get supplies earlier. Altogether, there are more than 15,000 nursing homes and nearly 29,000 assisted living residences in the U.S.

At a meeting of the federal Advisory Committee on Immunization Practices early this month, Dr. Nancy Messonnier, director of the CDC’s National Center for Immunization and Respiratory Diseases, acknowledged the agency was “very concerned” that information about vaccines be adequately explained to long-term care residents. “It’s very important for the frail elderly not only to ensure that they are understanding the vaccine that they’re getting but also that their family members do,” she said.

Each vaccine manufacturer will be required to prepare a fact sheet describing what’s known about benefits and risks associated with a vaccine, what’s not known, and making it clear that a vaccine has received “emergency use authorization” from the FDA — a conditional endorsement that falls short of full approval. A second vaccine, from Moderna, is poised to receive this kind of authorization after an FDA meeting on Thursday.

Something that will need to be made clear to residents: while vaccines have been tested on people age 65 and older, those tests did not include individuals living in long-term care, according to Dr. Sara Oliver, a CDC expert.

Some operators have crafted communication plans around the vaccines and already begun intensive outreach. Others may not be well prepared.

Juniper Communities operates 22 senior housing communities (a standalone nursing home, multiple memory care and assisted living facilities, and two continuing care retirement communities) in Colorado, New Jersey and Pennsylvania. This week, it is planning an hour-long town hall videoconferencing session for residents and families about coronavirus vaccines. Last week, it held a similar event for staffers.

Juniper has contracted with CVS, which is requiring that every resident and staff member fill out consent forms in triplicate before being inoculated. When written consent can’t be obtained directly, verbal consent, confirmed independently, may substitute. Walgreens has similar requirements.

For residents with memory impairment, two Juniper nurses will reach out by phone to whomever has decision-making authority. “One will ask questions and obtain verbal consent; the other will serve as a witness,” said Lynne Katzmann, Juniper’s founder and chief executive officer. Separately, emails, blog posts and prerecorded voice messages about the vaccines have gone out to Juniper residents and staffers, starting at the end of November.

A key message is “we’ve done this before, not at this scale, mind you, and not at this level of import, but we do flu vaccinations annually,” said Katzmann, who plans to be the first Juniper employee to get the Pfizer vaccine when it comes to New Jersey.

At Genesis Healthcare, crucial messages are “these vaccines have been studied thoroughly, tens of thousands of people have received them already, they’re very, very effective, and no steps have been skipped in the scientific process,” said Dr. Richard Feifer, executive vice president and chief medical officer. Genesis, the nation’s largest long-term care company, operates more than 380 nursing homes and assisted living residences in 26 states, with about 45,000 employees and more than 30,000 residents.

Medical directors at each Genesis facility have been scheduling video conferences with families, residents and staffers during the past few weeks to address concerns. They’ve also distributed a letter and a question-and-answer document prepared by the Society for Post-Acute and Long-Term Care Medicine, in addition to getting information out through closed-circuit TV channels and social media.

In partnership with Brown University researchers, the company will monitor daily the side effects that its long-term care residents experience after getting coronavirus vaccines. Most reactions are expected to be mild or moderate and resolve within a few days. They include fatigue, pain at the injection site, headaches, body aches, fever and, rarely, allergic responses.

Administering the vaccine will occur over three visits for all long-term care facilities. At the first, all Genesis residents and staffers will get inoculations. At the second, three to four weeks later, those same people will get a second dose, and new staffers and residents will get a first dose. At the third, those who still qualify for a second vaccine dose will get one.

What will happen if lots of people experience uncomfortable side effects and employees don’t come in for a couple of days while recovering? “It’s a very difficult problem and we’re making contingency plans to address it,” Feifer said.

And what about continuing care retirement communities — also known as “life plan communities” — where residents in skilled nursing, assisted living and independent living can reside in close proximity?

That’s the case at Bayview in Seattle, which houses 210 residents in a 10-story building. For the moment, independent living residents aren’t on the priority list but “I know there will be a contingent of residents and staff who won’t want to be vaccinated and we’ll see if we can use those vaccines for our independent living people instead,” said Joel Smith, Bayview’s health services administrator.

Logistical challenges are sure to arise, but many operators have an acute sense of mission. “It is critical that we lead the way out of this crisis,” Feifer of Genesis said. “Nursing homes need to go first and be the first ones to address vaccine hesitancy head-on and be successful at generating a high level of acceptance. There is no alternative, no Plan B right now. We have to be successful.”

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MINNEAPOLIS — Gloria Torres-Herbeck gets the flu vaccine every year, but the 53-year-old teacher in Rochester, Minnesota, isn’t yet convinced she wants to be first in line for a potential COVID-19 vaccine.

“I’m not super old, but I’m not as strong as other people,” she said. “So, I need to be realistic on my own situation. Do I want to participate in something that might be a big risk for me?”

This month, the Food and Drug Administration gave emergency use authorization for one vaccine and is weighing approval of another. So, public health officials around the country are gearing up for what might be as challenging as figuring out how to store a vaccine at 70 degrees below zero Celsius. They need to persuade people who are part of communities that have been hit hard by the virus — those in low-income families and some minority populations, especially Black and Latino residents — to take a vaccine developed in less than a year and approved under emergency use authorization.

Yet there are a few places where officials think they have a head start. Rochester, Minnesota, home of the Mayo Clinic, is one of them. The Rochester Healthy Community Partnership has been working to reduce health disparities in the area’s immigrant communities, including Somali, Hispanic, Cambodian, South Sudanese and Ethiopian residents, for 15 years.

The partnership is composed of Mayo health providers and researchers, county public health officials and community volunteers like Torres-Herbeck, who immigrated to the U.S. 27 years ago from Mexico. One of the first of its kind, other similar efforts have sprung up around the country, but no one officially tracks such partnerships.

“What we realized when the pandemic hit in spades in March was that with long-established partnerships we were uniquely positioned to leverage” trust built up over the years between Mayo experts and their community partners, said Dr. Mark Wieland, who helps direct the group and studies the impact of such partnerships. “We realized we were obligated to jump in with two feet.”

Although only preliminary evidence has been gathered so far, there are indications that since the efforts began, Rochester has increased COVID-19 testing, improved contact tracing and boosted preventive behaviors such as mask-wearing, hand-washing and physical distancing in these vulnerable communities, he said. The group is hoping those early successes portend well for vaccine acceptance.

Learning From a Measles Outbreak

The Rochester partnership is banking on a commonsense approach that focuses on shared values, transparency and clear communication.

It’s a strategy that has succeeded in the past.

When a measles epidemic hit the large Somali population in Minneapolis-St. Paul in 2017, the Mayo Clinic reached out to community leaders among the 25,000 Somali immigrants in the Rochester area. Many had been frightened of the measles vaccine by baseless claims that it could cause autism, and vaccination rates were low in the community. Medical experts held town hall meetings in mosques and community centers, answering questions about vaccine safety and reassuring people that there was no scientific evidence of a link to autism. Somali actors created YouTube videos to help address common concerns. In the end, there were no recorded cases of measles in Olmsted County, home to Rochester.

About a year ago, Dr. Robert Jacobson, medical director for the Population Health Science Program at Mayo Clinic, at the request of a rabbi visited an Orthodox Jewish community in New York in which vaccine refusal was fueling another measles outbreak. He helped health care leaders there allay concerns.

“The Orthodox Jews in that community were refusing that vaccine for the same reason we were recommending it,” Jacobson said. “They were trying to protect their children.”

Efforts by Jewish leaders, public health experts such as Jacobson and lawmakers who tightened up laws on vaccine exemptions helped quell the outbreak.

Since March, the Rochester partnership has broadcast similar messages about COVID-19 to diverse audiences. Fear or misunderstanding was an issue at the beginning of the pandemic. Health leaders found that members of the immigrant communities were hanging up when the public health department called. So, the partnership developed messaging in several languages to explain the importance of the phone calls. They worked around problems, including that other languages don’t always have terms that mesh with English words for illnesses. For example, the word for “cold” and “flu” is the same in Somali.

Now fewer people hang up.

At the same time, these public health teams report back to the medical experts on what the community needs. “They’re the experts on the subtleties of their communities,” Wieland said.

So when the group learned that many immigrants were intimidated by COVID-19 testing and unsure of the logistics, the group recommended simplifying the process: Now, videos featuring community leaders on social media direct people to testing sites. Once there, anyone who doesn’t speak English automatically gets tested — no identification or insurance card necessary.

“We think that’s part of the reason that, as a county, we have overtested minority populations in relation to white populations,” Wieland said.

The ‘Why’ Was Missing

Only 40% of older Black adults and 51% of older Hispanics said they are somewhat or very likely to get the COVID-19 vaccination — compared with 63% of older white people, a University of Michigan poll shows. Their concerns mirror Torres-Herbeck’s: how well will the vaccine work or how safe it will be.

An even more recent survey of people of all ages for the COVID Collaborative, an advocacy group of national and state health and economic leaders, the NAACP and other groups shows trust in vaccine safety is as low as 14% in Black Americans and 34% in Latinos.

Older adults said they would like recommendations from doctors, health officials, or family and friends — people they trust, according to the Michigan poll. And Black Americans are twice as likely to trust Black messengers versus white messengers, the other survey showed.

“Even if people don’t trust doctors in general, they trust their own doctor,” said Dr. Preeti Malani, one of the authors of the Michigan survey and chief health officer of the university.

The advantage of groups like the Rochester partnership is that its members are also trusted messengers.

Several weeks ago, Torres-Herbeck said, she talked to a landscaper who didn’t wear a mask while working with his business partner. She told him that COVID-19 is a virus and explained how it spreads. He was surprised, and Torres-Herbeck understood. “When I came here 27 years ago, we were not as educated on that,” she said. “When I grew up, it was believed that if you walk barefoot you will catch a cold.”

Often, she said, public health officials provide directions on how to act and what to do, such as use a mask and clean your hands, but don’t explain why.

“That ‘why’ was missing for him,” she said.

Now when she talks to him, he puts a mask on.

In mid-November, Jacobson visited with members of the Rochester partnership via Zoom, part of the group’s initial effort to disseminate vaccine information.

Approving a vaccine under emergency use authorization is no less stringent than the normal procedure, he explained. The process has been dramatically sped up and condensed, he said, by the amount of money poured in and newer technology — and by increased FDA resources.

It’s not all about disseminating facts, however. Focusing on shared values is key to building trust. So when Adeline Abbenyi, the Mayo Clinic program manager for the Center for Healthy Equity and Community Engagement Research, said her mother, who had never feared vaccines, was hesitant to get a COVID-19 vaccine, Jacobson understood.

“A lot of us are feeling the same way,” Jacobson said in that Zoom meeting. “I go into this optimistic that we will have a vaccine that’s safe and effective, but I won’t use it until I see that evidence” of safety and efficacy the FDA is reviewing.

It’s normal for people to hesitate, he said, but that is far different from — and more widespread than — the anti-vaccine movement. Doctors and nurses getting the first doses will likely help many people overcome that hesitancy, he said.

Indeed, one thing that would persuade Torres-Herbeck to be inoculated? Seeing Jacobson get the vaccine, she said.

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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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.

The demand for skilled nurses during the pandemic is through the roof! Travel nurses command a hefty salary and they are worth every penny… #COVID19 #pandemic #RN https://t.co/gYQpkHqaoX

— Talmage Egan, MD (@UofU_Anes_Chair) November 26, 2020

— Dr. Talmage Egan, Salt Lake City

Nurses Deserve to Be Paid Handsomely

I read your article “Need a COVID-19 Nurse? That’ll Be $8,000 a Week” (Nov. 24) in the Springfield Journal-Register. It was an interesting article as I have a daughter who is a nurse. Nurses have been underpaid and unappreciated for years. It made me angry that the article characterized the wages some hospitals are willing to pay for nurses as exorbitant. Hogwash if you think someone should risk their life every hour of the day to care for COVID patients without proper compensation. How many doctors make over a million a year? You don’t cite that as unusual. I feel that nurses should go for the gold as they have been taken advantage of for years and, too bad, but good for them. Choose your words more carefully in the future. Nurses ROCK!!!!

— Mike Booher, Lincoln, Illinois

Hospitals go out of their way to avoid competing for nursing labor by raising wages. Now hospital executives and public health advocates act like it’s a travesty that COVID nurses are finally getting paid market rates to take on risky jobs. https://t.co/6z0idToVn6

— Devon M. Herrick (@DevonHerrick) November 24, 2020

— Devon M. Herrick, Dallas

Missing in the Mix of Vaccine Coverage

I must note two important omissions in the article “Time to Discuss Potentially Unpleasant Side Effects of COVID Shots? Scientists Say Yes” (Nov. 12). First, although these were interim trial results, the placebo arm should also have been reported out. What was the placebo infection rate? Reporting 90% effectiveness is irrelevant without reporting the placebo rate simultaneously. And one needs to align the infection rate in trial subjects with the incidence of disease in the U.S. population. They should be similar, but if not, any discrepancy must be explained (such as, no elderly people or children participating in the trial). Secondly, and perhaps more important: What other mitigating measures were volunteers in this trial required/advised to take? For example, physical distancing, masks, etc. I could find no mention of this, positively or negatively, when reading the protocol on clinicaltrials.gov. Any vaccine alone could not provide 94.5% efficacy. To determine the relative contributions of other measures, you’d need, say, a four-arm study — placebo with mask, placebo without mask, vaccine with mask, vaccine without mask. Statistically and clinically, one must account for other variables that may confound an apparent result.

This is a crucial point as the lay public is thinking that, by getting the vaccine, masks might no longer be necessary and they’ll have a 95% chance of not being infected. This is rubbish. The media and the public “experts” need to address this as they are setting themselves up for an immense PR failure and still greater skepticism. People may need to wear masks for many more months, maybe years, even with an effective vaccine.

— Stephen Zaruby, Truckee, California

I’m already confused 😕 https://t.co/UlJPh2EEvK

— hameen tariq (@hameentariq) November 23, 2020

— Hameen Tariq, Wilmington, Delaware

Exploring Cancer Drug’s Effects on COVID

Your story “Clots, Strokes and Rashes: Is COVID a Disease of the Blood Vessels?” (Nov. 13) was reprinted in my local newspaper. My brother, James L. Kinsella Ph.D., led the original work at the National Institutes of Health researching how the chemotherapy drug Taxol could reduce inflammation in coronary articles following the placement of coronary stents. This led to the very effective use of drug-eluting coronary stents. My unprofessional musing causes me to wonder if this anti-inflammatory response to Taxol might have some application as an early therapeutic intervention to reduce the inflammatory response of COVID-19 being studied by Dr. William Li. I can’t ask my brother; he passed away.

— Rick Kinsella, Oneida, New York

He wouldn’t be dead without covid. We’ve learned that things that aren’t life threatening are made life threatening by this disease. It attacks your blood vessels so it can exacerbate anything anywhere in your body that uses blood vessels. Stay safe indeed https://t.co/BFsqrKSFmH

— James McPicnic (@WhiteRatbit) December 3, 2020

— James “J.P.” McPicnic, Los Angeles

Women’s Health Should Not Be Up for Debate

Birth control medication is so much more than a pawn in politics (“Coming Abortion Fight Could Threaten Birth Control, Too,” Nov. 5). It changes the lives of so many women for the better. Birth control access has been proven to lead to higher rates of education for women, lower levels of child poverty, lower Medicaid costs for women’s health and higher productivity of society as a whole. It also treats a large number of medical conditions associated with women’s health. It effectively treats severe menstrual migraines, hormonal acne, endometriosis, severe menstrual pain, uterine abnormalities, anemia and heavy menstrual bleeding, among other health conditions. This medication is involved in treating so many women’s health concerns, improves infant and child health outcomes, and reduces child poverty, and yet almost 20 million women in the U.S. currently have no access to birth control medication. American politicians need to consider, if nothing else, the spillover costs to society when birth control access is reduced.

Women’s reproductive health should not be up for debate and yet it is at the center of so many political agendas. As a 24-year-old woman pursuing dual master’s degrees in public health and physician assistant studies, my focus should be on learning to become an exceptional health care provider, not whether my health will be up for debate in court. If politicians truly have the best interests of Americans at heart, they should be looking to expand birth control access, not restrict it.  Evidence needs to be incorporated into political agendas, and the evidence shows that when women succeed, society succeeds. Women’s education, health and reproductive rights should be at the forefront of every discussion on what constitutes a thriving population — the evidence has proven that women’s autonomy holds the answer and access to birth control is a vital piece of that.

— Gabby Henshue, Madison, Wisconsin

Scary times for women’s bodies.

“States could effectively ban contraception by arguing that some contraceptives act as abortifacients.” Threat is real. I’ve worked in states where this argument has been made.https://t.co/LmdWFRUNOZ

— Elizabeth M. Baskett (@EMBaskett) November 11, 2020

— Elizabeth M. Baskett, Denver

Injustice in High Gear

I was appalled at the charges on the medical bill from the Carson City emergency department for that child who fell off his bike (“Bill of the Month: After Kid’s Minor Bike Accident, Major Bill Sets Legal Wheels in Motion,” Nov. 25) — $18,000 for an exam and stitches? What would it take to sort out such problems in our health system? Lower prices from providers could only result in lower insurance premiums.

— Karen Johnson, San Rafael, California

Attempted subrogation, man, I tell yah https://t.co/spxcMlSiCk

— Annie M. Davidson (@attyannie) November 25, 2020

— Annie M. Davidson, St. Paul, Minnesota

KHN Morning Briefing: A Wealth of Information in One Spot!

I just wanted to say it is awesome to have portions of articles from many major news outlets because never does one tell the whole story. Case in point: I was trying to research what exactly President Donald Trump had done that “allowed doctors to discriminate against LGBT people,” and it was very helpful having a wide array of media sources on a single page to help get the bigger picture and try and weed through the bias of all of them (“Trump Administration’s Expanded Conscience Rule Will Allow Medical Professionals To Refuse To Provide Health Care Services,” May 3). Just sending my compliments. Keep up the great work.

— Nolan Steeley, Greensburg, Pennsylvania

💥Racism in #healthcare undermines #quality of care and patient safety. There’s hard work to be done to weed it out of all parts of society, especially clinical care. https://t.co/TbK0yIuraB

— Natalie S. Burke (@natalie4health) November 28, 2020

— Natalie S. Burke, Washington, D.C.

Education and Coverage Gaps Lead to Avoidable Amputations 

Coming to terms with systemic racism in health care is long overdue (“What Doctors Aren’t Always Taught: How to Spot Racism in Health Care,” Nov. 16). The way medicine is taught and the payment policies that shape the system have created persistent disparities in patient outcomes across racial and ethnic groups.

As a result, Black Americans are 80% more likely than whites to be diagnosed with diabetes and are twice as likely to die from the disease. Furthermore, Black American patients are up to four times more likely to experience an amputation than their white counterparts due to advanced peripheral artery disease (PAD), a common complication for people with diabetes and other chronic conditions. Similarly, Latinos are up to 75% more likely to experience an amputation than whites, while Native Americans are twice as likely to lose a limb.

As many as 85% of the nation’s 200,000 non-traumatic amputations could be prevented with access to screening and early detection. By screening for PAD through non-invasive arterial testing, the likelihood of an individual needing a PAD-related amputation can be reduced by up to 90%. Unfortunately, too few Americans — particularly racial and ethnic minorities — are even offered routine screening for PAD due to a widespread lack of understanding about the disease, as well as structural coverage barriers to simple, painless tests. As a result, many do not even know they have the disease until it is too late to save their limbs.

Communities of color deserve better. Members of the Congressional PAD Caucus — led by Rep. Donald Payne Jr. (D-N.J.) — recently introduced the Amputation Reduction and Compassion (ARC) Act to establish an education program about the disease — particularly for high-risk populations — and update reimbursement policy to disallow payment for non-emergent amputations unless arterial testing has been done in the three months before amputation. These simple solutions have the power to prevent thousands of avoidable amputations, and begin to correct health disparities in minority communities.

While we still have a long way to go as our country continues to grapple with systemic racism in health care, the ARC Act represents an important step toward ending disparities in PAD care.

— Dr. Foluso Fakorede, CEO of Cardiovascular Solutions of Central Mississippi, Cleveland, Mississippi

Racism in Health Care? Another example of injecting Politics. Inarguably, racism exists everywhere, but to make this a big issue is a disservice. Diff DX requires inclusion of Race/Ethnicity, to wit: Sickle Cell in Blacks,Alpha & Beta Thalassemia in Asians https://t.co/xyP54dPjH8

— Alexander R. Lim, MD (@AlexanderLim13) November 25, 2020

— Dr. Alexander R. Lim, Corpus Christi, Texas

‘Obamacare’ Unfairly Politicizes Health Law

I found this article interesting (“Biden Plan to Lower Medicare Eligibility Age to 60 Faces Hostility From Hospitals,” Nov. 11) but was surprised that the Affordable Care Act was referred to as “Obamacare.” Please don’t politicize the ACA — we really need it to continue allowing people to access health care. Many people do not have health care through their workplace and are unable to afford private insurance premiums. I was once one of those people before I was hired at our local library. It was really tough. Thank you for your reporting.

— Pamela Elicker, Port Townsend, Washington

Putting People First on the Podcast

When you were talking about drug policy and the ballot in a recent podcast (“KHN’s ‘What the Health?’: Change Is in the Air,” Nov. 6), you used terms that are considered incorrect or stigmatizing. For example, saying “opioid epidemic” when it’s really a crisis and referring to substance use as “abuse.” The Associated Press and NPR, among others, have pledged to use people-first language, as also supported by the American Psychological Association.

— Deirdre Dingman, Philadelphia

 

Not Tickling My Funny Bone

You ought to find some cartoonists who are not so flagrantly left-leaning — continuing to provide left-sided commentary is not right. It’s like all of the news stations pushing for socialism.

— Harry Gousha, Upland, California

Editor’s note: It is the tradition and mission among editorial cartoonists to satirize those in power. As with the nation’s leadership, the targets of political cartoons toggle from right to left. Balance is not these artists’ goal, but over time their commentary balances out. Stick with us, and we hope to amuse you in the future.

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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Troy Muenzer has seen the damage that COVID can do. A flight attendant who was diagnosed with a “suspected” case of the deadly virus, Muenzer, 32, endured months of lingering breathing problems; hefty, unexpected medical bills; lost wages, then furlough; and, earlier this month, the loss of his health insurance.

Last week, his bank account was hacked, causing him to lie awake one night worrying he wouldn’t be able to get back all that 2020 has taken. “From everything that’s happened this year, it just seems like it’s never-ending,” he said.

At the beginning of the pandemic, Congress passed several relief bills to help the country’s companies and its workforce: business grants and loans, paycheck protection for furloughed workers, one-time stimulus checks for taxpayers, expanded unemployment benefits. Much of the aid is set to expire by year’s end, if it hasn’t already.

This week, Muenzer’s furlough checks will stop coming. His monthly unemployment check is not enough to cover food and rent. He gave up his health insurance earlier this month because he could no longer afford the premium.

A little over two months ago, just before cutting his hours from few to none, his employer — a major airline — told him Congress could save his job. But lawmakers have shown they can’t, or won’t, put partisan politics aside to help the millions of Americans like Muenzer suffering the devastating impacts of the pandemic.

The chances for another round of pandemic relief before the end of the year look grim. Senate Majority Leader Mitch McConnell has signaled that Republicans could not accept a $908 billion bipartisan compromise written by moderates. Last spring, House Democrats introduced a proposal more than three times larger that they said was necessary to tackle the pandemic. Congress approved its last substantial relief bill nearly eight months ago.

Muenzer first got blindsided by COVID-19 in March. He was on a business trip, and as he got ready for bed in his hotel room, he began having trouble breathing. A former college football player who normally ran near his home by Lake Michigan, he lay awake, short of breath and terrified he would die in his sleep.

When the pandemic first gripped the nation, he had taken what precautions he could but was not permitted to wear a mask while working crowded flights. The Centers for Disease Control and Prevention did not recommend that Americans wear masks in public until April 3, but Muenzer was already sick.

Muenzer notified his employer that he had COVID symptoms and isolated himself at home. A telehealth doctor told him he needed in-person medical attention, but he was afraid he couldn’t afford it. He was already burning through his sick days.

Meanwhile, on April 14, with COVID cases exploding in cities like New York and San Francisco and among close-quartered groups like nursing homes and prisons, McConnell announced the Senate would extend its already weeks-long recess on the advice of public health officials. The day before, Democratic leaders said the House would do the same.

Congress had just passed a record $2 trillion stimulus package, its third relief measure. With House Democrats calling for more, including worker protections and medical leave, Rep. Kevin McCarthy of California, the House Republican minority leader, said it was too soon to talk about more aid. “I wouldn’t be so quick to say you have to write something else,” he said, according to NPR. “Let’s let this bill work.”

Muenzer did benefit from those early interventions. He received the one-time $1,200 stimulus check. But it barely made a dent in the wages he had lost being out sick, let alone once passenger demand cratered and the airline reduced his hours.

His employer was one of many companies that accepted help from the government on the condition they would temporarily hold off on furloughing employees. Muenzer was furloughed Oct. 1.

Muenzer has been receiving unemployment since then. But the extra $600 Congress gave the unemployed early in the pandemic expired long before that, and his monthly $1,200 unemployment check is not enough to cover his rent in Chicago, let alone food or medical care.

The relief legislation also required Muenzer’s private insurance plan to cover testing to detect or diagnose COVID-19 without Muenzer being required to pay anything. But that didn’t work.

The day the Senate extended its recess, Muenzer was so short of breath that he went to Northwestern Memorial Hospital’s emergency room. There, health care workers in full protective suits examined him and administered a chest X-ray. Diagnosed as “suspected COVID” and sent home to quarantine for 14 days, he did not get a COVID test.

With those critical diagnostic tests in short supply across the country at that time, they were reserved for seniors or patients with serious health conditions.

Muenzer received a bill for $108.59 for that emergency room visit, which he paid. Then another arrived, this one for $806.85 for the chest X-ray and other emergency room charges. Such billing problems were not unusual in the early days of the pandemic. Because COVID tests were not administered widely, patients like Muenzer lacked the official COVID diagnosis that required the medical system to zero out patient charges.

“I went to the COVID testing sign,” Muenzer said. “Then I didn’t even get tested and still got billed all that money.”

Muenzer was fortunate: A local television reporter heard about his problems and called the billing department herself. Though he had been fighting the bills for weeks, that day, the hospital returned Muenzer’s calls, blaming the problem on a coding error and assuring him his bills would be covered. But the hospital never returned his first payment.

When the payroll protection program’s conditions expired on Oct. 1, thousands of pilots, flight attendants like Muenzer and other airline employees — whose hours had already been trimmed — were furloughed. Muenzer said they were told the airline may be able to hold onto them a little longer, if Congress could pass another relief bill.

Indeed, Congress had considered legislation that would specifically bail out the airline industry. Muenzer watched as lawmakers debated bills that could have saved his job. But he did not overtly root for the legislation to pass. “It felt almost selfish,” he said. “Everybody’s hurting.”

Muenzer’s employer will stop sending him furlough pay on Dec. 15. Because it was calculated by averaging his pay for the past year, and his pay is based on flight hours, it wasn’t much. And given he has barely worked since he began feeling sick in March, his average work hours dropped significantly. He has tried to find a new job, but no luck yet.

But he feels lucky because he received furlough pay at all. He feels lucky because the hospital reduced his COVID testing bill to just $109. He feels lucky because he has family who can help him.

His company has assured its furloughed employees that they hope to bring them back in waves next year, if a vaccine is successful, if customer demand goes up again and if Congress can pass a relief bill.

That’s a lot of ifs at the moment — especially that last one, with Congress at a partisan logjam over a new COVID stimulus bill as it also tries to close out business for the year. Republicans are pushing for broader protections for businesses that could be sued if workers or customers become infected with the coronavirus. Democrats are pushing for funding for state and local governments battling the pandemic. Some lawmakers are also pushing for another round of one-time, $1,200 stimulus checks.

Even the bipartisan compromise would boost unemployment by only $300 a week through April. But it also includes support for the transportation sector, including airlines.

When he isn’t drowning out his anxieties watching Netflix, he keeps a close eye on Congress, “praying for something to happen.” It has been “very stressful, to say the least,” he said, “to feel like your life depends on the decisions of people in political power.”

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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