Category: From California Healthline.org

Within one day, President Donald Trump announced his COVID diagnosis and was admitted to Walter Reed National Military Medical Center for treatment. The flurry of events was stunning, confusing and triggered many questions. What was his prognosis? When was he last tested for COVID-19? What is his viral load?

The answers were elusive.

Picture the scene on Oct. 5. White House physician Dr. Sean Conley, flanked by other members of Trump’s medical team, met with reporters outside the hospital. But Conley would not disclose the results of the president’s lung scans and other vital information, invoking a federal law he said allows him to selectively provide intel on the president’s health.

“There are HIPAA rules and regulations that restrict me in sharing certain things for his safety and his own health,” he told the reporters.

The law he’s referring to, HIPAA, is the Health Insurance Portability and Accountability Act of 1996, which includes privacy protections designed to shield personal health information from disclosure without a patient’s consent.

Because this is likely to remain an issue, we decided to take a look. In what cases does HIPAA restrict the sharing of information — and is the president covered by it?

Experts agreed that he is, but several noted there are exceptions to its protections — stirring debate over the airwaves and on Twitter regarding what information about the president’s health should be released.

Explaining the Protections

HIPAA and the rules for its implementation apply to medical providers — such as doctors, dentists, pharmacists, hospitals — and most health plans that either provide or pay for medical care.

In some cases, the law permits the sharing of medical information without specific consent, such as when needed for treatment purposes or billing. Examples include doctors or hospitals sharing information with other physicians or facilities involved in the patient’s care, or information shared about tests, drugs or other medical care so bills can be sent to patients.

Other than that, without specific patient consent, the law is clear.

“The default rule under HIPAA is that health care providers may not disclose a patient’s health information. Period,” said Joy Pritts, a consultant in Washington, D.C., and a former privacy official in the Obama administration.

The experts we consulted all agreed that Trump’s doctors are bound by HIPAA. Since he is their patient, they cannot share his medical information without his consent.

Patients can allow some information to be released while demanding that other bits be withheld.

That may be why the public has been given only select details about Trump’s COVID-19 status, such as when Conley discussed the president’s blood pressure reading but not the results of his lung scans.

Trump “can pick and choose what he wants to disclose,” Pritts said.

So it is up to Trump to give his doctors the green light to report to the public on his condition.

“HIPAA does not prevent the president of the United States from authorizing the disclosure of all publicly relevant information,” said Lawrence Gostin, a professor of global health law at Georgetown University. “He can share it if he wanted to and he can tell his doctors to share it.”

Elizabeth Gray, a teaching assistant professor of health policy and management at George Washington University, said that because Conley shared some medically private information with the American public, there must have been a conversation between the president and his doctors about what was OK to include in their press briefings.

“He would have had to have given his authorization,” said Gray. In other words, Trump OK’d the details his doctors mentioned, but when follow-up questions were asked, she said, HIPAA was “a shield” because “the president hadn’t authorized the release of anything else.”

Still, beyond HIPAA, other factors could lead to less-than-complete disclosure of the president’s health.

For starters, Trump is the commander in chief, and his personal physician is a member of the military.

“If your commander in chief says, ‘I’m giving you a command — forget about HIPAA,’” said Thomas Miller, a resident fellow with the American Enterprise Institute.

Pritts and others also said the president’s physician may not be covered by HIPAA if his care is provided by the White House medical unit, which does not bill for its services or involve health insurance.

But, “whether covered by HIPAA or not, a physician has an ethical obligation to maintain patient confidentiality,” Pritts said.

And Leaks?

It’s also important to note that HIPAA applies only to health care professionals and related entities working within that sphere.

So, when Sean Spicer, former White House press secretary, tweeted on Oct. 5 that a journalist had violated HIPAA (he misspelled it as “HIPPA”) by reporting that a member of the White House press shop had COVID-19, he was wrong, said the experts.

“Journalists are not bound by HIPAA,” said Gostin.

Gray likened HIPAA in that way to a door.

“Behind that door is health care information. Hypothetically, only doctors have access to that information, and HIPAA prevents health care providers from unlocking that door,” she said. “But, once the info gets out of that door, then HIPAA no longer applies.”

And the information is likely to come out — sooner or later, said Miller. “Leaking will take care of most reporting and disclosure” about the president’s health, he said.

The Exceptions

Within HIPAA are a couple of exceptions identifying when health information can be disclosed without the authorization of the patient.

For example, the law does allow for disclosure if it “is necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public.”

Might that apply here, given that Trump took a ride around Walter Reed in a government SUV with Secret Service agents, or returned to a White House filled with other employees?

Jonathan Turley, a professor of public interest law at George Washington University Law School, said he doesn’t think the public health exemption would apply in this case.

“If a patient is contagious and noncompliant, doctors can make disclosure in the interest of public health,” Turley wrote in an email. “However, the team of doctors stated that they felt that it was appropriate to send President Trump back to the White House to continue to recover.”

Moreover, Turley noted that nothing was withheld that would have qualified for this exception. “The world knows that the president is COVID-positive and still likely contagious,” he wrote. “It is unclear what further information would do in order to put the world on notice.”

Some experts, however, expressed a different view. They argued that the details of when the president last tested positive would provide insight into who may have been exposed and how long he should be considered infectious and asked to isolate. Even so, the law’s public health exemption is usually interpreted to mean such information would be shared only with state and local health officials.

There are two HIPAA exceptions that apply specifically to the president, said Gray.

“They could make that disclosure to people who need to know, to the Secret Service or the vice president, but it is essentially only to protect [the president],” said Gray. “There is also an armed forces exception, but disclosures are in regards to carrying out a military mission, which doesn’t apply here.”

What about national security?

Miller, at AEI, said concerns about national security could be among the reasons for more disclosure, such as questioning a president’s ability to carry out duties. But HIPAA wasn’t designed to address this point.

Some argue that because the president is not just an average citizen, he should waive his right to medical privacy.

“The president is not just an individual; the president is the chief executive,” said Charles Stevenson, an adjunct lecturer on American foreign policy at Johns Hopkins University. “The president loses a lot of privacy because our political system, our governmental system demands it. The president always has to be available to the military and that means the state of his health is a matter of national security.”

Historical precedent

Trump is one in a long line of presidents who have not been completely transparent in sharing their medical information.

“There’s a pretty strong tradition of these things being obscured,” said John Barry, an adjunct faculty member at the Tulane University School of Public Health and Tropical Medicine. And no federal law requires a president to provide this information.

One of the most notable examples is President Woodrow Wilson, said Barry.

Wilson likely caught the so-called Spanish influenza in 1919, which was kept secret. Later that year, he had a severe stroke that disabled him, the gravity of which was also hidden from the public.

President John F. Kennedy used painkillers and other medications while in office, which wasn’t made public until years after his death.

And when President Ronald Reagan was shot in 1981, he was much closer to death than his White House spokesperson described to the public. There were also questions about Reagan’s mental acuity while in his final years in office. He was diagnosed with Alzheimer’s disease five years after his final term.

Why would White Houses want to obscure health information of presidents?

“Every White House wants the public to think the president is healthy, strong and capable of leading the country,” said Barry. “That’s consistent across parties and presidencies.”

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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The Affordable Care Act, facing its first test during a deep recession, is providing a refuge for some — but by no means all — people who have lost health coverage as the economy has been battered by the coronavirus pandemic.

New studies, from both federal and private research groups, generally indicate that when the country marked precipitous job losses from March to May — with more than 25 million people forced out of work — the loss of health insurance was less dramatic.

That’s partly because large numbers of mostly low-income workers who lost employment during the crisis were in jobs that already did not provide health insurance. It helped that many employers chose to leave furloughed and temporarily laid-off workers on the company insurance plan.

And others who lost health benefits along with their job immediately sought alternatives, such as coverage through a spouse’s or parent’s job, Medicaid or plans offered on the state-based ACA marketplaces.

From June to September, however, things weren’t as rosy. Even as the unemployment rate declined from 14.7% in April to 8.4% in August, many temporary job losses became permanent, some people who found a new job didn’t get one that came with health insurance, and others just couldn’t afford coverage.

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The upshot, studies indicate, is that even with the new options and expanded safety net created by the ACA, by the end of summer a record number of people were poised to become newly uninsured.

What’s more, those losses could deepen in the months ahead, and into 2021, if the economy doesn’t improve and Congress offers no further assistance, health policy experts and insurers say.

“It’s a very fluid situation,” said Sara Collins, vice president for health care coverage and access at the Commonwealth Fund, a New York-based health research group. “The ACA provides an important cushion, but we don’t know how much of one yet, since this is first real test of the law as a safety net in a serious recession.”

Collins also noted that accurately tracking health insurance coverage and shifts is difficult in the best of times; amid an economic meltdown, it becomes even more precarious.

Coverage Was Already on the Decline

Some 20 million people gained coverage between 2010 and 2016 under the ACA’s expansion of Medicaid and its insurance marketplaces for people without employer-based coverage. A gradually booming economy after the 2008-2009 recession also helped. The percentage of the population without health insurance declined from about 15% in 2010 to 8.8% in 2016.

But then, even as the economy continued to grow after 2016, coverage began to decline when the Trump administration and some Republican-led states took steps that undermined the law’s main aim: to expand coverage.

In 2018, 1.9 million people joined the ranks of the uninsured, and the Census Bureau reported earlier this month that an additional 1 million Americans lost coverage in 2019.

The accelerating decline is helping fuel anxiety over the fate of the ACA in the wake of the death of Supreme Court Justice Ruth Bader Ginsburg. The high court is scheduled to hear a case in November brought by Republican state officials, and supported by the Trump administration, that seeks to nullify the entire law.

In July, researchers at the Urban Institute, a Washington, D.C., think tank, forecast that around 10 million workers and their dependents would lose employer coverage in 2020. But they estimated that two-thirds of them will have found new coverage by year’s end — leaving about 3.3 million uninsured.

A more recent Urban Institute report, released Sept. 18, and using 2020 data from the Census Bureau, calculated that of the roughly 3 million people under age 65 who had lost job-based insurance between May and July, 1.4 million found coverage elsewhere — most through Medicaid — and 1.9 million became newly uninsured. Notably, 2.2 million of those who lost their coverage were between 18 and 39 years old; 1.6 million were Hispanic.

Another recent study, using different methods, reported higher numbers for the same period. The analysis released by the Economic Policy Institute last month determined that between April and July 6.2 million people lost employer coverage. The authors didn’t calculate how many found alternative coverage via Medicaid or the ACA, however.

Other findings support the notion that the health insurance loss trend shifted by mid summer. KFF, for example, published an analysis Sept. 11 showing that most companies that offered coverage to begin with chose to continue insuring furloughed and temporarily laid-off workers between March and the end of June. But as the virus continued to batter the economy, employers moved to permanently shed those jobs. (KHN is an editorially independent program of KFF.)

“The issue now is that the temporary layoffs have greatly decreased and permanent job losses, including jobs that came with health coverage, are increasing,” said Cynthia Cox, a KFF vice president and director for the Program on the ACA.

Many low-income workers who lose their jobs and don’t have coverage through a spouse or parent turn to Medicaid, the federal-state health program for low-income people. The Centers for Medicare & Medicaid Services reported last week that enrollment in Medicaid and the Children’s Health Insurance Program grew by 4 million between February and June, a nearly 6% increase since the beginning of the coronavirus crisis.

The Impact of the Marketplaces

Gains and losses of coverage in the ACA marketplace are not yet clear, experts say. The Trump administration issued a report in June indicating that 487,000 people had, between January and June, enrolled in an ACA plan via the federal website, healthcare.gov. But that report failed to say how many people dropped an ACA plan in that period — for example, because they could no longer afford the premiums.

A study by Avalere, a health research and consulting firm in Washington, D.C., has estimated that enrollment in the ACA marketplaces since March could have swelled by around 1 million. That includes new enrollees in the 13 ACA marketplaces that states, plus the District of Columbia, operate. Many of those states held a “special enrollment period” when the pandemic hit. Healthcare.gov, run by the Trump administration, did not offer a special enrollment period.

About 11 million were enrolled in an ACA plan in February. Open enrollment for coverage that would start on Jan. 1, 2021, begins Nov. 1.

Jessica Banthin, a senior health policy researcher at the Urban Institute and until 2019 deputy director for health at the Congressional Budget Office, said it’s anyone’s guess how many people who lost their job-based coverage this year will choose this option. She said numerous factors will influence people’s health insurance decisions this fall, and into 2021.

Chief among them is gauging whether they might soon get a new job, or get back an old job, that offers insurance. That may hold some people back from enrolling in an ACA plan this fall, Banthin said. Plus, buying insurance may be too expensive, especially for families more concerned with paying for housing, food and child care while going without a paycheck.

“Health insurance may not be their immediate concern,” Banthin said. “Many people’s lives have been disrupted as never before. There’s a lot of trauma out there.”

Collins of the Commonwealth Fund said that, even before the pandemic, a growing proportion of families were vulnerable to loss of coverage and care.

In a survey of more than 4,000 adults early this year, Collins and colleagues found a “persistent vulnerability among working-age adults in their ability to afford coverage and health care that could worsen if the economic downturn continues.”

In large part, that’s because 1 in 5 respondents who had coverage were “underinsured.” Underinsurance reflects the extent to which coverage leaves people at risk of high out-of-pocket costs — a situation exacerbated by widespread job loss.

“Now is absolutely not be the time for the ACA to be further undermined, let alone killed outright,” said Stan Dorn, director of the National Center for Coverage Innovation at Families USA.

Older adults are especially vulnerable physically during the coronavirus pandemic. But they’re also notably resilient psychologically, calling upon a lifetime of experience and perspective to help them through difficult times.

New research calls attention to this little-remarked-upon resilience as well as significant challenges for older adults as the pandemic stretches on. It shows that many seniors have changed behaviors — reaching out to family and friends, pursuing hobbies, exercising, participating in faith communities — as they strive to stay safe from the coronavirus.

“There are some older adults who are doing quite well during the pandemic and have actually expanded their social networks and activities,” said Brian Carpenter, a professor of psychological and brain sciences at Washington University in St. Louis. “But you don’t hear about them because the pandemic narrative reinforces stereotypes of older adults as frail, disabled and dependent.”

Whether those coping strategies will prove effective as the pandemic lingers, however, is an open question.

“In other circumstances — hurricanes, fires, earthquakes, terrorist attacks — older adults have been shown to have a lot of resilience to trauma,” said Sarah Lowe, an assistant professor at Yale University School of Public Health who studies the mental health effects of traumatic events.

“But COVID-19 is distinctive from other disasters because of its constellation of stressors, geographic spread and protracted duration,” she continued. “And older adults are now cut off from many of the social and psychological resources that enable resilience because of their heightened risk.”

The most salient risk is of severe illness and death: 80% of COVID-19 deaths have occurred in people 65 and older.

Here are notable findings from a new wave of research documenting the early experiences of older adults during the pandemic:

Changing behaviors. Older adults have listened to public health authorities and taken steps to minimize the risk of being infected with COVID-19, according to a new study in The Gerontologist.

Results come from a survey of 1,272 adults age 64 and older administered online between May 4 and May 17. More than 80% of the respondents lived in New Jersey, an early pandemic hot spot. Blacks and Hispanics — as well as seniors with lower incomes and in poor health — were underrepresented.

These seniors reported spending less face-to-face time with family and friends (95%), limiting trips to the grocery store (94%), canceling plans to attend a celebration (88%), saying no to out-of-town trips (88%), not going to funerals (72%), going to public places less often (72%) and canceling doctors’ appointments (69%).

Safeguarding well-being. In another new study published in The Gerontologist, Brenda Whitehead, an associate professor of psychology at the University of Michigan-Dearborn, addresses how older adults have adjusted to altered routines and physical distancing.

Her data comes from an online survey of 825 adults age 60 and older on March 22 and 23 — another sample weighted toward whites and people with higher incomes.

Instead of inquiring about “coping” — a term that can carry negative connotations — Whitehead asked about sources of joy and comfort during the pandemic. Most commonly reported were connecting with family and friends (31.6%), interacting on digital platforms (video chats, emails, social media, texts — 22%), engaging in hobbies (19%), being with pets (19%), spending time with spouses or partners (15%) and relying on faith (11.5%).

“In terms of how these findings relate to where we are now, I would argue these sources of joy and comfort, these coping resources, are even more important” as stress related to the pandemic persists, Whitehead said.

Maintaining meaningful connections with older adults remains crucial, she said. “Don’t assume that people are OK,” she advised families and friends. “Check in with them. Ask how they’re doing.”

Coping with stress. What are the most significant sources of stress that older adults are experiencing? In Whitehead’s survey, older adults most often mentioned dealing with mandated restrictions and the resulting confinement (13%), concern for others’ health and well-being (12%), feelings of loneliness and social isolation (12%), and uncertainty about the future of the pandemic and its impact (9%).

Keep in mind, older adults expressed these attitudes at the start of the pandemic. Answers might differ now. And the longer stress endures, the more likely it is to adversely affect both physical and mental health.

Managing distress. The COVID-19 Coping Study, a research effort by a team at the University of Michigan’s Institute for Social Research, offers an early look at the pandemic’s psychological impact.

Results come from an online survey of 6,938 adults age 55 and older in April and May. Researchers are following up with 4,211 respondents monthly to track changes in older adults’ responses to the pandemic over a year.

Among the key findings published to date: 64% of older adults said they were extremely or moderately worried about the pandemic. Thirty-two percent reported symptoms of depression, while 29% reported serious anxiety.

Notably, these types of distress were about twice as common among 55- to 64-year-olds as among those 75 and older. This is consistent with research showing that people become better able to regulate their emotions and manage stress as they advance through later life.

On the positive side, older adults are responding by getting exercise, going outside, altering routines, practicing self-care, and adjusting attitudes via meditation and mindfulness, among other practices, the study found.

“It’s important to focus on the things we can control and recognize that we do still have agency to change things,” said Lindsay Kobayashi, a co-author of the study and assistant professor of epidemiology at the University of Michigan School of Public Health.

Addressing loneliness. The growing burden of social isolation and loneliness in the older population is dramatically evident in new results from the University of Michigan’s National Poll on Healthy Aging, with 2,074 respondents from 50 to 80 years old. (It found that, in June, twice as many older adults (56%) felt isolated from other people as in October 2018 (27%).

Although most reported using social media (70%) and video chats (57%) to stay connected with family and friends during the pandemic, they indicated this didn’t alleviate feelings of isolation.

“What I take from this is it’s important to find ways for older adults to interact face to face with other people in safe ways,” said Dr. Preeti Malani, chief health officer at the University of Michigan. “Back in March, April and May, Zoom family time was great. But you can’t live in that virtual universe forever.”

“A lot of well-intentioned families are staying away from their parents because they don’t want to expose them to risk,” Malani continued. “But we’re at a point where risks can be mitigated, with careful planning. Masks help a lot. Social distancing is essential. Getting tested can be useful.”

Malani practices what she preaches: Each weekend, she and her husband take their children to see her elderly in-laws or parents. Both couples live less than an hour away.

“We do it carefully — outdoors, physically distant, no hugs,” Malani said. “But I make a point to visit with them because the harms of isolation are just too high.”

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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As trust in the Food and Drug Administration wavers, several states have vowed to conduct independent reviews of any COVID-19 vaccine the federal agency authorizes.

But top health experts say such vetting may be misguided, even if it reflects a well-founded lack of confidence in the Trump administration — especially now that the FDA has held firm by releasing rules that make a risky preelection vaccine release highly unlikely.

At least six states and the District of Columbia have indicated they intend to review the scientific data for any vaccine approved to fight COVID-19, with some citing concern over political interference by President Donald Trump and his appointees. Officials in New York and California said they are convening expert panels expressly for that purpose.

“Frankly, I’m not going to trust the federal government’s opinion and I wouldn’t recommend [vaccines] to New Yorkers based on the federal government’s opinion,” New York Gov. Andrew Cuomo said last month.

“We want to make sure — despite the urge and interest in having a useful vaccine — that we do it with the utmost safety of Californians in mind,” Dr. Mark Ghaly, California’s health and human services secretary, said at a recent news conference.

The District of Columbia, Colorado, Michigan, Oregon and West Virginia also have said they’ll review vaccine data independently.

But scientists who study vaccine policy said such plans could backfire, confusing the public, eroding confidence in any eventual vaccine and undermining the best strategy to end the pandemic, which has sickened nearly 7.5 million Americans and killed more than 210,000.

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“Do you really want a situation where Texas, Alabama and Arkansas are making drastically different vaccine policies than New York, California and Massachusetts?” asked Dr. Saad Omer, an epidemiologist who leads the Yale Institute for Global Health.

Separate state vaccine reviews would be unprecedented and disruptive, and a robust regulatory process already exists, said Michael Osterholm, an epidemiologist and director of the Center for Infectious Disease Research and Policy at the University of Minnesota.

“States should stay out of the vaccine review business,” Osterholm said. “I think the Food and Drug Administration is doing their job right now. Unless there’s something that changes that, I do believe that they will be able to go ahead.”

The administration has given reasons for states to worry. Trump has repeatedly signaled a desire for approval of a vaccine by the Nov. 3 election, arousing fears that he will steamroll the normal regulatory process.

The president wields “considerable power” over the FDA because it’s part of the executive branch of government, said Lawrence Gostin, faculty director of the O’Neill Institute for National and Global Health Law. The president nominates the FDA commissioner and can replace him at any time.

Trump has already contradicted the advice of his own scientific advisers in order to promote unproven therapies to fight COVID-19. The FDA approved two treatments — hydroxychloroquine and convalescent plasma — without strong evidence of safety and efficacy after Trump pushed for the therapies to be widely available.

Late Monday, The New York Times reported that top White House officials planned to block FDA guidelines that would bolster requirements for emergency authorization of a COVID vaccine — because the new guidelines would almost certainly delay approval until after the election.

The White House’s actions undermine the agency, said Dr. Paul Offit, an infectious disease expert at Children’s Hospital of Philadelphia and a member of the FDA advisory committee on vaccines.

“Trump has perverted the FDA,” Offit said. “He has scared people into thinking that normal systems aren’t in place there anymore.”

But the FDA seems to be maintaining plans that would make it virtually impossible for a vaccine to be approved by Election Day.

Dr. Peter Marks, who heads the FDA division responsible for vaccine approval, has repeatedly said career scientists at the agency are working to ensure that political pressure isn’t a factor in any decision.

FDA reviewers are determined to “keep our hands over our ears to the noise that’s coming in from all sides and keep our eyes on the prize,” Marks said Monday in a JAMA webinar.

On Tuesday, the FDA pushed back against White House interference by publishing stricter guidance for vaccine developers on its website. The document instructs vaccine companies to follow patients for two months after their last shot in order to give researchers more time to detect serious side effects and ensure the vaccine works.

For now, supporters of the normal regulatory process are pinning their hopes on two advisory groups of respected scientists who will evaluate vaccines for safety and efficacy and send their recommendations to federal agencies.

The FDA’s advisory group, known as VRBPAC, will review data submitted by the pharmaceutical companies and the agency for any vaccine. The Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices, or ACIP, will weigh in on its use. Their recommendations aren’t binding, but the federal government has rarely contravened them.

Before jumping to independent reviews, states should allow ACIP and VRBPAC to do their jobs, said Dr. Marcus Plescia, chief medical officer of the Association of State and Territorial Health Officials. That’s the best defense against any political pressure, he said, and individual states likely wouldn’t have access to the data — or, perhaps, the expertise — to conduct their own reviews.

ACIP Chairman Dr. José Romero, who also is the chief medical officer for the Arkansas Department of Health, said the group has been meeting regularly since spring to discuss COVID vaccines and they’ve been able to proceed “in an unfettered fashion.”

“I have not felt pressured by the CDC, other government agencies or pharmaceutical companies to arrive at any particular recommendation,” he said.

Other safeguards are in place as well. Trump cannot simply override the FDA’s authority to approve drugs and vaccines, which comes from Congress.

“The president can influence the FDA, but it must be consistent with the FDA’s statutory mandate,” Gostin said. “The White House may not, for example, direct the agency to ignore science or use a lower scientific standard.”

Congress could sue the FDA for failing to follow its own standards, and a judge could issue a temporary restraining order blocking release of a COVID vaccine, Gostin said. Courts would require the FDA commissioner or health and human services secretary to have “valid, evidence-based reasons” for any decision.

“The commissioner or secretary may not act arbitrarily or according to political preferences alone,” Gostin said.

Individual states could not overrule the FDA’s authorization or approval of a vaccine, but they could wield their power in other ways. States distribute vaccines through contracts with the CDC, noted Dr. Kelly Moore, associate director of immunization education for the Immunization Action Coalition. They could say, “‘We will not place any orders until we’re sure,’” she said.

States probably could not prevent private companies, such as pharmacy chains, from distributing vaccines that are shipped directly to them. Pharmacies would likely sue any states that try to prevent them from distributing vaccines, Gostin said.

Although federal and state agencies play a crucial role in ensuring patient safety, they’re not the only entities looking out for patient interests, said Dr. Joshua Sharfstein, a former FDA deputy commissioner who is now a vice dean at the Johns Hopkins Bloomberg School of Public Health. Doctors and other medical providers won’t recommend a vaccine they don’t trust, he said.

“We have an entire health care system standing between politics and the patients,” Sharfstein said. “I think doctors are going to be very concerned if a vaccine is rushed.”

Even pharmaceutical companies that stand to profit from vaccines have a huge stake in protecting the integrity of the approval process. Nine rival vaccine makers took the unusual step last month of pledging not to release a COVID vaccine until it has been thoroughly tested for safety.

The bigger consideration, however, is how state-by-state vetting would affect consumer trust in a COVID vaccine — or any vaccine in the future, Plescia said. A recent KFF poll found 54% of Americans would not submit to a COVID vaccine authorized before Election Day.

“Are people going to mistrust the entire process?” he said. “We will get through COVID one way or another, but if we undermine confidence in public health, that would be a disaster.”

Throughout the 2020 election cycle, candidates’ positions on health care have been particularly important for voters with underlying and often expensive medical needs — in short, those with preexisting conditions.

It’s no surprise, then, that protections for people who have chronic health problems like diabetes and cancer have become a focal point for candidates nationwide — among them, Matt Rosendale, the Republican contender for Montana’s only U.S. House seat.

On Sept. 22, Rosendale’s campaign hit airwaves and online streaming services with an ad featuring a Whitefish resident named Sandee, whose son was diagnosed with a life-threatening disease. Sandee told the story of how Rosendale came to her family’s aid, concluding that “Matt fights for everyone with a preexisting condition.”

As is often the case with health care policy, however, the truth is far from simple. Rosendale and many other Republican congressional candidates face the challenge of convincing voters they support these safeguards even as they oppose the Affordable Care Act, which codifies those safeguards.

Polls show broad public support for keeping the ACA’s preexisting condition protections.

We decided to investigate.

Rosendale is up against Democrat Kathleen Williams for the congressional seat now occupied by Republican Rep. Greg Gianforte, who has entered the state’s gubernatorial race. The open seat has been controlled by the GOP for the past 12 terms, but this year’s race is expected to be close. Williams, who also ran for the seat in 2018, has made health care her top campaign issue.

We contacted the Rosendale campaign to find out the basis for his ad’s claim. Campaign spokesperson Shelby DeMars listed a range of health policies backed by the candidate that would help people with preexisting conditions directly or indirectly by holding down health care costs. She specifically pointed to Rosendale’s work on the state’s reinsurance program as Montana’s state auditor and insurance commissioner, a post he was elected to in 2016.

“Matt Rosendale is a champion for those with pre-existing conditions and he has the record to prove it,” DeMars said via email. “It is because of the Reinsurance program he implemented that Montanans with pre-existing conditions can access the affordable healthcare coverage they need.”

Examining Reinsurance

In a nutshell, Montana’s reinsurance program is designed to help insurers cover costly medical claims with a mix of federal pass-through dollars and funding generated by a premium tax on all major medical policies in the state. Gov. Steve Bullock announced the formation of a bipartisan group tasked with developing reinsurance program legislation in fall 2018, and the state’s legislature approved the plan in 2019, allowing Rosendale to apply for and receive the necessary waiver under the Affordable Care Act.

Subsequent news accounts indicated the idea worked. In-state insurers credited the program with lowering premiums by 8% to 14% for 2020. As Montana Health Co-op CEO Richard Miltenberger told MTN News shortly after the 2019 legislative session, “It allows the insurance companies to have rate stabilization for those really big claims, the ones that are the earthquakes in health insurance.” He went on to say that this stability “brings the cost down for the consumer.” More to the point, the American Medical Association has also stated that reinsurance not only serves to subsidize high-cost patients but “protects patients with pre-existing conditions.”

But there’s a rub.

The reinsurance program that Rosendale touts wouldn’t exist without a state innovation waiver created by the ACA, which Rosendale says he’ll work to repeal. That effort will doubtless continue to fuel pitched battles in Congress, and how the U.S. Supreme Court may rule on a pending ACA challenge remains a point of speculation. One thing is clear, though: If the entire ACA is thrown out, the reinsurance program goes with it, along with Montana’s Medicaid expansion and the ban on insurers from excluding people with health problems from affordable coverage.

When asked about the resulting elimination of the reinsurance program, DeMars reiterated that Rosendale’s work as auditor has created a system that will ensure protections for preexisting conditions “regardless of what happens to the ACA.” She did not elaborate or explain what protections would remain if the ACA were repealed.

The Short-Term Plan Component

In defending his stance on preexisting conditions, Rosendale continues to be haunted by another health care policy specter from his political past. During his unsuccessful challenge against Democratic U.S. Sen. Jon Tester in 2018, Rosendale faced criticism for promoting short-term, limited-duration health insurance plans. Unlike plans offered on the individual marketplace, these short-term plans are exempt from the ACA’s ban on excluding people with preexisting conditions. And, under a 2018 regulatory change pushed by the Trump administration, the length of these short-term plans has been extended from three months to 12, with the potential to renew for up to three years.

As state auditor, Rosendale included those plans in his March 2020 roundup of year-round options for immediate coverage. They often exclude coverage for a variety of higher-cost benefits. In Montana, for example, a review by KFF found that of four short-term plans available in Billings in 2018, none offered coverage for maternity care, mental health, substance abuse or prescription drug services. (KHN is an editorially independent program of KFF.)

Historically, short-term plans were designed to help individuals fill gaps in health coverage. According to Dania Palanker, an assistant research professor at Georgetown University’s Center on Health Insurance Reforms, the role short-term plans play on today’s health insurance landscape is to attract younger, healthier individuals seeking low-cost options to cover catastrophic events. That splits insurers into two pools — those who are less likely to incur medical expenses, and those who are more likely to incur them. Costs on the individual market go up as a result, leaving people with preexisting conditions no other option than to pay higher premiums. Short-term plans are, Palanker said, “actively hurting people with preexisting conditions.”

“Promoting short-term plans and stumping on supporting protections for preexisting conditions are mutually exclusive,” she continued.

Asked whether the cost-lowering effect of a reinsurance program would be enough to offset the effects of short-term plans, Palanker said the only way such an offset would be enough is if the program encompassed short-term plans. She hasn’t seen that happen anywhere.

Our Ruling

A campaign ad says Rosendale “fights for everyone with a preexisting condition.” While it is true that health insurance premiums have dropped during Rosendale’s tenure as state auditor, the choice to establish Montana’s reinsurance program ultimately fell to decision-makers in the state’s legislature and the governor’s office. Since his ad’s claim simply states that he “fights” for people with preexisting conditions, his testimony in support of that program and role in securing the state waiver do seem to fit the bill.

In the long-term, however, Rosendale’s positions begin to run counter to the claim. His support for short-term, limited-duration plans poses a considerable threat to keeping health insurance affordable for all, and absent a solid plan from Congress to ensure that state reinsurance programs survive, his stated goal of repealing the ACA would actually serve to unravel the very protection he’s built his case on.

We rate this statement as Mostly False.

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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CALEXICO, Calif. — The message wasn’t lost on Daniel Gonzalez.

Early in the pandemic, one of the first things Imperial County did to ward off the virus was close the public bathrooms and, later, public cooling centers. In this sprawling Southern California desert, where summer brings blistering triple-digit heat, that lack of access could amount to a death sentence for people without shelter.

People like Gonzalez, homeless the past two years, were simply not a priority.

Months into the coronavirus shutdown, Gonzalez, 47, felt lonely. Calexico’s quiet downtown had emptied out. July highs were topping 110, and it was uncomfortable wearing a mask in the swelter. But not having a place to rinse off or wash up, that was just a hazard.

Standing outside a closed restroom in Calexico’s Border Friendship Park, looking out over the complex of metal bars and security equipment that marks the U.S.-Mexico border, he waited for dinner. Every night at 7:30 p.m., volunteers assembled at the park to serve a hot meal to anyone in need. A few weeks before, pressured by the organizers, the county started dropping off hand-washing stations right before the meal, only to whisk them away as soon as it was served.

Gonzalez lined up. At least it was something.

This was supposed to be the year that California finally did something about its epidemic of homelessness. On February 19, Gov. Gavin Newsom stood before lawmakers in the state Capitol, and delivered an unprecedented State of the State address devoted entirely to the homelessness crisis. California is home to one-quarter of the nation’s homeless population, a grim distinction painfully visible not only on city sidewalks, but also along the state’s freeways and farm levees, in its urban parks and suburban strip malls.

Past administrations had mostly ignored the problem, Newsom said, but he’d be different. “It’s a disgrace that the richest state in the richest nation — succeeding across so many sectors — is falling so far behind to properly house, heal and humanely treat so many of its own people,” he told the crowd.

But even as Newsom spoke, a different epidemic was advancing silently across the state. Exactly one month later, he would order a far-reaching statewide shutdown, asking every person in California not working in an essential industry to shelter at home in an effort to stave off COVID-19.

It was a complicated ask for the more than 150,000 Californians without a home.

For two weeks in March, Newsom’s top homelessness adviser, Jason Elliott, gathered with academics, service providers and county representatives at the emergency operations center just outside Sacramento to confront the menace that COVID-19 presented for tens of thousands of people living outside, often without access to clean water or basic hygiene. They pored over data showing how California’s homeless population had gotten larger, older and sicker in recent years. More than 40% of homeless Californians are age 65 or older or have underlying health conditions such as heart disease, according to the state’s internal estimates — factors that put them at greater risk of infection and death from COVID-19.

“When you take the attack rate and apply it to more than 100,000 unsheltered people,” Elliott said, “you very quickly find out that tens of thousands of homeless people are potentially susceptible to dying of coronavirus.”

They would need to act quickly. The crowded shelters, in short supply and usually considered safe ground for homeless people, suddenly posed a risk of transmission and would have to be thinned out. Instead, the very conditions lambasted as California’s shameful legacy of neglect — people subsisting in makeshift shanties and battered tents in parks and alleys and freeway underpasses — emerged as a safer alternative. The federal Centers for Disease Control and Prevention advised that people sleeping outside should be left alone; the encampments that pre-pandemic were routinely dismantled would be largely left in place, state officials decided.

But California still would need somewhere to house people considered most at risk: those who are older and have chronic health conditions. His plan wasn’t ready for prime time, but Newsom had been quietly pursuing an ambitious idea to buy up hotel and motel rooms to get people off the streets and into housing with supportive services. Now, with the declaration of a state and national emergency, it looked as if the Federal Emergency Management Agency might help pay to rent them temporarily. Newsom set a goal of 15,000 rooms.

In the months since, the state’s efforts to shelter homeless residents amid COVID-19 have played out in starkly contrasting storylines, bent and molded by local politics and resources. The state and federal governments have pledged millions for Project Roomkey, the state’s signature public health effort to move the most vulnerable into housing, with local counties expected to foot a quarter of the bill, as well as arrange meals, security and support services. For now, the counties taking part are fronting all the funding and say they have no idea when they’ll be reimbursed.

Still, most counties are participating and have procured nearly 16,500 rooms, according to state data, housing 22,300 people at various times since March. And homeless services providers, particularly in the state’s urban centers, say the unprecedented promise of funds has allowed them to work small miracles, linking desperate people to social services, health care and sometimes jobs.

But if the hotel rooms have been lifesaving for those lucky enough to get inside, providers across the state also were forceful in noting they are reaching just a sliver of those in need. In some cases, hotel owners have been unwilling to participate in Project Roomkey, while elsewhere city and county leaders have been hesitant or flat-out opposed.

In the meantime, the prolonged closure of shelters, churches and charities — along with the restaurants and retailers that offer access to electricity, water and food — has made life far more brutal for the tens of thousands of homeless people who weren’t selected for a room. In many counties, the life hacks and cobbled-together supports that homeless people rely on for survival have disintegrated. The squalid encampments have only gotten larger, fueled by COVID-spurred prison and jail releases and an unprecedented economic shutdown that community leaders say has landed scores more people on the streets.

If the state’s goal was to ward off a deadly COVID-19 outbreak among the homeless, it can claim success. Quick work to thin out the shelters has so far prevented widespread homeless deaths from the virus, authorities say.

But suffering comes in other forms. And interviews with dozens of homeless people, activists and local officials in 12 counties reveal a new magnitude of hardship and indignity for California’s homeless — and no easy answers ahead. What follows are a few of their stories.

Imperial County

“I’m one of the ones that it would probably kill me quick if I got that virus. I’m just staying away from everyone.” — Carl Wilkinson, 60, El Centro

Carl Wilkinson had been living for several weeks on a stretch of dirt beside a plowed field in sight of the lone indoor mall in El Centro. Wilkinson has chronic obstructive pulmonary disease and probably qualifies for a COVID hotel room through Project Roomkey. But he lost his ID a while back, so he hasn’t even tried applying.

Wilkinson has no idea how he’ll get an ID; money is tighter than usual because the recycling centers, where he takes the cans and bottles he collects, have closed. He’s become so desperate that he has resorted to panhandling, though that hasn’t gone well either, since so many people are staying inside. “It’s all-around tougher,” he said.

In May, the only men’s shelter in Imperial County closed temporarily after seven of the 20 men staying there caught the coronavirus. Though the shelter spaced beds farther apart and hung plastic dividers, men say they are afraid to return. The Salvation Army, which typically offers meals and a place to shower, has closed several times as staffers have fallen ill.

Instead, Wilkinson has been bathing in the dingy waters of the irrigation ditch next to his tent.

He knew about the federal guidelines saying people are safer from the virus if they can stay in one place. That had given him and two neighbors some hope there would be at least one silver lining to the pandemic: not getting rousted by cops. But the sheriff had shown up the day before saying they had to pack up. He wasn’t sure where they’d go. “They move us around like cattle in a pasture when it’s grazed,” Wilkinson said.

Imperial County, which hugs the border with Mexico, is a desert valley transformed into an agricultural hub nearly a century ago by water diverted from the Colorado River. The county of 181,000 people has an official homeless count of 1,527, including several hundred people who live off the grid in a remote area known as Slab City. Imperial has the highest death rate from COVID-19 of any county in California.

The largest city in the county is El Centro, home to one of the county’s two hospitals, and, until its church leaders were arrested last year, a ministry the FBI accused of luring homeless people into forced labor. Though the homeless population has steadily grown in the past few years, the county has little in the way of services for the homeless.

Sgt. James Thompson of the El Centro Police Department and Anna Garcia, a code enforcement officer, serve as the lone homeless outreach team for the city but are limited in what they can do. “A lot of people are confused about my role,” Thompson said. “We have not gotten into the homeless business; it’s an effort to curb the quality-of-life issues.” The pair know many of the people who are homeless in El Centro by name. They know who gets in trouble with the law, who has an issue with drug use and who has a mental illness.

Before COVID-19, Thompson had a daily routine. Get in at 8, hit the streets to talk to people who are homeless. He’d move them, make sure they weren’t getting into trouble, offer help when he could. Then in June, a colleague on the force got into a physical altercation with a homeless man, contracted COVID-19 and died. Thompson’s chief has been a lot more cautious with his officers in the weeks since.

Before their work was curbed, Thompson and Garcia helped several people fill out paperwork for a hotel room. None got in. “They met the criteria, they did do what they were supposed to do. But for whatever reason, there was no funding when it was time for them to be placed,” Garcia said. She feels it fits a pattern of services going to those who are easiest to help, whether it’s families or people who just can’t make rent. People who chronically live on the streets are not the easiest to help.

In August, months into the pandemic, county officials had 36 hotel rooms to work with, and had placed 274 homeless people in rooms or trailers at some point. Among them were 27 people who had COVID-19, although there were almost certainly more since the county isn’t routinely testing homeless groups.

And the El Centro officers say they worry there’s been a spike in other types of deaths. Three people died of overdoses over three days in the same dusty parking lot this summer, said Thompson. One was a young woman who’d experienced years of family abuse. They had been working to get her off the streets. He’d thought she was doing better.

Twenty minutes south, Maribel Padilla has organized the nightly feeding program in Border Friendship Park since 2015. She’s seen how the closing of fast-food restaurants and local businesses have made it harder for the people she helps. When the county closed the public bathrooms early in the pandemic, the folks her Brown Bag Coalition feeds no longer had a place to wash their hands.

It took a protracted battle and her loud mouth to change that, Padilla said. County officials told her they were concerned the virus would spread through hand-washing stations, a concern that makes Padilla spew profanities.

“They’ve been out there and exposed to so much shit,” Padilla said. Thousands go back-and-forth between Mexico and the U.S. each day; farmworkers cram into crowded buses to get to work; elderly and homeless residents travel together via public transportation.

“It’s going everywhere,” she fumed “and you’re worried about the soap dispenser?”

Alameda County

“Due to the number of deaths especially in the African American community, I have reasonable concern of the likelihood of harm and injury, possibly death.” — Andre Alberty, 53, Oakland, in a grievance filed with the California Department of Corrections and Rehabilitation

Andre Alberty was born and raised in Oakland, like his parents. Except for the years he spent in prison, it has always been home. When he returned to the neighborhood after an early release from San Quentin, a maximum-security prison in one of the wealthiest counties in the country, he was blown away by the number of RVs, tents and live-in cars lining the streets. It was a striking testament to housing costs that had soared out of reach. “There needs to be more affordable housing for people,” he said. “I never saw it like this.”

Alberty’s most recent prison stint was for burglary. He contracted COVID-19 in San Quentin after the California Department of Corrections and Rehabilitation moved dozens of inmates to the Bay Area prison from the California Institute for Men in Chino while it was in the midst of a major coronavirus outbreak. “What makes you think it’s not going to come in here when it went around the world in four months?” he remembers thinking. “You don’t think it’s going to jump a hallway?”

When Alberty, 53, and his cellmate developed symptoms, they knew that telling the guards would get them thrown into solitary, a place usually used as punishment that has been turned into a de facto medical isolation wing. And so, for several weeks in June and July, he was alone in “the hole,” with nothing but his thoughts and a virus to keep him company. By the end of September, COVID-19 had killed 28 inmates at San Quentin and infected 2,241 others, as well as 290 staff members.

It was demoralizing, to be infected and confined in solitary as a result. “Psychologically, that affects you,” Alberty said. “You feel like you ain’t nobody. Then how do you expect us to come out here and try to make ourselves somebody?”

That’s where his mind was in mid-July when his sentence was cut short, part of a massive early-release program Newsom ordered as COVID-19 carved a deadly swath through the state’s 35 prisons. Since then, Alberty has alternated between staying on a sick friend’s couch and in a friend’s RV, part of a large community of locals camping along Mandela Parkway in the heart of West Oakland because they’ve been priced out.

Prison releases are just one of the ways the homeless population has grown since the pandemic began. Californians have experienced unprecedented job loss, with the unemployment rate at 13%. A moratorium on evictions has helped millions stay in their homes, but the protections are loosely enforced and many tenants aren’t aware of their rights. Others were kicked out of the homes of family and friends who weren’t eager to have someone sleeping on the couch or floor in the middle of a pandemic.

“This is a slow-moving train wreck on a scale that we have never seen,” said Dr. Anthony Iton, senior vice president for healthy communities at the California Endowment.

To Alberty’s south, in East Oakland, Megan Ruskofsky-Zuccato, 25, was living under an overhead rail line in an old RV with her partner and a friend. Though she’d been homeless on and off, they had a place when the pandemic hit — until April, when, without explanation, the landlord asked them to move out. “I wish I would have known that Gov. Gavin Newsom put that [eviction moratorium] in effect, because then I would have never left,” she said.

Her partner got the RV as a trade for unpaid work as a welder at the start of the pandemic. She finds the whole situation humiliating. “When you live out here, people just look at you like you’re a bad person,” she said.

Jennifer Friedenbach is executive director of the Coalition on Homelessness in San Francisco, which advocates for housing and social justice in the city. On a daily basis, she sees both the opportunity — and nightmare — of the pandemic response. She is thrilled nearly 3,000 people in San Francisco had a hotel to sleep in at some point during the pandemic. And that San Francisco has put out more portable hand-washing stations and bathrooms.

The problem is, there’s not nearly enough to go around. Not enough rooms, not enough sanitation, not enough enforcement of tenant protections, not enough places to charge a phone. The number of tenants calling an anti-eviction hotline has doubled to 200 a week since 2019, and Friedenbach thinks more should have been done for rental assistance. Vehicles are often a first stop for people when they lose their homes, she said, and she’s seeing a lot more people sleeping in cars.

And while homeless people aren’t dying from COVID-19 in the numbers once feared, they are dying nonetheless. Deaths among the homeless tripled in San Francisco in the early months of the pandemic. In Los Angeles County, homeless deaths were up 27% over 2019.

Friedenbach worries that’s about to get worse. “Everything is coming to a screeching halt; the placement in hotels is halted,” she said. “Things are going to start getting really bad again in terms of a lot of people being out on the streets.”

Fresno County

“It’s hard times and we are suffering. My voices are getting stronger and stronger.” — Juan Gallardo, 53, Selma

Luciana Lopez sat in the back seat of a van rumbling across rutted roads in the rural outskirts southeast of Fresno. Her eyes scanned the dusty expanse of orchards and vineyards looking for the telltale hollows. Her attention was tuned to a bitter reality in this breadbasket-feeding-a-nation: the dozens of people living underground in the farm fields, subsisting in burrows hand-dug into the ground and irrigation levees — where they can hide from the sun, immigration authorities, violence, judgment.

Just days before, after local landowners complained, law enforcement had descended on this encampment, known casually as “The Hole,” and rousted an estimated 60 people from their dirt caves, many of them seniors. Outreach workers said maybe two landed in a shelter. The rest, a mix of addicts, itinerant farmhands and those with a run of bad luck, had dispersed to god-knows-where.

For Lopez, who works as an outreach worker for a homeless services provider that contracts with Fresno County, it was yet another COVID setback. Whatever trust had been built, whatever efforts underway to connect these men and women with ID cards, food stamps, disability payments, medical services — the chances of follow-through had largely evaporated.

Nearly five months into the pandemic, finding housing for Fresno County’s homeless seemed an insurmountable challenge. A January count pegged the homeless population of Fresno and Madera counties at more than 3,600, a 45% rise from 2019. Even in non-COVID times, this region of mega-farms and meatpacking plants had relatively little to offer in terms of government-sponsored shelters and supportive housing outside the city of Fresno. Instead, social workers looked to the relatively cheap housing stock as a solution, using federal and state funds to rent apartments for their clients.

But COVID has changed the real estate arithmetic. Local providers say large numbers of middle-income residents have lost jobs in the state’s months-long shutdown and are relocating to less expensive rentals. The units once available for $600 or $800 a month — and affordable for someone living on government assistance — are disappearing amid pitched demand.

Hotel and motel operators in Fresno County have not enthusiastically embraced Project Roomkey. Under the program, the county is sparingly using just one hotel to house homeless people infected with COVID-19. Drawing on other state and federal funds, the county managed to rent out two additional hotels, open to anyone who is homeless and vulnerable, in Selma and the nearby town of Sanger. As of late September, all 82 rooms were filled, with waiting lists stretching dozens long. Vacancies at four other converted sites, with about 350 beds, are quickly filled.

“It’s heartbreaking, we go through the breakdowns with them, we go through all the frustrations to get them ready for housing, just for the freaking system to spit them out and say there’s nothing for you,” Lopez said.

Her crew had resorted to basics, driving the farm roads southeast of the city to distribute water, snacks and masks to people living in ragtag encampments amid bountiful acres of fruit and nuts. They did so not knowing who might be carrying the virus, because there has been so little testing.

Juan Gallardo, 53, was on one of Lopez’s stops on a muggy morning in mid-July. Homeless most of his life, Gallardo had set up camp under suspended tarps on a dirt field just below the Golden State Highway near Selma. When the stores and churches shut down, he was cut off from the critical supports he’d developed for a life on the streets: odd jobs; gathering cans and bottles for recycling. There was nowhere close by to charge a phone or buy groceries, no access to clean water. He had taken to bathing in a nearby drainage canal, though it triggered rashes. For drinking water, he’d haul back a couple of pails for boiling.

“It’s hard to get food on your table right now, you have to hustle even more,” Gallardo said, as he rinsed clothes in a bucket. “It’s hard being in the crisis; you never know who can have [the virus]. But I try not to think about it, because the more you think about it, you start getting worried and then you stop doing what you’re supposed to be doing.”

Gallardo, who has untreated bipolar disorder and arthritis in both his knees, said he had lost access to medication and it was getting harder to cope. “My voices are getting stronger,” he said.

About a mile away, in downtown Selma, Delfina Vazquez said the pandemic has exposed a whole new level of desperation in her county. Vazquez heads Selma Community Outreach Ministries, a charity run out of a converted storefront that launched a daily food pantry at the start of the pandemic. As other local charities shuttered, she said, “We knew people would still need to eat. We looked to the Lord, who said, ‘Open your doors.’”

What started as a hot midday meal expanded into a food delivery service to families in a circle of farm towns, from Selma to Reedley to Parlier and Orange Cove. Vazquez said her ministry, funded primarily by donations and government contracts, is now providing 10,000 meals a month, mostly to homeless people and farmworker families struggling amid the shutdown. “People are becoming homeless because of COVID,” she said. “It’s absolutely growing.”

Through her ministry, Vazquez also oversees a Super 8 in Selma and Townhouse Motel in Sanger that have been converted to COVID shelters for the homeless. All 30 rooms at the Super 8 are full, she said, providing housing for 14 families, including 30 children. The waitlist stands at 60.

Like many advocates working with the homeless amid COVID-19, she worries about what will happen when the state and federal emergency funding wind down at year’s end. If the newly converted hotels close down, she said, “that’s 81 families out on the street.” And where would they go? The real estate offices “don’t want to flat-out say we don’t want to rent” to homeless people, she said, so instead have started demanding that applicants earn three times the rent to qualify.

Vazquez is already working on a Phase Two: talking with local officials about raising money to buy land in Selma where they could build a community of tiny homes. “Realistically, no one wants to rent to someone evicted,” she said. “There’s no second chance here. That’s where we’re at right now.”

Los Angeles

“He was really afraid of finding out what his true identity was, but we assured him he’s staying here no matter what. We’re not kicking him out.” — Dr. Coley King, speaking about Charles Poindexter, 71, Santa Monica

For people who did get indoors during the pandemic, the rooms have, in many cases, been life-changing.

Dr. Coley King, a physician with the Venice Family Clinic and director of homeless services, practices “street medicine,” bringing health care directly to people on the street. His patients have complex histories, and it’s rare that he gets clear signs their health is improving. But during the pandemic, it’s happened several times after patients have received housing. One patient with uncontrolled diabetes started having normal blood sugar readings. One of his “super users,” who makes regular visits to the emergency room, hadn’t been to a hospital in months. And multiple clients with addiction issues were getting sober.

Then there was, perhaps, the most dramatic case, involving the tall, sturdy man he’d seen on the streets of Santa Monica over the years. The man had previously confided in King that he wasn’t sure who he was, and the doctor noted signs of memory loss. In June, the street medicine team found him a space in a Santa Monica hotel. It took just a few days to find a diagnosis for his cognitive issues: untreated syphilis and a traumatic brain injury from a bus accident.

They also found his name: Charles Poindexter.

“He’s telling me, ‘I don’t know if I did something wrong out there, and I don’t know if I want to know who I am,’” King said. “It turned out good because he’s not wanted by the law anywhere, and we’re all good.”

These stories can be found across the state. In Fresno, Cammie Bethel, 37, could bring her six children back to live with her after getting into transitional housing. Cornelio Mendoza, 52, who in December became homeless for the first time, was able to get sober after getting a city-sanctioned tent in Santa Rosa. “Being here, I’m grateful,” he said.

Seeing the transformation that can happen when someone has a safe place to sleep makes it all the more tragic how limited resources are, advocates say.

Across the state, counties have marshaled thousands of rooms and safe camping sites for hundreds of tents. The state gave counties more than 1,300 trailers to isolate people infected with or exposed to COVID-19. Still, lack of interest from hotel owners and opposition from neighbors have blunted the program’s reach. That’s true also in Los Angeles, which set its own goal of renting 15,000 rooms and fell far short.

In L.A., rooms are not evenly distributed across the sprawling county. Less-affluent areas like South Los Angeles, a historically Black neighborhood that’s now predominantly Latino and experiencing high rates of COVID-19, have few hotels available. Whiter, wealthier cities like Santa Monica, meanwhile, have bolstered the county supply by renting hotels with their own budgets.

In Bakersfield, neighbors and a hospital pushed back on two different plans to rent motel rooms. Kern County, where Bakersfield is located, has not made available any new hotel rooms to the homeless during the pandemic.

And officials in liberal cities — including on Newsom’s home turf of San Francisco — say the governor must do more to persuade business owners and financiers to participate in housing the homeless.

“I’m surprised and honestly a bit disappointed that the state hasn’t been more forceful and proactive to secure the adequate number of hotel rooms,” said San Francisco Supervisor Matt Haney, whose district includes the Tenderloin, a neighborhood where hundreds of people sleep on sidewalks and in alleys. “I would like to see more leadership from the governor on some larger negotiated statewide solution with hotels and unions.”

The hotel rooms weren’t meant for everyone unsheltered, said Kim Johnson, director of the California Department of Social Services. For those who didn’t have mental and physical health conditions that put them at extreme risk, “the right environment wasn’t necessarily a hotel room,” she said.

Newsom said he is staying the course on his vow to make this the year California finally starts tackling its epidemic of homelessness. In some ways, the pandemic gave him a leg up — he would have been hard-pressed to find even temporary housing for the 22,300 people moved into hotels and motels in recent months.

But it’s also a short-term response to a long-term public health crisis. To battle homelessness, the state needs more housing.

Counties across the state say they are already winding down Project Roomkey. The state has launched a new program called “Project Homekey,” which will allocate an estimated $800 million in federal and state emergency funding to cities and counties to purchase hotels and motels, vacant apartment buildings and other structures, then convert them into supportive housing. So far the state has approved $450 million worth of projects in 34 jurisdictions, stretching from El Centro to Ukiah. If successful, they’d open more than 3,300 housing units — a valiant effort but a fraction of what experts say is needed.

Newsom has acknowledged the extraordinary task ahead but said solving homelessness in the age of COVID-19 remains his priority.

“We need a permanent response,” Newsom said at a recent news conference. “I can assure you, we are just winding up.”

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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Closing a hospital hurts. In Fort Scott, Kansas, no one was a bigger symbol for that loss — or bigger target for the town’s anger — than hospital president Reta Baker. Baker was at the helm when the hospital doors closed.

“I don’t even like going out in the community anymore, because I get confronted all the time,” Baker said. “Someone confronted me at Walmart. You know — ‘How could you let this happen?’”

The closure put Baker at bitter odds with City Manager Dave Martin, who some in town call “the Little Trump” of Fort Scott. Martin said his town wasn’t given the chance to keep the hospital open.

Click here to read the episode transcript.

Reta Baker

“Where It Hurts” is a podcast collaboration between KHN and St. Louis Public Radio. Season One extends the storytelling from Sarah Jane Tribble’s award-winning series, “No Mercy.”

Subscribe to Where It Hurts on iTunes, Stitcher, Google, Spotify or Pocket Casts.

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Breaking up parties, confiscating booze and answering noise complaints — being a resident adviser has always required a willingness to be the “bad guy” and uphold university policy despite the protests of friends and peers.

Now there’s a new element to the job description: COVID cop.

The worst part of his job as a resident adviser and dormitory hall security manager is verifying residents’ ID cards in the evening and dealing with the mask policy, said Marco Maldonado. But the positions help him afford his annual $20,000 tuition at the University of Massachusetts-Amherst.

Almost every night, he said, at least one person tries to enter the building without a mask. While most will take advantage of the box of disposable masks at the security desk, “every once in a while, you’ll meet someone who’s like, ‘Oh, it’s all bulls—. Stop — I don’t want to hear it,’” said Maldonado, 20, a political science and legal studies double major.

And sometimes people get aggressive. “Pardon my French, but they could say, ‘Who the f— do you think you are? Get the f— out of here!’”

It can be frightening and even dangerous to enforce mask-wearing and social distancing. Public tantrums and physical assaults on employees enforcing COVID-19 policies prompted federal officials to issue guidance for retail workers on how to de-escalate situations and avoid violence.

It’s particularly tricky for students whose job involves monitoring their peers. Residential staff members, including security monitors and resident assistants, represent the front line of enforcement in dormitories.

Many say they are struggling with a lack of communication and unrealistic expectations from their institutions. They feel caught between competing interests: connecting with their fellow students, protecting their health, and being able to afford their education.

Maldonado is clear about his priorities.

“When it comes to my personal health, I’m concerned but not afraid,” said Maldonado. “I’m more afraid of losing my housing and my ability to go to school.”

The position of resident assistant or adviser, RA for short, is a sought-after college job — not just for the free or discounted housing and meal plans that are often offered as compensation, but because of the built-in community and mentorship opportunities and the chance to showcase leadership on a résumé.

This fall, however, RAs are balancing the perquisites of the job with the difficulties of doing it.

Resident assistants from the University of Pennsylvania, University of Wisconsin-La Crosse, Washington University in St. Louis and other schools wrote letters and submitted petitions to their administrations raising concerns about the risk the virus posed to them as students and staffers returning to campus this fall.

“While we concede that there is a need to verify that our private residences are up to standard,” said a petition from Stony Brook University in New York, “we feel that having an RA carry out these checks brings up a number of logistic[al] health concerns,” such as higher risk of exposure to coronavirus, they wrote.

Despite these pleas, at institutions that welcomed students back to campus, resident assistants are finding that the perks — like community building and mentorship — are scant, while risk, frustration and fractured relationships are plentiful. For some, the job is no longer worth it.

Kenny Leon, 21, flew into New York City in mid-August from Miami, his hometown, for RA training at New York University, where he’s a senior. He was required to get tested for the coronavirus and then wait in isolation in his dorm until he received his results. The university was responsible for bringing him meals.

The first two days of isolation passed with no problems, Leon said. On the third day, he said, he didn’t receive his first meal until about 9 p.m. The next day, it arrived around 5 p.m. On the fifth day of isolation, Leon said, he sent his resignation email.

“If they had months to plan for this and they still managed to completely blunder it, I can only imagine how they were going to blunder a potential response to COVID or an outbreak on campus,” Leon said.

Such outbreaks have been common at reopened campuses. The University of North Carolina-Chapel Hill reverted to online classes Aug. 19, one week into the new school year, after hundreds of students tested positive for the virus. The University of Notre Dame in Indiana and Temple University in Philadelphia did the same soon after classes began again.

Since the beginning of the pandemic, more than 88,000 positive cases and at least 60 deaths have been reported on more than 1,100 college campuses, according to a New York Times survey.

Leon is finishing his studies online at home in Miami. The university gave him a deal that included the monetary value of the housing and meals he would have received as a resident assistant, he said.

Some of those who stayed on the job are finding that enforcing rules and creating community is more difficult than in the past, even though fewer students are physically present.

UMass-Amherst is allowing only international students, those with in-person lab classes and some with other special circumstances to live on campus. Instead of holding game nights or cereal buffets for students the way he’d have done in a normal year, Maldonado’s job now is to create a virtual community for the 25 students living in the three floors he supervises. He does this through group Zoom meetings and one-on-one FaceTime chats for those who want to talk about an issue.

He said he’s gotten mixed instructions about what to do when students resist his directions on mask-wearing and distancing. One supervisor told him to deny entry to those who refuse a mask, while others have said his job is more about education than enforcement. On Sept. 13, three weeks into the semester, Maldonado said he got new instructions: Don’t force a mask on anyone, but report those who refuse.

Maldonado is also unsure how to enforce the no-guest policy when he walks the halls of his nine-floor dormitory. Should he approach every group of students and ask for proof of residence? He’s already seen students erupt when challenged.

The residence hall security staff has an educational role and was trained on how to communicate the university’s policies starting Aug. 11, said Mary Dettloff, a spokesperson for UMass-Amherst. The university knows of only one troubling incident, in which a resident rushed through a dorm lobby without a mask and with two guests in tow, she said in an email.

On some campuses, confrontations arise if the university has stricter guidelines than the areas students come from.

In South Dakota, Gov. Kristi Noem opposes mask mandates, but the University of South Dakota requires students, staffers and visitors to wear masks in all public indoor spaces, with few exceptions. Addison Miller, 19, a sophomore and resident assistant at the university, said he had to remind students on move-in day to wear their masks.

Miller said he didn’t get enough training on COVID-related policies, and feels limited in his ability to keep the 50 to 60 students on his dormitory floor in line.

“Once the dorm room doors close, what can we do if we don’t see it directly?” he asked.

COVID-related considerations were woven into the resident assistants’ training and their role is vital, said Kate Fitzgerald, director of university housing. For example, the assistants are required to deliver dinners and weekend meals to students quarantined in their rooms.

“I definitely wouldn’t be wanting to do this without them,” Fitzgerald said.

Miller sympathizes with students who seek a quintessential, mask-free college experience. But if they break the rules they just raise the odds of the school closing down again, he said. He has to remind students daily to comply.

“It’s really easier for us both if you wear a mask,” he said.

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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As stores, restaurants, airlines and offices try to lure clients back, this is what they need to do to earn my business: Make me feel safe — no, make me be as safe as possible. As I’ve begun to explore old haunts, some are doing a fabulous job. Others are not.

So my dollars will flow to the former, and I’ll effectively boycott the latter. Think of it as ethical shopping, with a safety twist: I’ll reward businesses that are seriously implementing recommended COVID-19 precautionary guidelines. And I’ll punish, in my own tiny way, those who don’t take them to heart.

Yes, I know businesses across the country have lost huge amounts of money because of the pandemic. But many did get billions of dollars of federal aid to sustain them.

All many of us got was a $1,200 check. Some who would not normally be eligible for unemployment benefits will be able to get them, and some beneficiaries got extended benefits. Some of those have since run out.

It is not that hard to make many businesses relatively COVID-friendly and safe, though it requires making that a priority, investing a bit and thinking out of the box.

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My local Trader Joe’s in Washington, D.C., did a stellar job. While I initially limited my shopping to once a week at the crack of dawn, I quickly came to view the store as a safe zone: Shoppers received a squirt of hand sanitizer at the door and were directed to a row of sanitized carts.

Mandatory masking was (politely) enforced, the number of customers in the store was limited, and customers waiting outside were carefully spaced in line at 6-foot intervals. Checkout clerks scanned your items from behind a plexiglass partition and placed them back in your cart.

Customers could put their groceries in their carrier bags on a frequently sanitized table outside. If you lived close by, you could simply use the cart to walk the groceries home. Used carts were gathered in an area for re-sanitizing.

Contrast that with a local CVS Pharmacy. Yes, there was a sign on the door indicating masking was required, and plexiglass partitions had been placed at checkout counters. But there was no active enforcement once inside, and it was sometimes crowded. The pile of baskets was, as always, inside the front door, and used ones were placed on top by shoppers as they left.

Some customers picking up medicines had masks around their necks, and even some of the employees — including sometimes the pharmacist — had pulled down their masks so both nose and mouth were exposed. I know wearing a mask for hours can feel stifling, but if surgeons can do it in the operating room, so can we. And if the coronavirus lingers in the air in enclosed spaces, as we now know it does, not masking could be a problem.

Last week, when I went to pick up a prescription that was not quite ready, I said I wouldn’t wait in a place where so many people were not following our local masking mandate. I left.

On a recent trip to my hometown, New York City, many restaurants in my neighborhood had erected outdoor seating areas on sidewalks and into the street. (Indoor dining was still prohibited at that time.)

But my (formerly) favorite eatery had merely put out a few tables on the sidewalk, which employees wiped down with the same damp cloth. Yes, the tables were (maybe) 6 feet apart. But tables don’t get infectious diseases, people do. The chairs, where potential COVID carriers would sit (without masks when they eat), were far closer together.

In contrast, the restaurant next door, whose food I normally consider mediocre, had sanitizer at check-in and had set up a tent hung with flowers in what was formerly a parking lane, under which tables were widely spaced with plexiglass partitions separating them.

The wait staff was scrupulous about social distancing. It limited dining to 90 minutes. The food tasted great. Did the restaurant have a new chef, or was it its lovely setup — which really allowed us to relax and not consider a world gone COVID-mad as we ate — that made us enjoy its food more than we ever had?

A high-end Mexican restaurant we visited in Brooklyn went one step further: Each diner had to give a cellphone number at the door in case contact tracing was required. It had created an online menu, so diners made their selections from their phones.

And don’t get me started on airlines, and their varying policies. The risk of in-flight transmission appears to be low if everyone is masked and doesn’t knowingly fly ill. But that’s a big if. Remember, the novel coronavirus’s cousin, SARS-CoV, a far more dangerous but less contagious virus, created an infamous outbreak on a two-hour flight from Hong Kong to Beijing in 2003.

There have been cases related to in-flight exposures in Europe and Asia. Yet Airlines for America, an industry group, said this month that there have been “no confirmed cases of COVID-19 transmission on U.S. flights [italics mine].” Are the Boeings and Airbuses somehow different in Europe than in the U.S.?

And let’s remember epidemiology: There may be demonstrated cases of in-flight transmission elsewhere only because people abroad have resumed a more normal life than America has. Very few people in the U.S. are flying these days because America still has tens of thousands of new cases a day and leads the world in deaths.

Some airlines, like Delta and Southwest, are not selling middle seats or are selling only about half their seats. United and American have been flying full whenever they can. On June 30, United’s chief communications officer Josh Earnest (yes, the former Obama White House spokesperson), dismissed the blocking of middle seats as “PR.”

“When you’re on board the aircraft, if you’re sitting in the aisle, and the middle seat is empty, the person across the aisle from you is within 6 feet of you,” he said. “The person at the window is within 6 feet of you. The people in the row in front of you are within 6 feet of you. The people in the row behind you are within 6 feet of you.”

But 3 feet is better than cheek-by-jowl. In fact, the World Health Organization says that 3 feet is acceptable for social distancing.

Yet that’s not so good if you take off your mask. So why do airlines distribute those little bags of pretzels and nuts, anyway? When my daughter flew to grad school in California, I insisted she fly Delta, though other carriers fly the same route.

Instead of trying to create a bit of social distancing, some airlines offer a few concessions. Says American: “Customers on all flights receive sanitizing wipes or gel.” United offers to rebook your flight without a change fee if it’s too full for your comfort the night before. It will notify “customers when we can if their flight is fairly full and give them the option to change it” — though you pay the price difference for a new ticket.

A friend of mine flying London to New York checked a United flight seating chart beforehand and — seeing the middle seat was free — prepared for a long, but relatively safe, flight. Shortly after they took their seat, another passenger sat in the middle seat next to them. If you’re going to start college or visit a sick relative, delaying (and paying a higher price) isn’t really a viable option.

Remember, airlines received tens of billions in taxpayer-funded loans to help them survive the pandemic. And — with their crowded, uncomfortable seats and an explosion of new fees — they do not have a good record in recent years of catering to customers’ needs.

So if the government won’t act to enforce some kind of COVID-era standards for customer satisfaction, we all can use our hard-earned dollars to do so.

Yes, COVID precautions often feel like overkill. There is little chance that I will get COVID-19 from one meal, one flight or one trip to the pharmacy. But multiply those odds by over 300 million Americans visiting millions of places. Many people — maybe someone you love — will.

Cozbi Mazariegos stays in shape these days by running room to room inside her Marin City apartment to answer questions from her kids, ages 7, 10 and 12. They’re all working at home on laptops issued by their school, Bayside Martin Luther King Jr. Academy.

Meanwhile, Shannon Bynum’s son, Kamari, 10, and daughter, Keyari, 8, who live nearby, are back on the Bayside MLK campus. Bynum had warned them, however, that if he heard they weren’t wearing masks, they’d have to learn remotely, too.

The two households, less than 3 miles apart, have found different answers to one of the most perplexing questions this fall: Should parents send their children back to school for classes during an ongoing pandemic or keep them at home?

At Bayside MLK, a K-8 school serving the ethnically and economically diverse community of Marin City, 103 children are attending class in person, including the Bynum children. The Mazariegos kids are among 12 learning remotely.

In March, the coronavirus consigned nearly all of the nation’s 55 million schoolchildren to home schooling. One by one, school districts across the country are weighing the risks of reopening. Some that have reopened have seen a spike in coronavirus cases among students who returned to class.

Bayside MLK was one of 15 Marin County schools that received waivers from the local public health department to reopen full time on Sept. 8, but officials gave parents the choice whether to send their children to campus or keep them home.

The start of classes was delayed for a week when one school employee contracted the virus, said Principal David Finnane. Once they started, the challenges mounted.

“This is the most mind-numbing time I’ve ever had as an educator,” said Finnane, who’s been a school principal for two decades.

“These are crazy days of temperature checks, telling third grade Jenny she entered the second grade gate at the wrong time, telling Xavier to use sanitizer on his elbow after he sneezes, reminding students not to touch this thing or that thing. It’s a job this school has never had to do and now we’re doing it every day, all day long.”

Health and safety protocols enacted by the school include staggered arrival times for students (via parent drop-offs), smaller classes, spaced-out desks, routine temperature and health checks, and an intensified cleaning schedule.

Mazariegos, 52, spent a difficult summer deciding whether to send Emily, 12, Ezekiel Jr., 10, and 7-year-old Evelyn back to class if and when school reopened in the fall.

But her husband, Ezekiel, a 42-year-old construction worker, had made up his mind. “He said, ‘Are you crazy? We can’t send our kids back to school without a vaccine,’” she recalled. “‘How do we know they’d be safe?’”

Mazariegos, who was a schoolteacher in her native Guatemala but now stays at home with her kids, has juggled the roles of teacher, tech consultant and even hall monitor in recent weeks.

School hadn’t been back in session for a week before her home Wi-Fi connection crashed. The two eldest kids could not connect to their Zoom instruction sessions, so Mazariegos called the school for help. To make sure they didn’t resort to computer games in the interim, she gave them textbooks to read.

“The phone was ringing, the kids were all calling my name from different rooms,” she said. “It was crazy.”

Single father Bynum, on the other hand, chose to send his two kids back to school.

“Kids learn from other kids, not just teachers,” said the 29-year-old real estate developer. “In school, they know what’s expected of them. It’s the best place for them to be.”

Finnane, the principal, had hoped all 115 students would return to classrooms. “Many kids doing distance learning just don’t have the same support network,” he said. “They might not have the resources, a quiet place to work, a supportive adult right there who can mentor and encourage them.”

And then there are the technical issues. Students who have stayed at home have experienced internet failures, Zoom glitches and computer bandwidth problems — “or when a teacher gives out the wrong Zoom link, all of which has already happened,” Finnane said.

A recent study by the Economic Policy Institute on the educational challenges posed by the pandemic found that remote-learning programs are effective only if students have consistent access to the internet and computers and if teachers receive targeted training and support for online instruction.

While researchers acknowledged the risk of virus infection is greater at school, they found that students who have not returned to the classroom are falling behind.

“Children’s academic performance is deteriorating during the pandemic, along with their progress on other developmental skills,” the study said.

When Bayside MLK resorted to remote teaching for the entire school in the spring, officials identified 41 students who were demonstrably falling behind, Finnane said. Standardized tests given to students this academic year will provide a report card on students’ success, he added.

Over the summer, Bayside MLK teachers received one day of training to perform online classes in addition to their at-school duties.

“A full day of online-learning training helps, but when it comes to the constant challenges of teaching, especially those with special needs, I’m not sure that’s sufficient,” said Emma García, who co-authored the Economic Policy Institute study.

Mazariegos knows this all too well. Her daughter Emily has comprehension issues that have kept her back a grade.

A quiet girl who loves animals and science, and who one day wants to become a veterinarian, the sixth grader relies on her mother to spend extra time reviewing lessons.

“She has to touch and feel things, to have a lesson demonstrated before she can best understand,” her mother said. “She can’t just sit in front of a computer reading some concept over and over and over.”

Mazariegos understands her daughter may fall another year behind but says she’ll take that chance. “If we lose her to COVID-19, that year is nothing,” she said. “This is a hard decision for any mother. But Emily is so afraid of the virus that sending her back to school would just be traumatizing.”

Bynum, whose fourth grade son, Kamari, suffers from attention deficit disorder, believes the classroom is the best place for the restless child. In March, when the school was closed at the start of the pandemic, Bynum got a taste of the demanding task of being a teacher.

“With two kids in two different grades asking me questions, I struggled to explain things,” he said. “It would have been easy for me to just tell them the answer, but the object of a good instructor is to teach them to find it themselves. And I had to learn that.”

Bynum has developed his own protocol. He requires his children to shower the moment they return from school, and they get regular lectures about hand-washing and common sense.

“If I even suspect they’re not wearing their masks, I’ll say, ‘OK, it’s back to the house and your laptop,’ and they’ll say, ‘Oh yeah, Dad, I’m wearing my mask.’”

Mazariegos remains comfortable with her decision, especially when she reads about all the COVID-19 outbreaks at schools and colleges.

Her kids aren’t so sure.

Second grader Evelyn, an outgoing girl, recently joined a Zoom lesson that included classmates she hadn’t seen in person for months.

“She cried,” her mother said. “She wanted to be back at school to see her friends.”

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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