Category: From California Healthline.org

With his state reeling amid one of the worst COVID-19 outbreaks in the nation, the last thing South Dakota Speaker of the House Steven Haugaard wants to be dealing with during the upcoming legislative session is marijuana. But the state’s voters haven’t left the Republican much choice.

This fall, South Dakota became the first state in the U.S. to legalize both medical marijuana and recreational marijuana in the same election. Haugaard, who long opposed any form of marijuana legalization, now must participate in the creation of a medical marijuana program.

South Dakota voters enshrined legal marijuana in the state’s constitution. So if Haugaard had any thoughts about reversing the initiative once lawmakers reconvene on Jan. 12, they’ve been dashed.

“With a constitutional amendment, there’s really not much we can do about it. It’s written in stone until it’s repealed,” Haugaard said.

South Dakota is one of a handful of states in which voters both approved marijuana ballot questions and elected Republicans to lead state governments. Montana and Arizona, two other states in which Republicans control (or will soon control) the governor’s office and legislature, also backed recreational marijuana at the ballot box. Mississippi passed a measure legalizing medical marijuana.

New Jersey, which has a Democratic governor and Democratic-majority legislature, also passed a recreational marijuana ballot question.

Many conservative lawmakers oppose the legalization of marijuana, an illegal drug under federal law. But they are discovering obstacles to simply passing bills to reverse the initiatives when state legislatures return to work in January. Some marijuana opponents, realizing the limitations to altering a constitutional amendment, are turning to the courts or local officials to undo the measures or at least blunt the effects of legal pot.

Before the November election, 11 states and Washington, D.C., had legalized recreational marijuana, most of them left-leaning states, with exceptions like Alaska. An additional 21 states allow medical marijuana. In the wake of the election, 15 states will have legalized recreational marijuana and 35 will allow medical marijuana.

In conservative states like Montana, where passage of a bill can change or negate a ballot initiative, one thing giving lawmakers pause is that many voters who elected them also approved the legalization of marijuana use for adults 21 and up.

In Montana, 57% of voters approved the recreational marijuana initiative — the same share received by President Donald Trump. In South Dakota, 54% voted for recreational marijuana and a whopping 70% approved medical marijuana. In Arizona, the recreational pot proposition also passed easily.

Those kinds of margins are what caused state Rep. Derek Skees to reconsider a bill he was drafting to repeal the Montana ballot measure in anticipation of its passage.

Skees told the Missoulian the day after the election that after it became clear voters supported it — while also supporting Republican candidates for office up and down the ballot — he decided to shelve it.

“There’s no way I’m going to try to overturn the will of Montana,” Skees told the newspaper.

Haugaard said opposition to the South Dakota measure was derailed by the pandemic and voters never got the message from opponents about the potential negative impacts of legalization.

Proponents of legalization spent nearly $800,000 on their campaign in South Dakota — most of it coming from the New Approach Political Action Committee, a pro-legalization group that works across the country — and five times what opponents of ballot measures raised.

Colorado, the first state to allow recreational use of marijuana in 2014, is often held up as the poster child for what can happen. Proponents say the state has benefited from increased tax income and economic activity. But opponents, including Haugaard, point to studies about increased traffic deaths in Colorado since legalization to explain why they think it’s a bad idea.

“That side of the story wasn’t told and had it been told I think this vote would have gone differently,” Haugaard said.

Marijuana opponents aren’t waiting to see what state lawmakers do, if anything — they’re going to court. The Pennington County, South Dakota, sheriff and the superintendent of the South Dakota Highway Patrol have filed a lawsuit challenging the constitutionality of the marijuana amendment. The Rapid City Journal reported the suit had the backing of Gov. Kristi Noem, and that the state was paying for part of the suit. Noem was a vocal opponent of legalization during the campaign.

Should the legal challenge fail, the amendment is scheduled to take effect July 1 and, according to the governor’s office, it will be up to the state health department to implement it. The legislature will have more control over how the medical marijuana program will work. Haugaard said that will be a big focus of the 37-day session.

Opponents in Montana are also asking the courts to disallow recreational marijuana. Steve Zabawa, a Billings car dealer who has campaigned against legalized marijuana for years, said in his lawsuit that what the voters passed would illegally take power from state lawmakers by designating where tax revenue will go.

Zabawa blamed its passage at the ballot box on pro-marijuana advocacy groups that so outraised and outspent opponents of the measure that he compared it to David and Goliath.

“They candy-coated this deal. They lied to the entire state of Montana by saying that this would benefit veterans and fish and wildlife,” Zabawa said. “They crossed a line and we’re calling them on it.”

Zabawa said that if the courts don’t block recreational marijuana, he’s hopeful that Montana’s Republican-controlled Statehouse will stymie its implementation.

“I just don’t think there’s a lot of love for marijuana in Montana,” Zabawa said.

In Arizona, a recreational marijuana ballot measure was rejected by voters just four years ago. This year it passed by a wide margin. The state’s voters also chose Joe Biden over President Donald Trump, the first time a Democrat won the presidential election in the state since 1996.

It’s unlikely Arizona’s Republican-led legislature can do anything to stop implementation because of a 1998 law that prohibits lawmakers from changing a voter-approved initiative without a three-quarters majority.

State lawmakers’ hands may be tied, but the initiative did give municipalities some power to restrict its use. The day after the initiative passed, Oro Valley Town Council approved an emergency declaration that would limit which type of businesses could sell marijuana and prohibited its use in public places.

The declaration was based on language written by the League of Arizona Cities and Towns and given to members prior to Election Day.

One of the major backers of the state ballot measures is the Marijuana Policy Project, a Washington, D.C.-based organization that supports sweeping marijuana policy changes across the country. Deputy Director Matthew Schweich said this election showed how the public’s opinion on marijuana is rapidly evolving.

Schweich said he believes the results of the 2020 election bode well for future legalization efforts in states and even at the federal level. Because of that growing support, he dismissed any chance Montana or South Dakota could derail recreational legalization but added that his organization will do whatever it can to fight those efforts.

“This is a bipartisan issue [and] I think we’re at a tipping point. We’ve passed it in big states and small states, liberal states and conservative states,” he said. “We’re feeling pretty good. We believe that 2021 is our year.”

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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I still remember exactly where I was sitting decades ago, during the short film shown in class: For a few painful minutes, we watched a woman talking mechanically, raspily through a hole in her throat, pausing occasionally to gasp for air.

This story also ran on The New York Times. It can be republished for free.

The public service message: This is what can happen if you smoke.

I had nightmares about that ad, which today would most likely be tagged with a trigger warning or deemed unsuitable for children. But it was supremely effective: I never started smoking and doubt that few if any of my horrified classmates did either.

When the government required television and radio stations to give $75 million in free airtime for antismoking ads between 1967 and 1970 — many of them terrifyingly graphic — smoking rates plummeted. Since then, numerous smoking “scare” campaigns have proved successful. Some even featured celebrities, like Yul Brynner’s posthumous offering with a warning after he died from lung cancer: “Now that I’m gone, don’t smoke, whatever you do, just don’t smoke.”

As the United States faces out-of-control spikes from COVID-19, with people refusing to take recommended, often even mandated, precautions, our public health announcements from governments, medical groups and health care companies feel lame compared with the urgency of the moment. A mix of clever catchphrases, scientific information and calls to civic duty, they are virtuous and profoundly dull.

The Centers for Disease Control and Prevention urges people to wear masks in videos that feature scientists and doctors talking about wanting to send kids safely to school or protecting freedom.

Quest Diagnostics made a video featuring people washing their hands, talking on the phone, playing checkers. The message: “Come together by spending time apart.”

As cases were mounting in September, the Michigan government produced videos with the exhortation, “Spread Hope, Not Covid,” urging Michiganders to put on a mask “for your community and country.”

Forget that. Mister Rogers-type nice isn’t working in many parts of the country. It’s time to make people scared and uncomfortable. It’s time for some sharp, focused, terrifying realism.

“Fear appeals can be very effective,” said Jay Van Bavel, associate professor of psychology at New York University, who co-authored a paper in Nature about how social science could support COVID response efforts. (They may not be needed as much in places like New York, he noted, where people experienced the constant sirens and the makeshift hospitals.)

I’m not talking fear-mongering, but showing in a straightforward and graphic way what can happen with the virus.

From what I could find, the state of California came close to showing the urgency: a soft-focus video of a person on a ventilator, featuring the sound of a breathing machine, but not a face. It exhorted people to wear a mask for their friends, moms and grandpas.

But maybe we need a PSA featuring someone actually on a ventilator in the hospital. You might see that person “bucking the vent” — bodies naturally rebel against the machine forcing pressurized oxygen into the lungs, which is why patients are typically sedated.

(Because I had witnessed this suffering as a practicing doctor, I was always upfront about the trauma with loved ones of terminally ill patients when they were trying to decide whether to consent to a relative being put on a ventilator. It sounds as easy as hooking someone to an IV. It’s not.)

Another message could feature a patient lying in an ICU bed, immobile, tubes in the groin, with a mask delivering 100% oxygen over the mouth and nose — eyes wide with fear, watching the saturation numbers rise and dip on the monitor over the bed.

Maybe some PSAs should feature a so-called COVID long hauler, the 5% to 10% of people for whom recovery takes months. Perhaps a professional athlete like the National Football League’s Ryquell Armstead, 24, who has been in and out of the hospital with serious lung issues and missed the season.

These PSAs might sound harsh, but they might overcome our natural denial. “One consistent research finding is that even when people see and understand risks, they underestimate the risks to themselves,” Van Bavel said. Graphs, statistics and reasonable explanations don’t do it. They haven’t done it.

Only after Chris Christie, an adviser to President Donald Trump, experienced COVID, did he start preaching about mask-wearing: “When you have seven days in isolation in an ICU, though, you have time to do a lot of thinking,” Christie said, suggesting that people, “follow CDC guidelines in public no matter where you are and wear a mask to protect yourself and others.”

We hear from many who resist taking precautions. They say, “I know someone who had it and it’s not so bad.” Or, “It’s just like the flu.”

Sure, most longtime smokers don’t end up with lung cancer — or tethered to an oxygen tank — either. (That, in fact, was the justification of smokers like my father, whose two-pack-a-day habit contributed to his death at 47 of a heart attack.)

These new ads will seem hard to watch. “We live in a Pixar era,” Van Bavel reflected, with traditional fairy tales now stripped of their gore and violence.

But studies have shown that emotional ads featuring personal stories about the effects of smoking were the most effective at persuading folks to quit. And quitting smoking is much harder than maintaining physical distance and mask-wearing.

Once a vaccine has proved successful and enough people are vaccinated, the pandemic may well be in the rearview mirror. In the meantime, the creators of public health messaging should stop favoring the cute, warm and dull. And — at least sometimes — scare you.

Xavier Becerra, President-elect Joe Biden’s choice to head the Department of Health and Human Services, is set to be a pandemic-era secretary with no public health experience. Whether that matters depends on whom you ask.

Becerra built his career in the U.S. House of Representatives before becoming California’s attorney general, and some wonder whether his political and legal skills would be the right fit to steer HHS through a health catastrophe that’s killing thousands of Americans every day.

Although he would bring years of health politics and policy work to the role, none of it comes from front-line experience as an executive or administrator running public health programs, managing patient care or controlling the spread of disease.

Yet beyond the immediate COVID-19 crisis, many Democrats see Becerra as an important ally to undo what they view as years of damage from the Trump administration’s efforts to undermine the Affordable Care Act; the Medicaid program, which provides coverage for more than 70 million Americans; reproductive health; and more.

As California’s attorney general since 2017, Becerra has been a thorn in the side of the Trump administration, filing 107 lawsuits to overturn federal action on the Affordable Care Act, contraception, immigration, workers’ rights, LGBT rights, education, consumer protection, gun violence and the environment.

“COVID is the biggest issue on the table, but it is not the only issue on the table,” said Dr. Georges Benjamin, executive director of the American Public Health Association. “If you look at his body of work, he is not your traditional attorney. His body of work in the health area is substantial. And I think that counts.”

On Tuesday, Biden will formally introduce Becerra along with other candidates for top health jobs, many with deep public health experience.

They include Dr. Rochelle Walensky, an infectious disease expert at Harvard Medical School who practices at Massachusetts General Hospital in Boston, as the next director of the Centers for Disease Control and Prevention. Biden’s choice for COVID “czar” is Jeffrey Zients, a private equity executive and former Obama administration official who will steer the pandemic response from the White House. Dr. Vivek Murthy is the nominee for U.S. surgeon general, a position he held in the final Obama years.

Biden has said he will let the federal government’s longtime scientists guide his pandemic response, in particular those at the CDC, which is overseen by HHS. President Donald Trump sidelined the agency, damaging its reputation as the world’s most trusted public health institution.

That Becerra’s deepest experience is political makes some observers wary.

“I think there’s always a danger of letting that sort of cloud the scientific and medical judgment of how best to do things. I hope they can manage that well,” said Jeffrey Morris, a biostatistics professor at the University of Pennsylvania who has worked on COVID issues. He said he had mixed feelings about the Becerra selection. “What is the leadership style, and is there going to be micromanaging from the top down into these organizations? To me, that’s the key aspect.”

Garry South, a Los Angeles-based Democratic strategist, called Becerra’s appointment “curious.”

“A lot of people are raising eyebrows — even those who are pleased and proud that Biden picked another Californian to join his administration,” South said. “If Republicans are looking to target a few Biden appointees for rejection, you can expect them to make the case that there is no logical nexus between a state attorney general and serving as secretary of Health and Human Services.”

Still, Becerra, who as a member of Congress worked in the House Democratic leadership and was a member of the powerful Ways and Means Committee, has more health policy background and knowledge of U.S. health care finance and delivery systems than many previous heads of the sprawling HHS, which employs more than 80,000 people and has a $1.3 trillion budget.

For three years, Becerra has managed California’s Justice Department, with a $1.1 billion budget and 4,800 employees. As attorney general, he’s been deeply involved in crafting health policy. His office has gone after anti-competitive behavior from hospitals. And he’s sponsored legislation to take on drugmakers and pay-for-delay schemes.

“He’s gone after powerful health care interests,” said Anthony Wright, executive director of the nonprofit Health Access California.

Antitrust enforcement is more commonly handled by the U.S. Department of Justice and the Federal Trade Commission. But Becerra made it a priority as California’s top cop. In May 2018, he brought an antitrust case against nonprofit health care giant Sutter Health, accusing the system of monopolistic practices that drove up the cost of medical care in Northern California.

“This is a big ‘F’ deal,” Becerra said at a news conference unveiling the lawsuit. The case — which encompassed years of work by the department and his predecessors and millions of pages of documents — alleged that Sutter had aggressively bought up hospitals and physician practices across the region and illegally exploited that market power for profit. Health care costs in Northern California, where Sutter dominates with its 24 hospitals, are 20% to 30% higher than in Southern California, even after adjusting for Northern California’s higher cost of living, according to a 2018 study from the Nicholas C. Petris Center at the University of California-Berkeley that was cited in the complaint.

In December 2019, Sutter agreed to pay $575 million to settle the case and promised to end a host of practices that Becerra alleged stifled competition.

Becerra channeled lessons learned from the Sutter case into an antitrust bill in the California legislature. The legislation ultimately failed, but it would have given the attorney general power to review private equity- or hedge fund-led mergers or acquisitions of a health care system or hospital.

“The Sutter case is a blueprint for a national policy that could start to restore competition for the health care system and save American health care consumers billions of dollars right away,” said Glenn Melnick, a health care economist at the University of Southern California. He views Becerra as “a real expert in some of the most important issues facing our health care system, not just in California but nationally.”

If confirmed by the Senate, Becerra supporters say, he will bring to the job a political acumen from his two decades-plus on Capitol Hill that’s likely to be an asset for the Biden administration as it negotiates pandemic relief bills and other health legislation with a politically divided Congress.

Former California Democratic member of Congress Henry Waxman worked with nearly a dozen HHS secretaries during his time on the House Energy and Commerce Committee. He said he’s not worried that Becerra lacks experience leading a vast health care bureaucracy. The HHS secretary job, he said, is one “where you need political skills to see how far you can get with other people in a political context.” That’s why most HHS secretaries, Republicans and Democrats, have had political backgrounds.

Becerra “understands the policies and has a deep commitment to them,” he said. “I think he’ll do well.”

Public health officials say the job before Becerra is gigantic.

Dr. Gary Pace, the health officer in rural Lake County, California, said Becerra would be tasked with rebuilding a broken public health system.

“We want a federal partner who can give us good guidance — we haven’t had that,” Pace said. “For him, I’d say what we need first is starting to get the CDC back into a flagship public health role, with trusted and timely evidence-based guidance.”

Born in Sacramento to Mexican immigrant parents, Becerra would be the first Latino HHS secretary. He was elected to Congress in his 30s and has been involved in national health legislation during the past two decades, even though he is more widely known for his involvement in immigration and tax issues. He joined the powerful House Ways and Means Committee, which oversees tax and health legislation, in the 1990s. The committee played a central role in the drafting of what would become the Affordable Care Act in 2010.

While HHS oversees major federal health agencies, including the CDC, the Centers for Medicare & Medicaid Services, the Food and Drug Administration and the National Institutes of Health, it also has a wide-ranging human services portfolio, including oversight of child care and welfare programs, Head Start, programs for seniors and refugee resettlement.

“It’s not like any one person is going to have everything,” said Dan Mendelson, a former Clinton administration health official, who called Becerra an “inspired choice.” “I think that the most important point is that this is a leader of a team and not the be-all and end-all.”

KHN staff writers Rachel Bluth and Samantha Young contributed to this story.

This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

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

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Early in the pandemic, Ximena Rebolledo León, a registered nurse at Telluride Regional Medical Center in southwestern Colorado, needed to find everyone who’d been in contact with a sick Latino worker whose boss had told him he would lose his job if he didn’t show up.

The man had gone to work and infected four co-workers, all Latinos, with COVID-19 — so Rebolledo León then had to track down their movements to determine who else had been exposed to the coronavirus in the wealthy ski resort community.

“I ended up calling 13 different families, and I put a total of 85 people in isolation or quarantine,” Rebolledo León recalled.

People fighting the spread of COVID-19 face many unique challenges when doing contact tracing among low-income Latino immigrants in tight-knit communities. Long-standing health care disparities, job insecurity, immigration status, language barriers and a profound distrust of government all complicate the already tricky task.

COVID-19 has also highlighted how essential those immigrants are to their communities. While Telluride is known for its glitzy resort tucked into the mountains, the place functions because of the workers — many of them first-generation immigrants — within the surrounding San Miguel County. When the medical center implemented new COVID-cleaning protocols, it fell to the cleaning staff of Latinos. Grocery stores, restaurants and many other businesses remained open only because their Hispanic workers continued to come to work.

“They are the backbone of what makes this town go round,” Rebolledo León said.

That’s why Latino front-line workers in Telluride and across the country suffer some of the greatest consequences of COVID-19. Hispanic people in the U.S. face higher rates of infection than the general population. And while they make up about 17% of the population, they have accounted for 24% of COVID deaths.

San Miguel County had 267 confirmed cases of COVID-19 as of Dec. 6, but no deaths. Hispanics account for about 11% of the population of roughly 8,000 but 23% of the cases from March to August.

Even so, it took weeks as the pandemic unfolded for the county health department to provide information about the virus in either Spanish or Chuj, a Mayan language spoken by many of the county’s residents from Guatemala.

“We were in crisis mode, and I think one of the first things that falls by the wayside is health equity,” said Grace Franklin, director of the health department. “It took a little bit of time for us to check back in and say, ‘What are we missing? Who are we missing?’”

So public health officials, like those in Telluride and the surrounding county, are leaning on trusted voices such as Rebolledo León from within those immigrant communities to track and contain the virus, and to help vulnerable people access the care and resources they need.

“Trust is a huge factor,” said Maggie Gómez, deputy director of the Center for Health Progress, a Denver-based health advocacy group. “When you show up in a Latinx community in a suit, and you’re knocking on the door and they don’t know who you are, they can tell you’re not from there — they’re going to be pretty suspicious.”

Many of the people Rebolledo León was calling hadn’t received even the most basic information about COVID-19 in words they could understand. She said they hadn’t gotten clear messages on why they had to stay home if they weren’t feeling sick or why a negative COVID test didn’t mean they were in the clear. She was calling homes every morning, checking to see if anybody had developed symptoms, or needed food or other support to remain in quarantine. She gave them her personal cellphone number.

“I wanted them to have access to a nurse,” Rebolledo León said. “So it became a round-the-clock job.”

A woman with diabetes called asking whether she’d be safe working in a restaurant. A house cleaner wondered if it was safe for her to clean if the owners were at home. They would call her late at night, wondering if they should go to the emergency room when having trouble breathing.

“If you’re insured? Yeah, you go to the ER,” she said. “But if you’re uninsured? You’re terrified of that $2,000 bill.”

Whenever new information became available, Rebolledo León, who emigrated from Mexico more than 20 years ago, recorded Spanish-language videos on her phone, posting them on Facebook and texting them out. She doesn’t speak Chuj, but the health department hired an interpreter and posted a COVID video in Chuj on its website.

The videos went viral among the Latino communities in the county. So much so that many people Rebolledo León had never met recognized her as Nurse Ximena from the videos.

But by summer, Rebolledo León was overwhelmed and had to step back to focus on her work at Telluride Medical Center. The county health department in April had hired Dominique Bruneau Saavedra, an architect who emigrated from Chile in 2016 and had been working at a local nonprofit. Bruneau Saavedra took over the bulk of contact tracing among Spanish-speaking residents.

In one case, Bruneau Saavedra asked four Latino men to isolate. One lost his job because of it. Many of the people she contacted worked multiple jobs. That expanded their potential contacts.

Housing intended for four people often sheltered six or seven, she said. Some homes had a single bathroom, making it hard for one person to isolate from the rest of the household. For many immigrants, she said, their entire social circle is the people at work. When asked to stay away from their jobs, they may not have other friends outside their home who can help with food or other needs.

Bruneau Saavedra also discovered that many who worked multiple jobs used different names or nicknames with different employers. In trying to track possible cases, at times she discovered two people on her list were one and the same, having the same cellphone number. But she also found households where multiple residents shared a single number.

Bruneau Saavedra said that, when she called non-Hispanics, she noticed a contrast in their level of concern. Some chose to isolate by going camping alone in the woods, she said, almost like a vacation. For low-income immigrants, isolation can be an economic and legal crisis. In Colorado, an estimated 1 out of 3 immigrants are undocumented.

While social services could help with food and other assistance, the agencies needed to know Social Security numbers, immigration status and who else lived in the home. Those were nonstarters for many who had status issues or undocumented family members living with them.

“It’s been a fight every single step,” Rebolledo León said. “If you’re undocumented in this country, you are aware that the information you are sharing could put so many others in serious problems.”

Telluride is small enough that when one person is infected, it’s not hard to find connections to half the town.

On the other hand, Bruneau Saavedra said, the county is lucky because it is a small community.

“It feels like contact tracing is manageable and is possible, unlike in an urban infrastructure,” Bruneau Saavedra said. “Everybody knows each other.”

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

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Senate Republicans are signaling they will delay considering President-elect Joe Biden’s nominee to run the Department of Health and Human Services, threatening to slow the Biden administration’s response to the pandemic that has killed more than 283,000 Americans.

On Monday, Republican spokespeople for the committees responsible for vetting HHS nominations said the Senate may not hold hearings on California Attorney General Xavier Becerra, Biden’s pick to lead the department, until the Senate approves committee assignments and other organizational details for the new Congress.

Republicans, who will hold at least 50 seats next year, remain in control of the Senate until Jan. 20. But Georgia has two Senate runoff elections scheduled for Jan. 5, and those results will determine which party controls the chamber in the new, 117th Congress.

Political observers say the results could take days or even weeks.

“Every day is a wasted day,” said Kathleen Sebelius, who served as President Barack Obama’s first HHS secretary. (Sebelius is on the board of KFF, and KHN, which publishes California Healthline, is an editorially independent program of KFF.)

On Monday, Biden announced he has asked Becerra to serve as HHS secretary. Becerra mounted a vigorous defense of Democratic health laws against the Trump administration and other Republicans. He led the effort by 20 states and the District of Columbia to fight a suit brought by Republican state officials and supported by President Donald Trump to overturn the Affordable Care Act. That case was argued before the Supreme Court last month.

The early reaction from Republicans signaled Becerra could face strong political opposition to his nomination, with critics like Arkansas Sen. Tom Cotton citing Becerra’s opposition to abortion restrictions and calling him “unqualified” to lead HHS.

“I’ll be voting no, and Becerra should be rejected by the Senate,” he wrote on Twitter. Becerra also supported single-payer health care reform.

In addition, Biden intends to name Dr. Rochelle Walensky, chief of infectious diseases at Massachusetts General Hospital, as the head of the Centers for Disease Control and Prevention, and private equity executive Jeffrey Zients to be his COVID “czar” heading up a task force in the White House. Those jobs do not require Senate confirmation. Biden is nominating Dr. Vivek Murthy as surgeon general, who must face hearings before the Senate.

Becerra would be the first Latino to lead HHS. Before becoming attorney general, he served in the House of Representatives, representing Los Angeles for 24 years. There, he was a member of Democratic leadership and served on the Ways and Means Committee, the House committee charged with writing health-related tax policy.

Becerra returned to California in 2017, replacing the outgoing attorney general who had just been elected to the Senate — now Vice President-elect Kamala Harris.

The HHS secretary is responsible for one of the federal government’s largest departments, coordinating not only the Centers for Medicare & Medicaid Services but also the Food and Drug Administration and the CDC — agencies critical to the nation’s pandemic response.

Although Biden has created his own task force to address the pandemic, the White House lacks many of the powers of the HHS secretary — including the authority to implement its own recommendations, said Donna Shalala, who served as HHS secretary under President Bill Clinton for eight years.

“Any delay [in confirmation] delays COVID, despite a strong White House coordination,” Shalala said, “because you’ve got to get the agencies in sync and you can’t do that from the White House.”

In 2009, as H1N1 flu began to spread and Obama’s first HHS pick withdrew from consideration, the administration was forced to improvise. With no confirmed health secretary, Obama turned to Janet Napolitano, the Homeland Security secretary, to coordinate a plan to distribute vaccines with the CDC.

Sebelius was sworn in as HHS secretary in late April, two days after the Obama administration declared H1N1 a public health emergency.

It would be hard to mount a pandemic response without a secretary, she said. “That pressure falls on Congress,” Sebelius said. “There’s just a sense we can’t screw around with this.”

She also added that the Obama administration did not pursue any lower-level health appointments before confirming the secretary, a protocol that left many offices vacant. She expects Biden will follow the same process.

The Senate can, and often does, begin considering nominees before a new president is sworn in, in particular by arranging one-on-one meetings for senators and examining a nominee’s qualifications and background. Presidents Donald Trump and George W. Bush’s nominees for HHS secretary both received confirmation hearings before Inauguration Day, though Democrats later fought Trump’s nominee, then-Rep. Tom Price (R-Ga.), by boycotting his committee vote.

Republicans say that until the Senate approves what is known as an organizing resolution, which formalizes details like which senators sit on which committees, they cannot move forward with confirmation hearings.

A further complication is that while Republicans already control the two committees tasked with vetting an HHS secretary, neither chairman is staying in that job next year. Sen. Lamar Alexander of Tennessee, who runs the Health, Education, Labor and Pensions Committee, is retiring from Congress. And due to term limits, Iowa Sen. Chuck Grassley, who runs the Finance Committee, will move to a different committee.

Senate Democrats, who would take control of the confirmation process next month should they win both of Georgia’s Senate seats, praised the selection of Becerra and promised to push for a speedy process.

Becerra “has been a staunch defender of affordable health care and preexisting condition protections in the face of Trump’s attacks in court and federal regulation,” said Oregon Sen. Ron Wyden, the Finance Committee’s top Democrat. “I look forward to Attorney General Becerra’s hearing in the Finance Committee as soon as possible next year, so he is on the job quickly.”

“Xavier Becerra is a highly qualified nominee, and I will be pushing for a swift, fair confirmation so we can get to work on the serious health issues our nation faces,” said Sen. Patty Murray of Washington, the HELP Committee’s top Democrat.

If Democrats win both of the Georgia elections next month, the Senate would be evenly split 50-50, likely leading to debates about how to divide control and distracting senators from nomination hearings.

When that happened in 2001, Senate Democrats held the majority for a couple of weeks until Bush was sworn in, making Vice President Dick Cheney the tie-breaking vote and giving Republicans the majority on Jan. 20. Bush’s first HHS secretary, Tommy Thompson, was confirmed four days later.

Bill Dauster, who advised Democrats on the Senate’s procedural rules for decades, said that the split took a long time to negotiate in 2001 but that it left behind a model that senators can use today.

Senate Republicans could follow the precedent of holding hearings before the inauguration, especially due to the urgency of responding to the pandemic, Dauster said.

“If they don’t, it will clearly be foot-dragging,” he said.

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

A mom of eight boys, Kim Gudgeon was at her wits’ end when she called her family doctor in suburban Chicago to schedule a sick visit for increasingly fussy, 1-year-old Bryce.

He had been up at night and was disrupting his brothers’ e-learning during the day. “He was just miserable,” Gudgeon said. “And the older kids were like, ‘Mom, I can’t hear my teacher.’ There’s only so much room in the house when you have a crying baby.”

She hoped the doctor might just phone in a prescription since Bryce had been seen a few days earlier for a well visit. The doctor had noted redness in one ear but opted to hold off on treatment.

To Gudgeon’s surprise, that’s not what happened. Instead, when she called, her son was referred to urgent care, a practice that has become common for the Edward Medical Group, which included her family doctor and more than 100 other doctors affiliated with local urgent care and hospital facilities. Because of concerns about the transmission of the coronavirus, the group is now generally relying on virtual visits for the sick, but often refers infants and young children to urgent care to be seen in person.

“We have to take into consideration the risk of exposing chronically ill and well patients, staff and visitors in offices, waiting areas or public spaces,” said Adam Schriedel, chief medical officer and a practicing internist with the group.

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Gudgeon’s experience is not unusual. As doctors and medical practices nationwide navigate a new normal with COVID-19 again surging, some are relying on urgent care sites and emergency departments to care for sick patients, even those with minor ailments.

That policy is troubling to Dr. Arthur “Tim” Garson Jr., a clinical professor in the College of Medicine at the University of Houston who studies community health and medical management issues. “It’s a practice’s responsibility to take care of patients,” Garson said. He worries about patients who can’t do video visits if they don’t have a smartphone or access to the internet or simply aren’t comfortable using that technology.

Garson supports protocols to protect staff and patients, including in some instances referrals to urgent care. In those cases, practices should be making sure their patients are referred to good providers, he said. For instance, children should be seen by urgent care facilities with pediatric specialists.

Referrals for children have become so prevalent that the American Academy of Pediatrics came out with interim guidance on how practices can safely see patients, in an effort to promote patient-centered care and to ease the strain on other medical facilities as the peak of flu season approaches. The academy recommended that pediatricians strive “to provide care for the same variety of visits that they provided prior to the public health emergency.”

The academy raises concerns about unintended consequences of referrals, such as the fragmentation of care and increased exposure to other illnesses, both caused by patients seeing multiple providers; higher out-of-pocket costs for families; and an unfair burden shifting to the urgent care system as illnesses surge.

“I think this is all being driven by fear, not really knowing how to do this safely, and not really thinking about all of the sorts of consequences that are going to come as flu and other respiratory illnesses surge this fall and winter,” said Dr. Susan Kressly, who recently retired from her practice in Warrington, Pennsylvania, and authored the AAP guidance.

Fear is not unfounded. More than 900 health care workers, 20 of them pediatricians and pediatric nurses, have died of COVID-19, according to a KHN-Guardian database of front-line health care workers lost to the coronavirus.

For the Edward Medical Group, referrals are a safe way to treat patients by using all the resources of its medical system, Schriedel said.

“We can assure patients, regardless of COVID-19, we have multiple options to provide the care and services they need,” he said.

Besides urgent care referrals and virtual visits, doctors have been given guidelines on how to safely see sick patients. That might mean requesting a negative COVID test before a doctor visit or having staff escort a sick patient from the car directly to an exam room. Also, a pilot program is underway with designated offices taking patients with a respiratory illness that could be flu or COVID-19.

Kim Gudgeon, a Chicago-area mom, was frustrated to be referred to an urgent care facility when she suspected her son Bryce had an ear infection. (Kim Gudgeon)

It is a balancing act with some risks. In August, friends sent Kressly screenshots of parents’ online message boards from states such as Texas, Indiana and Florida that were seeing a summer spike in COVID-19 cases. Mothers felt abandoned by their pediatricians because they were being sent to urgent care and emergency departments. Kressly fears some patients will fall through the cracks if they are seen by several different providers and don’t have a continuity of care.

Also, there’s the expense. Bryce’s case is a good example. Gudgeon reluctantly took him to an urgent care facility, worried about exposure and frustrated because she felt her doctor knew Bryce best. His exam included a COVID test. “They barely looked in his ears, and we went home to wait for the results,” she said, and got no medicine to treat Bryce. The next day, she had a negative test and still a fussy, sick baby.

Urgent care facilities across the country are reporting higher numbers of patients, said Dr. Franz Ritucci, president of the American Board of Urgent Care Medicine. His clinic in Orlando, Florida, is seeing twice as many patients, both children and adults, as it did at this time last year.

“In urgent care, we’re seeing all comers, whether they are sick with COVID or not,” he said.

Meanwhile, ERs are seeing far fewer pediatric patients than usual, said Alfred Sacchetti, a spokesperson for the American College of Emergency Physicians and the director of clinical services at Virtua Our Lady of Lourdes Emergency Department in Camden, New Jersey. Although adult emergency room visits have largely returned to pre-COVID levels, pediatric visits are 30% to 40% lower, he said. Sacchetti suspects several factors are at play, including fewer kids in daycare and school with less opportunity to spread illness and people avoiding emergency rooms for fear of the coronavirus.

“You see parents looking around the department and if someone clears their throat, you can look in their eyes and see the concern,” Sacchetti said. “We reassure them” that the precautions taken in hospitals will help keep them safe, he added.

Gudgeon considered taking Bryce to an emergency room, but she felt increasingly uncomfortable both with the thought of exposing him to another health care facility and the cost. In the end, she called an out-of-state doctor she had seen often years before moving to Illinois. That doctor phoned in an antibiotic prescription, and Bryce quickly improved, she said.

“I just wish he didn’t have to suffer for so long,” Gudgeon said.

Kressly hopes doctors become more creative in finding ways to provide direct care. She likes the “Swiss cheese” approach of layering several imperfect solutions to see patients and offer protection from COVID-19: screening for symptoms before the patient comes in, requiring everyone to wear masks, allowing only one caregiver to accompany a sick child and offering parking lot visits for sick kids in their cars.

Most important is good communication, Kressly said. Not only does that help the patient, it can also help protect the doctor from patients who may not want to admit they have COVID symptoms.

“We can’t create this barrier to care for uncomplicated, acute illnesses,” Kressly said. “This is not temporary. We all have to creatively figure out how to get patients and families connected to the right care at the right place at the right time.”

If you’ve been watching TV lately, you may have seen actor Danny Glover or Joe Namath, the 77-year-old NFL legend, urging you to call an 800 number to get fabulous extra benefits from Medicare.

There are plenty of other Medicare ads, too, many set against a red-white-and-blue background meant to suggest officialdom — though if you stand about a foot from the television screen, you might see the fine print saying they are not endorsed by any government agency.

Rather, they are health insurance agents aggressively vying for a piece of a lucrative market.

This is what Medicare’s annual enrollment period has come to. Beneficiaries — people who are 65 or older, or with long-term disabilities — have until Dec. 7 to join, switch or drop health or drug plans, which take effect Jan. 1. By switching plans, they can potentially save money or get benefits not ordinarily provided by the federal insurance program.

For all its complexity and nearly endless options, Medicare fundamentally boils down to two choices: traditional fee-for-service or the managed care approach of Medicare Advantage.

The right choice for you depends on your financial wherewithal and current health status, and on future health scenarios that are often difficult to foresee and unpleasant to contemplate.

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Costs and benefits among the multitude of competing Medicare plans vary widely, and the maze of rules and other details can be overwhelming. Indeed, information overload is part of the reason a majority of the more than 60 million people on Medicare, including over 6 million in California, do not comparison-shop or switch to more suitable plans.

“I’ve been doing it for 33 years and my head still spins,” says Jill Selby, corporate vice president of strategic initiatives and product development at SCAN, a Long Beach nonprofit that is one of California’s largest purveyors of Medicare managed care, known as Medicare Advantage. “It’s definitely a college course.”

Which explains why airwaves and mailboxes are jammed with all that promotional material from people offering to help you pass the course.

Many are touting Medicare Advantage, which is administered by private health insurers. It might save you money, but not necessarily, and research suggests that, in some cases, it costs the government more than administering traditional Medicare.

But the hard marketing is not necessarily a sign of bad faith. Licensed insurance agents want the nice commission they get when they sign somebody up, but they can also provide valuable information on the bewildering nuances of Medicare.

Industry insiders and outside experts agree most people should not navigate Medicare alone. “It’s just too complicated for the average individual,” says Mark Diel, chief executive officer of California Coverage and Health Initiatives, a statewide association of local outreach and health care enrollment organizations.

However, if you decide to consult with an insurance agent, keep your antenna up. Ask people you trust to recommend agents, or try eHealth or another established online brokerage. Vet any agent you choose by asking questions on the phone.

“Be careful if you feel like the insurance agent is pushing you to make a decision,” says Andrew Shea, senior vice president of marketing at eHealth. And if in doubt, don’t hesitate to get a second opinion, Shea counsels.

You can also talk to a Medicare counselor through one of the State Health Insurance Assistance Programs, which are present in every state. Find your state’s SHIP at www.shiptacenter.org.

Medicare & You, a comprehensive handbook, is worth reading. Download it at the official Medicare website, www.medicare.gov.

The website offers a deep dive into all aspects of Medicare. If you type in your ZIP code, you can see and compare all the Medicare Advantage plans, supplemental insurance plans, known as Medigap, and stand-alone drug (Part D) plans.

The site also shows you quality ratings of the plans, on a five-star scale. And it will display your drug costs under each plan if you type in all your prescriptions. Explore the website before you talk to an insurance agent.

California Coverage and Health Initiatives can refer you to licensed insurance agents who will provide local advice and enrollment assistance. Call 833-720-2244. Its members specialize in helping people who are eligible for both Medicare and Medicaid, the health insurance program for low-income people.

These so-called dual eligibles — nearly 1.5 million in California and about 12 million nationwide — get additional benefits, and in some cases they don’t have to pay Medicare’s monthly medical (Part B) premium, which will be $148.50 in 2021 for most beneficiaries, but higher for people above certain income thresholds.

If you choose traditional Medicare, consider a Medigap supplement if you can afford it. Without it, you’re liable for 20% of your physician and outpatient costs and a hefty hospital deductible, with no cap on how much you pay out of your own pocket. If you need prescription drugs, you’ll probably want a Part D plan.

Medicare Advantage, by contrast, is a one-stop shop. It usually includes a drug benefit in addition to other Medicare benefits, with cost sharing for services and prescriptions that varies from plan to plan. Medicare Advantage plans typically have low to no premiums — aside from the Part B premium that most people pay in either version of Medicare. And they increasingly offer additional benefits, including vision, dental, transportation, meal deliveries and even coverage while traveling abroad.

Beware of the risks, however.

Yes, the traditional Medicare route is generally more expensive upfront if you want to be fully covered. That’s because you pay a monthly premium for a Medigap policy, which can cost $200 or more. Add to that the premium for Part D, estimated to average $41 a month in 2021, according to KFF. (KHN is an editorially independent program of KFF.)

However, Medigap policies will often protect you against large medical bills if you need lots of care.

In some cases, Medicare Advantage could end up being more expensive if you get seriously ill or injured, because copays can quickly add up. They are typically capped each year, but can still cost you thousands of dollars. Advantage plans also typically have more limited provider networks, and the extra benefits they offer can be subject to restrictions.

Over one-third of Medicare beneficiaries nationally are enrolled in Advantage plans. In California, about 40% are.

The main appeal of traditional Medicare is that it doesn’t have the rules and restrictions of managed care.

Dr. Mark Kalish, a retired psychiatrist in San Diego, says he opted for traditional fee-for-service with Medigap and Part D because he didn’t want a “mother may I” plan.

“I’m 69 years old, so heart attacks happen; cancer happens. I want to be able to pick my own doctor and go where I want,” Kalish says. “I’ve done well, so the money isn’t an issue for me.”

Be aware that if you don’t join a Medigap plan during a six-month open enrollment period that begins when you enroll in Medicare Part B, you could be denied coverage for a preexisting condition if you try to buy one later.

There are a few exceptions to that in federal law, and four states — New York, Massachusetts, Maine, Connecticut — require continuous or yearly access to Medigap coverage regardless of health status.

Make sure you understand the rules and exceptions that apply to you.

Indeed, that is an excellent rule of thumb for all Medicare beneficiaries. Read up and talk to insurance agents and Medicare counselors. Talk to friends, family members, your doctor, your health plan — and other health plans.

When it comes to Medicare, says Erin Trish, associate director of the University of Southern California’s Schaeffer Center for Health Policy and Economics, “it takes a village.”

The notice from the federal health insurance marketplace grabbed Andrew Schenker’s attention: ACT NOW: YOU’RE AT RISK OF LOSING FINANCIAL ASSISTANCE STARTING JANUARY 1, 2021.

As he read the notice, though, the Blacksburg, Virginia, resident became exasperated. Schenker, his wife and their teenage son have a bronze-level marketplace plan. Based on their income of about $40,000 a year, they receive tax credits that cover the $2,036 monthly premium in full.

When they file their annual taxes they complete an IRS form that reconciles how much they received in advance tax credits against their actual income for the year. The letter from the marketplace said they hadn’t filed for 2019, but Schenker knew they had — just as they have every year.

“I was more annoyed than anything else,” Schenker, 55, said, remembering an earlier enrollment problem that took months to resolve. “I didn’t want to get stuck in some sort of appeals category.”

Schenker’s 25-year-old daughter, Kaily Schenker, who is part owner of the family’s organic farm, got the same letter about her plan. Schenker helps her with her taxes, and she also filed the Form 8962 paperwork, he said.

Andrew Schenker (left) stands with his daughter, Kaily Schenker; wife, Lauren Cooper; and son, Julian Schenker. Andrew received a letter saying he was at risk of losing financial assistance for the bronze-level plan he shares with his wife and son. His daughter got the same letter about her plan. (WINEMA LANOUE)

Officials at the Centers for Medicare & Medicaid Services, which oversees the ACA marketplaces, confirmed that some consumers received notices from the agency alerting them that, according to the IRS, they hadn’t filed a tax return or reconciled their advance payments for tax credits. The letters, consumer advocates suggested, may be a result of the IRS extending the deadline for filing income taxes due to the coronavirus to July 15.

State-based marketplaces have similar requirements and likely send some version of this notice as well, said Tara Straw, a senior policy analyst at the Center on Budget and Policy Priorities who works on income tax issues related to the Affordable Care Act.

People who don’t file their taxes and the reconciliation form aren’t eligible for financial assistance with their marketplace coverage next year, including premium tax credits and any cost-sharing reductions they qualify for.

Because of the filing deadline extension, the tax form data may not have yet arrived when the federal marketplace initially asked the IRS for it in the fall, Straw said. Or other issues, including longer processing times for paper tax returns, could be responsible for a delay, Straw said.

“We don’t know how many people are in this boat,” Straw said. “We think it’s higher than in previous years because of anecdotal accounts from marketplace assisters around the country.”

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Schenker said he and his daughter both filed paper returns — his family’s, in the spring, while his daughter took advantage of the pandemic extension.

Under ACA rules, people with incomes up to 400% of the poverty level ($86,880 for a family of three) can qualify for advance tax credits to help pay for coverage purchased through state or federal health insurance exchanges. When they sign up for insurance during open enrollment, their tax credits are based on estimates of their income for the coming year, and the exchanges pay insurers that amount directly. Then when people file their income taxes the following year, they use Form 8962 to reconcile their actual income against what they estimated and square off the amount in tax credits they received. If they received too much in subsidies, they must pay that back to the government.

According to the notice Schenker received, people who have already filed their 2019 tax return and Form 8962 don’t need to take any action.

Straw recommends a more hands-on approach.

“It’s really a dangerous thing to just wait and cross your fingers and hope that the data will resolve your issue,” she said.

Consumers who filed and reconciled taxes for 2019 can keep their tax credit in 2021, CMS officials said, by updating their 2021 HealthCare.gov application on or before Dec. 15 and checking the box that says, “Yes, I reconciled premium tax credits for past years.”

Straw encouraged marketplace customers to follow that advice. (State-based marketplaces generally follow the same process as the federal marketplace, perhaps with slight variations.)

Still, that might not be sufficient. Straw also recommends that people contact the IRS directly and ask for a tax transcript that shows their return was received, including Form 8962.

That way, if the marketplace does cut off premium tax credits and people have to appeal, they have documentation proving they filed the necessary forms. (If it comes to this, consumers can elect to continue receiving premium tax credits while they appeal.)

Unfortunately, people who run into this trouble might not get much expert help. Navigators are no longer required to help consumers with problems after they’ve enrolled, though they may still do so, Straw said.

Likewise, insurance brokers generally don’t help people with these problems, said Karen Pollitz, a senior fellow at KFF. (KHN is an editorially independent program of KFF.) Marketplace plan commissions are so low, “they’re much less likely to help people with complex problems,” she said.

After he got the letter, Schenker called marketplace representatives and was told to go ahead and apply for a plan for next year. He did so, making sure to check the box that said he’d filed his taxes, including the reconciliation form. And at the end of the application process, the system told him that, based on his income, his family is eligible for a tax credit of $2,000 a month. He picked a bronze plan.

He hopes that’s the end of it.

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When Barack Obama was elected president in 2008, the country was in the midst of a dire economic crisis. Twelve years later, his vice president, Joe Biden, has been elected president in the midst of a dire economic crisis and a worldwide, worsening coronavirus pandemic.

In 2008, Obama’s team and that of outgoing President George W. Bush worked together to allow the new administration to be as prepared as possible on Jan. 20, 2009. That’s not happening for Biden, as President Donald Trump continues to fight the election results and block the official transition.

Particularly when it comes to the COVID-19 pandemic, experts say, that delay could cost lives.

“If the new team has to waste time getting up to speed, that’s a huge waste of resources,” said Donald Kettl, a professor at the LBJ School of Public Affairs at the University of Texas-Austin and an expert in presidential transitions.

Until the formal transition begins, there are critical — and usually routine — things the incoming Biden officials cannot do, said Kettl. “Among the things not allowed right now are formal briefings by government officials, including Tony Fauci,” the head of the National Institute of Allergy and Infectious Diseases and the top federal infectious disease expert. In addition, Kettl said, Biden’s landing teams — the handful of people who go inside government agencies to start the actual transition work — “cannot actually land and talk to the people doing front-line planning. And they can’t see some of the front-line documents.”

Biden can — and is — meeting with plenty of people who will be vital to carry out his administration’s fight against COVID. On Thursday, he met remotely with a bipartisan group of governors and vowed afterward to continue to work with state and local officials. He also has his own COVID advisory board, led by former Surgeon General Vivek Murthy; former commissioner of the Food and Drug Administration, David Kessler; and Yale researcher Dr. Marcella Nunez-Smith.

But Kettl warned that it’s not enough for Biden to surround himself with smart, experienced people with good policy ideas. “The biggest risk they face is in managing these details, and that’s where a direct connection with the bureaucracy is so important, and we can’t afford to fumble this handoff,” he said.

So what can Biden do between now and Jan. 20?

Some public health advocates suggest he could set up a shadow COVID effort, to compete with the Trump administration’s task force. “He could do briefings three times a week telling us what we know and what we don’t,” said Dr. Arthur Kellermann, a longtime public health expert who is now CEO of the Virginia Commonwealth University Health System. Without better information for the public, Kellermann said, “we could lose tens of thousands of people between now and” Inauguration Day.

But others worry that Biden needs to be careful not to appear to have more power than he does, lest he end up with the blame if things don’t go well, particularly on the complicated issue of getting a vaccine distributed and accepted by the general public.

“I think we have to have reasonable expectations of what they can do,” said Farzad Mostashari, a senior health official at HHS in the Obama administration. “A lot has got to be planning and creating a ‘whole of government’ approach to tackling COVID.”

Kettl said the incoming Biden administration is better positioned than many others would have been because they have such recent experience running the government. Incoming White House chief of staff Ron Klain, for example, coordinated the federal government’s response to the Ebola outbreak in 2014. “There’s never been a group or team more prepared to run the government than this one,” Kettl said.

But it won’t be as easy as just picking up where they left off, he said, because of how politicized health and science has become. “The places they are walking into are not the same places they walked out of four years ago. The CDC is a shell of itself, the FDA is not the same.”

Mostashari, though, said he is confident the federal government can do more to combat the virus. “There are plenty of experts [still in the government] who are amazing at what they do,” he said. “They just have to unshackle them.”

HealthBent, a regular feature of Kaiser Health News, offers insight and analysis of policies and politics from KHN’s chief Washington correspondent, Julie Rovner, who has covered health care for more than 30 years.

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

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Puede que hayas visto al actor Danny Glover o a Joe Namath, la leyenda de la NFL de 77 años, en comerciales de TV animándote a que llames a un número 800 para obtener fabulosos beneficios extra de Medicare.

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Hay muchos otros anuncios de Medicare, algunos de ellos con un fondo rojo, blanco y azul para sugerir que son oficiales; aunque si te acercas a la pantalla del televisor, podrás ver que la letra chica dice que no están respaldados por ninguna agencia del gobierno.

En realidad, son agentes de seguros de salud compitiendo agresivamente por un pedazo de un mercado lucrativo.

A esto es a lo que ha llegado el período de inscripción anual de Medicare. Los beneficiarios —personas de 65 años o más, o con discapacidades a largo plazo— tienen hasta el 7 de diciembre para participar, cambiar o dejar los planes de salud o de medicamentos, que entran en vigencia el 1 de enero.

Al cambiar de plan, se podría ahorrar dinero o conseguir beneficios que normalmente no ofrece el programa federal.

A pesar de toda su complejidad y de sus opciones casi infinitas, Medicare se reduce fundamentalmente a dos alternativas: la clásica tarifa por servicio del Medicare Tradicional o el enfoque de atención administrada de Medicare Advantage.

La elección correcta para cada uno depende de los recursos financieros y del estado de salud, así como de los futuros escenarios de atención médica que a menudo son difíciles de pronosticar.

Los costos y beneficios entre la multitud de planes de Medicare que compiten entre sí varían, y el laberinto de normas y otros detalles puede resultar abrumador.

De hecho, la sobrecarga de información explica, en parte, porqué la mayoría de las más de 60 millones de personas que tienen Medicare, incluidos más de 6 millones en California, no hacen comparaciones ni se cambian a planes más adecuados.

“LLevo haciendo esto 33 años y mi cabeza todavía da vueltas”, dijo Jill Selby, vicepresidenta de iniciativas estratégicas y desarrollo de productos de SCAN, una organización sin fines de lucro de Long Beach que es una de las mayores proveedoras de cuidados administrados de Medicare de California, conocida como Medicare Advantage. “Definitivamente es un curso universitario”.

Esta es la razón por la que los medios de comunicación y los buzones de los correos electrónicos se abarrotan con publicidad de gente que se ofrece a ayudarle a aprobar “el curso”.

Muchos promocionan Medicare Advantage, que es administrado por aseguradoras de salud privadas. Puede que se ahorre dinero, pero no necesariamente, y las investigaciones sugieren que, en algunos casos, le cuesta al gobierno más que administrar el Medicare tradicional.

Pero el marketing no es necesariamente un signo de mala fe. Los agentes de seguros autorizados buscan la buena comisión que reciben cuando contratan a alguien, pero también pueden proporcionar información valiosa sobre los desconcertantes matices de Medicare.

Los conocedores de la industria y los expertos coinciden en que la mayoría de las personas no debería navegar solas por Medicare. “Es demasiado complicado”, asegura Mark Diel, director ejecutivo de California Coverage and Health Initiatives, una asociación estatal de organizaciones de alcance local y de inscripción en el cuidado de la salud.

Pero si la decisión es consultar con un agente de seguros, hay que mantenerse alerta. Pídeles a personas de confianza que te recomienden agentes, o visita eHealth o cualquier otra agencia en línea establecida. Pon a prueba al agente que elijas haciéndole preguntas por teléfono.

“Tenga cuidado si siente que el agente de seguros lo está presionando para que tome una decisión”, advierte Andrew Shea, vicepresidente de marketing de eHealth. Y si tienes dudas, busca una segunda opinión, aconseja Shea.

También puedes hablar con un consejero de Medicare a través de uno de los Programas Estatales de Asistencia de Seguros de Salud (SHIP), presentes en todos los estados. Encuentra el SHIP de su estado en www.shiptacenter.org.

Vale la pena leer Medicare & You, un manual completo. Descárgalo en el sitio web oficial de Medicare, www.medicare.gov.

El sitio web ofrece una inmersión profunda en todos los aspectos de Medicare. Si escribes tu código postal, puedes ver y comparar todos los planes de Medicare Advantage, los planes de seguro suplementario, conocidos como Medigap, y los planes de medicamentos (Parte D).

El sitio también te muestra las calificaciones de calidad de los planes, en una escala de cinco estrellas. Y los costos de tus medicamentos en cada plan. Explora el sitio web antes de hablar con un agente de seguros.

California Coverage y Health Initiatives puede remitirte a agentes de seguros autorizados que te proporcionarán asesoramiento local y asistencia para la inscripción. Llama al 833-720-2244. Sus miembros se especializan en ayudar a quienes son elegibles tanto para Medicare como para Medicaid, el programa de seguro de salud para personas de bajos ingresos.

Los llamados elegibles duales —casi 1.5 millones en California y cerca de 12 millones en todo el país— obtienen beneficios adicionales, y en algunos casos no tienen que pagar la prima médica mensual de Medicare (Parte B), que será de $148.50 en 2021 para la mayoría de los beneficiarios, pero más alta para las personas que superan ciertos umbrales de ingresos.

Si eliges el Medicare tradicional, considera un suplemento de Medigap si puedes pagarlo. Sin él, serás responsable del 20% de los costos de tu médico y de servicios ambulatorios, así como un elevado deducible de hospital, sin un límite a lo que pagas de tu propio bolsillo. Si necesitas medicamentos recetados, probablemente convendrá un plan de la Parte D.

Por su parte, Medicare Advantage es una ventanilla única. Por lo general, incluye un beneficio de medicamentos además de otros beneficios de Medicare, con un costo compartido para servicios y recetas que varía de un plan a otro. Los planes de Medicare Advantage suelen tener primas bajas o nulas, aparte de la prima de la Parte B que la mayoría de las personas paga en cualquiera de las dos versiones de Medicare. Y cada vez más ofrecen servicios adicionales, incluyendo visión, dental, transporte, entrega de comidas e incluso cobertura en el extranjero.

Pero ten cuidado con los riesgos.

Sí, la ruta tradicional de Medicare suele ser más cara al principio si deseas estar totalmente cubierto. Eso se debe a que pagas una prima mensual por una póliza Medigap, que puede costar $200 o más. Añade a eso la prima de la Parte D, estimada en un promedio de $41 al mes en 2021, según KFF. (KHN es un programa editorialmente independiente de KFF.)

Sin embargo, las pólizas Medigap a menudo te protegerán contra grandes facturas médicas si necesitas muchos cuidados.

En algunos casos, Medicare Advantage podría terminar siendo más caro si te enferma o lesionas gravemente, porque los copagos pueden sumar rápidamente. Por lo general, tienen un límite máximo cada año, pero aun así pueden costarte miles de dólares. Los planes Advantage también suelen tener redes de proveedores más limitadas, y los beneficios adicionales que ofrecen pueden estar sujetos a restricciones.

Más de un tercio de los beneficiarios de Medicare a nivel nacional están inscritos en los planes Advantage. En California, alrededor del 40%.

El principal atractivo del Medicare tradicional es que no tiene las reglas y restricciones de la atención médica administrada.

El doctor Mark Kalish, un psiquiatra retirado de San Diego, dijo que optó por el tradicional pago por servicio con Medigap y la Parte D porque no quería un plan en que tuviera que “pedir permiso”.

“Tengo 69 años, así que los ataques al corazón ocurren; el cáncer ocurre. Quiero poder elegir mi propio médico e ir a donde quiera”, señala Kalish. “Me ha ido bien en la vida, así que el dinero no es un problema para mí”.

Ten en cuenta que si no te inscribes en un plan Medigap durante el período de inscripción abierta de seis meses, que comienza cuando te inscribes en la Parte B de Medicare, se te podría negar la cobertura de una condición preexistente si intentas comprar una más tarde.

Hay algunas excepciones a esto en la ley federal, y cuatro estados —Nueva York, Massachusetts, Maine, Connecticut— exigen el acceso continuo o anual a la cobertura Medigap sin importar el estado de salud.

Asegúrate de entender las reglas y excepciones que aplican en tu caso.

De hecho, esa es una excelente regla general para todos los beneficiarios de Medicare. Lee y habla con los agentes de seguros y los consejeros de Medicare. Habla con amigos, familiares, tu médico, tu plan y otros planes de salud.

Cuando se trata de Medicare, dijo Erin Trish, directora adjunta del Centro Schaeffer de Política y Economía de la Salud de la Universidad del Sur de California, “se necesita de una comunidad”.