Category: From California Healthline.org

[khn_slabs slabs=”260982″ view=”pull-right” /]

La temporada de influenza se verá diferente este año, ya que los Estados Unidos se enfrentan a una pandemia de coronavirus que ya ha matado a más de 176.000 personas.

Muchos estadounidenses son reacios a ir al médico y los funcionarios de salud pública temen que las personas eviten vacunarse.

[khn_slabs syndicated=”863440″ view=”pull-right” /]

Aunque a veces se considera incorrectamente como un resfriado, la gripe también mata a decenas de miles de personas en el país cada año. Los más vulnerables son los niños pequeños, los adultos mayores y las personas con enfermedades subyacentes. Cuando se combina con los efectos de COVID-19, los expertos en salud pública dicen que es más importante que nunca vacunarse contra la gripe.

Si una cantidad suficiente de la población se vacuna, más del 45% lo hizo la temporada de gripe pasada, podría ayudar a evitar un escenario de pesadilla este invierno, con hospitales llenos de pacientes con COVID-19 y los que sufren los efectos graves de la influenza.

Además de la posible carga para los hospitales, existe la posibilidad de que las personas contraigan ambos virus y “nadie sabe qué sucede si se contrae influenza y COVID simultáneamente porque nunca sucedió antes”, dijo la doctora Rachel Levine, secretaria de Salud de Pennsylvania, a reporteros.

En respuesta, este año los fabricantes están produciendo más suministros de vacunas, entre 194 y 198 millones de dosis, unas 20 millones más de las que se distribuyeron la temporada pasada, según los Centros para el Control y Prevención de Enfermedades (CDC).

Mientras se acerca la temporada de gripe, aquí hay algunas respuestas a preguntas frecuentes:

P: ¿Cuándo debo vacunarme contra la gripe?

La publicidad ya ha comenzado y algunas farmacias y clínicas ya tienen sus suministros. Pero, debido a que la efectividad de la vacuna puede disminuir con el tiempo, los CDC recomiendan no recibir la dosis en agosto.

Muchas farmacias y clínicas comenzarán las inmunizaciones a principios de septiembre. Generalmente, los virus de la influenza comienzan a circular a mediados o fines de octubre, pero se expanden masivamente más tarde, en el invierno. Se necesitan aproximadamente dos semanas después de recibir la inyección para que los anticuerpos, que circulan en la sangre y frustran las infecciones, se acumulen.

“Las personas jóvenes y sanas pueden comenzar a vacunarse contra la gripe en septiembre, y las personas mayores y otras poblaciones vulnerables pueden hacerlo en octubre”, dijo el doctor Steve Miller, director clínico de la aseguradora Cigna.

Los CDC recomiendan que las personas “se vacunen contra la influenza a fines de octubre”, pero señalaron que se puede recibir la vacuna más tarde porque “aún puede ser beneficiosas y la vacunación debe ofrecerse a lo largo de toda la temporada de influenza”.

Aun así, algunos expertos recomiendan no esperar demasiado este año, no solo por COVID-19, sino también en caso de que haya escasez debido a la abrumadora demanda.

P: ¿Cuáles son las razones por las que las que debería ofrecer mi brazo para vacunarme?

Hay que vacunarse porque brinda protección contra la gripe y, por lo tanto, contra la propagación a otras personas, lo que puede ayudar a disminuir la carga para los hospitales y el personal médico.

Y hay otro mensaje que puede resonar en estos tiempos extraños.

“Le da a la gente la sensación de que hay algunas cosas que pueden controlar”, dijo Eduardo Sánchez, director médico de prevención de la American Heart Association.

Si bien una vacuna contra la gripe no evitará COVID-19, recibirla podría ayudar al médico a diferenciar entre las dos enfermedades si se desarrolla algún síntoma (fiebre, tos, dolor de garganta) que ambas infecciones comparten, explicó Sánchez.

Y aunque las vacunas contra la gripe no evitarán todos los casos de gripe, vacunarse puede reducir la gravedad si la persona se enferma, dijo.

Todas las personas elegibles, especialmente los trabajadores esenciales, los que sufren de afecciones subyacentes y aquellos en mayor riesgo, incluidos los niños muy pequeños y las mujeres embarazadas, deben buscar protección, dijeron los CDC. La entidad recomienda la vacunación a partir de los 6 meses.

P: ¿Qué sabemos sobre la efectividad de la vacuna de este año?

Se deben producir nuevas vacunas contra la gripe cada año, porque el virus muta y la efectividad de la vacuna varía, dependiendo de qué tan bien coincida con el virus circulante.

Se calculó que la formulación del año pasado tuvo una eficacia de aproximadamente un 45% para prevenir la gripe en general, con una efectividad de aproximadamente un 55% en los niños. Las vacunas disponibles en el país este año tienen como objetivo prevenir al menos tres cepas diferentes del virus, y la mayoría cubre cuatro.

Todavía no se sabe qué tan bien coincidirá el suministro de este año con las cepas que circularán en los Estados Unidos. Las primeras indicaciones del hemisferio sur, que atraviesa su temporada de gripe durante nuestro verano, son alentadoras. Allí, las personas practicaron el distanciamiento social, usaron máscaras y se vacunaron en mayor número este año, y los niveles mundiales de gripe son más bajos de lo esperado. Sin embargo, expertos advierten que no se debe contar con una temporada igual de suave en los Estados Unidos, en parte porque los esfuerzos por usar mascara facial y de distanciamiento social varían ampliamente.

P: ¿Qué están haciendo diferente los seguros y sistemas de salud este año?

Las aseguradoras y los sistemas de salud contactados por KHN dicen que seguirán las pautas de los CDC, que exigen limitar y espaciar la cantidad de personas que esperan en las filas y las áreas de vacunación. Algunos están programando citas para vacunas contra la gripe para ayudar a controlar el flujo.

Health Fitness Concepts, una compañía que trabaja con UnitedHealth Group y otras empresas para establecer clínicas de vacunación contra la gripe en el noreste del país, dijo que está “fomentando eventos más pequeños y frecuentes para apoyar el distanciamiento social” y “exigiendo que se completen todos los formularios y arremangarse las camisas antes de entrar al área de vacunación contra la influenza”.

Se requerirá que todos usen máscaras.

Además, a nivel nacional, algunos grupos médicos contratados por UnitedHealth instalarán carpas, para que las inyecciones se puedan administrar al aire libre, dijo un vocero.

Kaiser Permanente planifica las vacunas directamente en autos en algunos de sus centros médicos y está probando los procedimientos de detección y registro sin contacto en algunos lugares.

Geisinger Health, un proveedor de salud regional en Pennsylvania y Nueva Jersey, dijo que también tendría programas de vacunación contra la influenza al aire libre en sus instalaciones.

Además, “Geisinger exige que todos los empleados reciban la vacuna contra la influenza este año”, dijo Mark Shelly, director de prevención y control de infecciones del sistema. “Al dar este paso, esperamos transmitir a nuestros vecinos la importancia de la vacuna contra la influenza para todos”.

P: Por lo general, me vacunan contra la gripe en el trabajo. ¿Seguirá siendo una opción este año?

Con el objetivo de evitar riesgosas reuniones en interiores, muchos empleadores se muestran reacios a patrocinar las clínicas de gripe en oficinas como han ofrecido en años anteriores. Y con tanta gente que sigue trabajando desde casa, hay menos necesidad de llevar las vacunas contra la gripe al lugar de trabajo. En cambio, muchos empleadores están alentando a los trabajadores a que reciban vacunas de sus médicos de atención primaria, en farmacias u otros entornos comunitarios. El seguro generalmente cubrirá el costo de la vacuna.

Algunos empleadores están considerando ofrecer cupones para vacunas contra la gripe a sus trabajadores sin seguro o a aquellos que no participan en el plan médico de la compañía, dijo Julie Stone, directora general de salud y beneficios de Willis Towers Watson, una firma consultora.

Estos cupones podrían, por ejemplo, permitir a los trabajadores obtener la vacuna en un laboratorio en particular sin costo.

Algunos empleadores están comenzando a pensar en cómo podrían usar sus estacionamientos para administrar vacunas contra la gripe enlos autos, dijo el doctor David Zieg, líder de servicios clínicos para el consultor de beneficios Mercer.

Aunque la ley federal permite a los empleadores exigir a los empleados que se vacunen contra la gripe, ese paso generalmente lo toman solo los centros de atención médica y algunas universidades donde las personas viven y trabajan en estrecha colaboración, dijo Zieg.

Pero sucede. El mes pasado, el sistema de la Universidad de California emitió una orden ejecutiva que requiere que todos los estudiantes, profesores y personal se vacunen contra la gripe antes del 1 de noviembre, con limitadas excepciones.

P: ¿Qué están haciendo las farmacias para alentar a las personas a vacunarse contra la gripe?

Algunas farmacias están haciendo un esfuerzo adicional para salir a la comunidad y ofrecer vacunas contra la gripe.

Walgreens, que tiene casi 9,100 farmacias en todo el país, continúa una asociación iniciada en 2015 con organizaciones comunitarias, iglesias y empleadores que ha ofrecido alrededor de 150,000 clínicas de gripe móviles hasta la fecha.

El programa pone especial énfasis en trabajar con poblaciones vulnerables y en áreas desatendidas, dijo el doctor Kevin Ban, director médico de la cadena de farmacias.

Walgreens comenzó a ofrecer vacunas contra la gripe a mediados de agosto y está animando a las personas a no demorar en vacunarse.

Tanto Walgreens como CVS están estimulando a las personas a programar citas y hacer trámites en línea este año para minimizar el tiempo que pasan en los locales.

En los CVS MinuteClinic, una vez que los pacientes se han registrado para recibir la vacuna contra la gripe, deben esperar afuera o en su automóvil, ya que las áreas de espera interiores ahora están cerradas.

“No tenemos un arsenal contra COVID”, dijo Ban, de Walgreens. “Pero quitar la presión del sistema de atención médica proporcionando vacunas por adelantado es algo que sí podemos hacer”.

President Donald Trump told the American people this week that convalescent plasma is a potential new treatment for COVID-19. His announcement followed the Food and Drug Administration’s decision Sunday to grant fast-track authorization for its emergency use as a treatment for hospitalized COVID patients.

This “emergency use authorization” triggered an outcry from scientists and doctors, who said the decision was not supported by adequate clinical evidence and criticized the FDA for what many perceived as bowing to political pressure.

With all the news swirling around convalescent plasma this week, we thought we’d break it down for you.

1. Convalescent plasma contains antibodies against disease. Donations are being promoted as a potential COVID-19 treatment.

“Convalescent” refers to recovery from a disease. And plasma is the yellowish, liquid part of blood in which blood cells are suspended.

When someone is infected with a virus, the body generates antibodies to fight off the viral particles. Enter COVID-19. If an individual who has recovered from this virus donates their plasma, scientists can isolate the antibodies from the plasma and give it to patients who are still in the early stages of their COVID-19 infection. This infusion, in theory, should help people fight off the virus while their own body catches up and makes its own supply of antibodies.

It’s not a new concept. An infusion of antibodies via plasma has been used as a treatment for other types of diseases, such as rabies.

[khn_slabs slabs=”241884″ view=”inline” /]

2. Some experts took issue with the data presented to approve the treatment and thought the FDA action crossed a political line.

An FDA emergency use authorization allows companies and medical providers to deploy unapproved treatments or medical products in a crisis. The FDA said health care providers would be authorized to distribute COVID convalescent plasma to treat suspected or confirmed patients with COVID-19 while in the hospital.

Before the authorization, some top researchers and clinicians at the National Institutes of Health felt there was not sufficient scientific evidence to support pushing the treatment forward.

“A randomized placebo control trial is the gold standard,” said Dr. Howard Koh, who was an assistant secretary at the Department of Health and Human Services from 2009 to 2014 under President Barack Obama. “If you don’t have that standard and don’t have some evidence from a high-quality study or [a randomized controlled trial], you are left with suboptimal science and treatments in the long run that may not prove to work.”

Koh also said that for other COVID-19 treatments including the medication remdesivir, a randomized clinical trial had been done before the FDA OK’d it for emergency use.

When the emergency authorization for convalescent plasma was announced, HHS officials pointed to findings from a Mayo Clinic preliminary analysis as the rationale. The analysis has not been reviewed by other scientists and doctors.

Suspicions of a political motive behind the decision were heightened because the authorization came one day before the start of the Republican National Convention.

“The timing raises so many questions,” said Koh, also a professor of the practice of public health leadership at Harvard University. “I think this announcement shakes the confidence of the medical community in the rigor of the FDA decision-making process.”

Trump tweeted just a day before the FDA’s action, “The deep state, or whoever, over at the FDA is making it very difficult for drug companies to get people in order to test the vaccines and therapeutics. Obviously, they are hoping to delay the answer until after November 3rd. Must focus on speed, and saving lives!”

Scott Gottlieb, a former Trump administration FDA commissioner, offered his take in a tweet the day after the announcement: “Plasma may provide a benefit, and it could be meaningful for certain patients, but we need more evidence to prove it. The data FDA had supports an authorization for emergency use, where the standard is ‘may be effective’ but we need better studies to confirm preliminary findings.”

3. Dr. Stephen Hahn, the current FDA commissioner, misrepresented the data on the treatment’s effectiveness during Sunday’s press conference. Hahn later corrected himself.

The Mayo Clinic analyzed outcomes of patients who were given a low dose of plasma and those given a high dose. Those who got the high dose had a lower seven-day mortality rate (8.9%) compared with the seven-day mortality rate of those given a low dose (13.7%).

Dr. Adam Gaffney, a critical care doctor and instructor in medicine at Harvard Medical School, said these two variables were used to calculate what is known as a “relative risk reduction,” or the percent difference between the risk of two different treatment outcomes. In this case, the risk reduction between the high dose and low dose of plasma is 35%.

That’s the number Hahn misrepresented.

“Many of you know I was a cancer doctor before I became FDA commissioner, and a 35% improvement in survival is a pretty substantial clinical benefit,” said Hahn. “What that means is — and if the data continue to pan out — 100 people who are sick with COVID-19, 35 would have been saved because of the administration of plasma.”

But, that was an incorrect statement. Hahn had confused relative risk with absolute risk, as many members of the medical community later pointed out. Absolute risk reduction refers to the number of people who experienced reduced mortality from a treatment compared with the rest of the entire population who didn’t get the treatment. The absolute risk reduction in this situation is probably closer to 3-5 cases out of 100.

On Monday night, Hahn issued a tweet to set the record straight: “I have been criticized for remarks I made Sunday night about the benefits of convalescent plasma. The criticism is entirely justified. What I should have said better is that the data show a relative risk reduction not an absolute risk reduction.”

Hahn also noted in the Twitter thread that the agency’s decision was not political, but “made by FDA career scientists based on data submitted a few weeks ago.” He also said the approval was not final and the FDA could revoke authorization if needed.

4. President Trump referred to the use of blood plasma during the RNC, and is likely to do so throughout the remainder of his presidential campaign.

During the first night of the Republican National Convention, in a meeting with a group of first responders, Trump told a police officer who had recovered from COVID-19 that her blood was “valuable.”

“Once you’re recovered, we have the whole thing with plasma happening. That means your blood is very valuable, you know that, right?” Trump said. Vice President Mike Pence also mentioned it in his Wednesday night speech.

5. Critics of the convalescent plasma treatment say there must be randomized clinical trials to prove its effectiveness.

Koh said receiving convalescent plasma doesn’t appear to be dangerous, but a recent study in China did report that 2 in about 100 people experienced adverse events associated with the treatment.

And multiple experts said a randomized clinical trial is necessary to ensure that the mortality outcomes shown in the Mayo Clinic analysis weren’t confounded by other factors.

A randomized clinical trial would involve one group receiving a placebo and another group receiving the treatment. Who is assigned to each group would be completely random to eliminate bias.

Gaffney said he noticed that patients in the low-dose plasma group seemed to be sicker than those in the high-dose plasma group — which could have affected the Mayo Clinic’s findings.

“To ensure that the effect we see is the effect of the intervention, and not a manifestation of differences in how sick the two groups are,” the trial has to be randomized, said Gaffney.

The Mayo Clinic analysis also reported that some patients who received plasma also took remdesivir or steroids, which could have influenced their mortality outcomes.

Dr. Eric Topol, director of the Scripps Research Translational Institute, said, at best, he sees the outcomes of this analysis as a hypothesis that needs to be tested in a randomized clinical trial. “No survival benefit has been proven,” he wrote in an email.

An attack ad, which was released in mid-July, states that Montana Gov. Steve Bullock, a Democratic candidate for the Senate, supports a government-run health care program that would wreak havoc on the state’s health care infrastructure.

“Bullock’s health care plan will force rural hospitals to close. Medicare as we know it will change, replaced by a government-run program with fewer doctors and longer wait times,” says the narrator in the dark and grainy advertisement paid for by the National Republican Senatorial Committee (NRSC).

Bullock is running against first-term incumbent Republican Sen. Steve Daines in a race viewed as a toss-up. Given the COVID-19 pandemic, both candidates have been focusing on health issues.

Because this race is critical to determining whether Democrats or Republicans control the Senate, and considering that its themes are likely to be repeated in many congressional campaigns, we thought it was important to check the ad’s validity.

We first asked the NRSC for the evidence on which the ad was based. A spokesperson pointed to Bullock’s support for a “public option” health plan and provided us with a report predicting this proposal’s negative impact on rural hospitals, as well as quotes from both Republicans and Democrats about how the public option could lead to the eventual implementation of a “Medicare for All” program. (Medicare for All refers to the single-payer health system, advocated by Vermont Sen. Bernie Sanders, which would eliminate private insurance and replace it with a government-run health care system.)

We also reached out to the Bullock campaign for its response.

In a statement, Sean Manning, spokesperson for Montanans for Bullock said, “The claims in this ad are false. Montana hasn’t lost one rural hospital under Governor Bullock, and he will continue to support policies that protect rural hospitals while making affordable healthcare available to all Montanans in the Senate.” (According to the University of North Carolina Sheps Center for Health Services Research, no rural hospitals have closed in Montana since 2005.)

Hold Up ― Which Health Care Plan Is the NRSC Ad Talking About?

The ad vaguely refers to Bullock’s “health care plan” but doesn’t say outright what the candidate supports.

According to Bullock’s campaign website, he supports the creation of a public option.

A public option is generally defined as a health plan administered by the federal government that exists alongside and competes with private health insurance plans on the Affordable Care Act exchanges. Public option proposals differ by political candidate, and can take various forms, including Medicare or Medicaid buy-ins as well as a new government-run entity.

Opponents of such plans say that a public option, which would have the scale and regulatory power of the federal government to set lower reimbursement rates to providers, would have a competitive advantage and could put private insurance companies out of business. This would leave Americans with only one choice ― government-backed insurance. But that conclusion is debatable. Some health care scholars argue a public option would increase competition, leading to expanded access to health coverage, lower health care costs and lower premiums for consumers.

In the end, the outcomes from implementing this approach are difficult to predict unless a specific plan is released, said Benedic Ippolito, a health care research scholar at the American Enterprise Institute.

“Things can be radically different based on what the public option looks like,” said Ippolito. “The two big variables are, who is covered? And how does that insurer actually pay health care providers? You can imagine two public options looking totally different.”

The Payment Rate Is Key 

Now to tackle the first part of the ad, which says that “Bullock’s health care plan will force rural hospitals to close.”

This argument stems from the idea that a public option would lead to lower reimbursement rates, based on the model provided by Medicare, which pays less than private insurance. And, because many rural hospitals are already severely financially strapped, lowered payments would do them in, the argument goes.

When we asked the NRSC for the evidence to support this position, a spokesperson provided an August 2019 study conducted by Navigant, a consulting firm. The study was commissioned by the Partnership for America’s Healthcare Future, a health industry coalition including  drugmakers, insurance companies and private hospitals. The organization opposes Medicare for All and a public option.

The study modeled what would happen to rural hospitals if three separate public option approaches were implemented.

While it found that a public option could, depending on the scenario, cause a revenue reduction for rural hospitals of between 2.3% and 14%, the study reached these findings by assuming that the hospitals would be paid at Medicare rates.

Bullock’s campaign website, though, under his rural health care policy proposals, specifically states: “We need a public option that includes higher reimbursements for rural hospitals.”

We asked the Bullock campaign if it could provide us with details about what the “higher reimbursement” rate would be based on. It declined. A campaign staffer told us Bullock would support a public option that pays rural hospitals above Medicare rates. Since the reimbursement rates would be higher than Medicare’s, the assumptions in the Navigant study cannot be applied here.

“If the public option is a reasonably generous payer, that won’t be the end of rural health care,” said Ippolito. “But, you can easily imagine due to budgetary concerns, a public payer could have a lower reimbursement, which would have consequences.”

Some health policy experts argue that a public option would help rural hospitals by increasing the number of people in rural areas who have health insurance.

This would “benefit rural hospitals, since getting virtually nothing from uninsured patients is worse than getting a reasonably good rate from the public option,” said Gerard Anderson, a professor of health policy and management at Johns Hopkins University in Baltimore.

That’s a Big Jump 

Next, we’re on to the NRSC ad’s second claim: “Medicare as we know it will change, replaced by a government-run program with fewer doctors and longer wait times.”

As several experts pointed out, this sentence doesn’t make a lot of sense. Medicare is already a government-run program.

Also, the design of most public option proposals thus far keeps Medicare and the public option as two separate government programs, said Linda Blumberg, a health policy analyst at the Urban Institute, a think tank.

The NRSC clarified its position and told us it was referring to the idea that a public option would stifle competition in the insurance market, eventually leading to only government-run insurance or Medicare for All. The evidence the NRSC provided to support this claim were quotes from a selection of Republicans, Democrats, professors, and experts from conservative think tanks saying that the public option is a stepping stone to this single-payer approach.

But others suggest that’s a big leap in logic.

“I think that analysis is almost surely wrong,” said Matthew Fiedler, a fellow with the Brookings Institution. “In a world where there is a public option, the negotiating dynamics between insurers and providers would change substantially.”

This would likely create an environment in which private insurers could negotiate lower rates and providers would have to respond to that change in revenue with more efficiencies, he added. However, depending on how a public option plan is structured — specifically if providers can opt out of participating — some in-demand providers may choose to stay in private-plan networks where they could negotiate higher payments. This would keep private plans competitive.

“I don’t think it’s reasonable to argue that a public option would drive all other plans out of the market,” Fiedler said.

Again, Ippolito said it all depends on how the public option program is designed, and he allowed that if providers and hospitals were paid at Medicare rates, the public option would have a huge competitive advantage over commercial insurers because it would be paying out less for services and then could charge lower premiums, and “there’s no question in the short run, that it would be disruptive.”

As we noted earlier, the prediction of any outcome is difficult without specifics. Without details of Bullock’s public option plan, it’s misleading to characterize the outcome of the public option as surely leading to Medicare for All.

Why It Matters 

The race between Bullock and Daines is indicative of a trend occurring in campaigns across the country. Republicans often paint Democrats as left of the general public and health care has often been one of the issues the GOP highlights in that effort.

In this case, the NRSC ad links  Bullock to Medicare for All, despite his expressed support for a public option. Sean Manning, Bullock’s campaign spokesperson, said the governor does not support Medicare for All.

Jeremy Johnson, an associate professor of political science at Carroll College in Helena, Montana, said that even before COVID-19 became a major campaign issue, Daines, echoing a Trump theme, had pushed the idea that he stood for freedom versus socialism.

“One of the things [Daines] gives as a symbol of socialism is Medicare for All,” said Johnson. “Because Bullock says he favors a public option, there is a conflation of that on the Republican side to mean Medicare for All.”

But the public option and Medicare for All are not the same program and it’s misleading to lump them together.

Our Rating 

The NRSC claimed in a television ad that Steve Bullock’s support for the public option would cause rural hospitals to close.

While the NRSC did provide us with one study that offered support for its rural hospital claim, the study was industry-funded and based on broad assumptions that don’t accurately reflect positions outlined on Bullock’s website. Thus, this claim doesn’t stand up.

The second part of the ad asserts that the public option would lead to the implementation of Medicare for All. While supporters and critics debate how a public option would affect the private health insurance market and some on both sides consider it a “glide path” to a single-payer health care system, it’s too big of a jump to say it would definitely trigger this outcome.

We rate this False.

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

As Xinyi Christine Zhang watched the COVID-19 death toll among health care workers rise this spring, she wanted to find a way to give solace — and thanks — to their families.

The teenager, of South Brunswick Township, New Jersey, joined her church in commemorating members who had died of COVID-19. But she was driven to try to do more, something personal.

“I thought there could be something more meaningful I could do for the families of the doctors who lost their lives fighting the pandemic,” said Christine, 15.

A gifted artist, Christine resolved to draw the fallen U.S. health care workers in colorful memorial portraits, distribute them to their families and post them on her website. She wanted the relatives to know that people appreciated those who were trying to help Americans heal while putting their own lives in jeopardy.

Christine frequently draws portraits for her friends and knew memorial portraits are usually rather expensive. She realized that drawing front-line workers could actually help families and was a better use of her time than drawing her friends — whom she said she’d drawn “like 10 times already.”

According to KHN and The Guardian’s “Lost on the Frontline” project, more than 1,000 health care workers in the United States have died after helping patients battle the coronavirus. The pandemic overburdened many hospitals and led to shortages in protective equipment such as masks and gowns that endangered many of those assisting patients.

Christine found her subjects through that project. She set up a website to upload her portraits and to let families request drawings of their loved ones. Her portraits are free and easily accessible online, Christine said.

She has finished and posted 17 portraits since she started in late April. Each one takes six to eight hours, and Christine spreads that work out over a few days so as not to interfere with her school assignments. Using a close-up image as a reference, she first digitally sketches the proportions of the person’s face with a pencil and then adds unique colors to “really bring life to the portrait.”

Her largest obstacle is getting in touch with the families. She hopes more families will request portraits through her website so she can work with them from the beginning.

One person Christine featured is Sheena Miles, a semiretired nurse from Mississippi who died of COVID-19 on May 1. Christine tracked down her son, Tom Miles, who expressed his gratitude on Facebook.

“When you’re going through a loss like that, like the loss of a mom, to get the email from out of the blue just kind of gives you a profound feeling that there are some good people in this world,” Tom Miles said in an interview. “For her to have such talent at such a young age, and that she really cares about people she doesn’t even know — she is what makes America what it is today.”

This kind of response is exactly what Christine aims for — she wants the families to know that she is thankful for the work of their loved ones.

“Someone they don’t know personally, even a stranger, appreciates what their loved one has done,” she said.

The portraits may be a source of brightness for grieving families, said Christine’s mother, Helen Liu.

“I hope that families who receive these portraits will have a feeling of hope that better times will come,” Liu said. “A memorial is something meaningful and permanent, and I feel her portraits capture the happiness that will forever be with them.”

She hopes to get additional requests for the memorials from families.

In addition to drawing, Christine is a member of the South Brunswick High School’s Science Olympiad team and helps build projects for competitions. She’s interested in exploring engineering or product design as a career. Anything related to building or creating, she said.

She plans to either major or minor in art in college. For now, she wants to continue this project throughout high school — hopefully with help from others who know how to create digital art. She has a form on her website where others with art experience can sign up to help out. She said they can also add “other heroes in our society, such as war veterans or firefighters.”

“There are so many people that need to be honored, but I can’t do it by myself,” Christine 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.

USE OUR CONTENT

This story can be republished for free (details).

As the coronavirus began to spread through Minneapolis this spring, Health Commissioner Gretchen Musicant tore up her budget to find funds to combat the crisis. Money for test kits. Money to administer tests. Money to hire contact tracers. Yet even more money for a service that helps tracers communicate with residents in dozens of languages.

While Musicant diverted workers from violence prevention and other core programs to the COVID-19 response, state officials debated how to distribute $1.87 billion Minnesota received in federal aid.

[khn_slabs slabs=”241884″ view=”inline”]

As she waited for federal help, the Minnesota Zoo got $6 million in federal money to continue operations, and a debt collection company outside Minneapolis received at least $5 million from the federal Paycheck Protection Program, according to federal data.

It was not until Aug. 5 — months after Congress approved aid for the pandemic — that Musicant’s department finally received $1.7 million, the equivalent of $4 per Minneapolis resident.

“It’s more a hope and a prayer that we’ll have enough money,” Musicant said.

Since the pandemic began, Congress has set aside trillions of dollars to ease the crisis. A joint KHN and Associated Press investigation finds that many communities with big outbreaks have spent little of that federal money on local public health departments for work such as testing and contact tracing. Others, like Minnesota, were slow to do so.

For example, the states, territories and 154 large cities and counties that received allotments from the $150 billion Coronavirus Relief Fund reported spending only 25% of it through June 30, according to reports that recipients submitted to the U.S. Treasury Department.

Many localities have deployed more money since that June 30 reporting deadline, and both Republican and Democratic governors say they need more to avoid layoffs and cuts to vital state services. Still, as cases in the U.S. top 5.2 million and deaths soar past 167,000, Republicans in Congress are pointing to the slow spending to argue against sending more money to state and local governments to help with their pandemic response.

“States and localities have only spent about a fourth of the money we already sent them in the springtime,” Senate Majority Leader Mitch McConnell said Tuesday. Congressional Democrats’ efforts to get more money for states, he said, “aren’t based on math. They aren’t based on the pandemic.”

Negotiations over a new pandemic relief bill broke down last week, in part because Democrats and Republicans could not agree on funding for state and local governments.

Minneapolis Health Commissioner Gretchen Musicant visits a COVID-19 testing event at Incarnation-Sagrado Corazon Church on Aug. 15, 2020, in Minneapolis. As the coronavirus spread through Minneapolis this spring, Musicant tore up her budget to find money to combat the crisis. It was not until Aug. 5 — months after Congress approved the pandemic relief aid — that her department received $1.7 million, the equivalent of $4 per Minneapolis resident. (AP Photo/Craig Lassig)

KHN and the AP requested detailed spending breakdowns from recipients of money from the Coronavirus Relief Fund — created in March as part of the $1.9 trillion CARES Act — and received responses from 23 states and 62 cities and counties. Those entities dedicated 23% of their spending from the fund through June to public health and 7% to public health and safety payroll.

An additional 22% was transferred to local governments, some of which will eventually pass it down to health departments. The rest went to other priorities, such as distance learning.

So little money has flowed to some local health departments for many reasons: Bureaucracy has bogged things down, politics have crept into the process, and understaffed departments have struggled to take time away from critical needs to navigate the red tape required to justify asking for extra dollars.

“It does not make sense to me how anyone thinks this is a way to do business,” said E. Oscar Alleyne, chief of programs and services at the National Association of County and City Health Officials. “We are never going to get ahead of the pandemic response if we are still handicapped.”

Last month, KHN and the AP detailed how state and local public health departments across the U.S. have been starved for decades. Over 38,000 public health worker jobs have been lost since 2008, and per capita spending on local health departments has been cut by 18% since 2010. That’s left them underfunded and without adequate resources to confront the coronavirus pandemic.

“Public health has been cut and cut and cut over the years, but we’re so valuable every time you turn on the television,” said Jan Morrow, the director and 41-year veteran of Ripley County health department in rural Missouri. “We are picking up all the pieces, but the money is not there. They’ve cut our budget until there’s nothing left.”

Politics and Red Tape

Why did the Minneapolis health department have to wait so long for CARES Act money?

Congress mandated that the Coronavirus Relief Fund be distributed to states and local governments based on population. Minneapolis, with 430,000 residents, missed the threshold of 500,000 people that would have allowed it to receive money directly.

The state of Minnesota, however, received $1.87 billion, a portion of which was meant to be sent to local communities. Lawmakers initially sent some state money to tide communities over until the federal money came through — the Minneapolis health department got about $430,000 in state money to help pay for things like testing.

But when it came time to decide how to use the CARES Act money, lawmakers in Minnesota’s Republican-controlled Senate and Democratic-controlled House were at loggerheads.

Myron Frans, commissioner of Minnesota Management and Budget, said that disagreement, on top of the economic crisis and pandemic, left the legislature in turmoil.

After the police killing of George Floyd in Minneapolis, the city erupted in protests over racial injustice, making a difficult situation even more challenging.

Dr. Jackie Kawiecki stands outside her home on Aug. 15, 2020, her day off from her job at a medical station in Richfield, Minnesota, near the location where George Floyd was killed. “I still don’t think that the amount of testing offered is adequate, from a public health standpoint,” Kawiecki says. (AP Photo/Craig Lassig)

Democratic Gov. Tim Walz favored targeting some of the money to harder-hit communities, a move that might have helped Minneapolis, where cases have surged since mid-July. But lawmakers couldn’t agree. Negotiations dragged on, and a special session merely prolonged the standoff.

Finally, the governor divvied up the money using a population-based formula developed earlier by Republican and Democratic legislative leaders that did not take into account COVID-19 caseloads or racial disparities.

“We knew we needed to get it out the door,” Frans said.

The state then sent hundreds of millions of dollars to local communities. Still, even after the money got to Minneapolis a month ago, Musicant had to wait as city leaders made difficult choices about how to spend the money as the economy cratered and the list of needs grew.

“Even when it gets to the local government, you still have to figure out how to get it to local public health,” Musicant said.

Meanwhile, some in Minneapolis have noticed a lack of services. Dr. Jackie Kawiecki has been providing help to people at a volunteer medical station near the place where Floyd was killed ― an area that at times has drawn hundreds or thousands of people per day. She said the city did not do enough free, easy-to-access testing in its neighborhoods this summer.

“I still don’t think that the amount of testing offered is adequate, from a public health standpoint,” Kawiecki said.

A coalition of groups that includes the National Governors Association has blamed the spending delays on the federal government, saying the final guidance on how states could spend the money came late in June, shortly before the reporting period ended. The coalition said state and local governments had moved “expeditiously and responsibly” to use the money as they deal with skyrocketing costs for health care, emergency response and other vital programs.

[datawrapper id=”fIudq” height=”650″ /]

New York’s Nassau County was among six counties, cities and states that had spent at least 75% of its funds by June 30.

While most of the money was not spent before then, the National Association of State Budget Officers says a July 23 survey of 45 states and territories found they had allocated, or set aside, an average of 74% of the money.

But if they have, that money has been slow to make it to many local health departments.

As of mid-July in Missouri, at least 50 local health departments had yet to receive any of the federal money they requested, according to a state survey. The money must first flow through local county commissioners, some of whom aren’t keen on sending money to public health agencies.

“You closed their businesses down in order to save their people’s lives and so that hurt the economy,” said Larry Jones, executive director of the Missouri Center for Public Health Excellence, an organization of public health leaders. “So they’re mad at you and don’t want to give you money.”

[datawrapper id=”qg7ws” height=”300″ /]

The winding path federal money takes as it makes its way to states and cities also could exacerbate the stark economic and health inequalities in the U.S. if equity isn’t considered in decision-making, said Wizdom Powell, director of the University of Connecticut Health Disparities Institute.

“Problems are so vast you could unintentionally further entrench inequities just by how you distribute funds,” Powell said.

‘Everything Fell Behind’

The amounts eventually distributed can induce head-scratching.

Some cities received large federal grants, including Louisville, Kentucky, whose health department was given $42 million by April, more than doubling its annual budget. Because of the way the money was distributed, Louisville’s health department alone received more money from the CARES Act than the entire government of the city of Minneapolis, which received $32 million in total.

Philadelphia’s health department was awarded $100 million from a separate fund from the Centers for Disease Control and Prevention.

Honolulu County, where COVID cases have remained relatively low, received $124,454 for every positive case it had reported as of Aug. 9, while El Paso County in Texas got just $1,685 per case. Multnomah County, Oregon — with nearly a quarter of its state’s COVID-19 cases — landed only 2%, or $28 million, of the state’s $1.6 billion allotment.

Rural Saline County in Missouri received the same funding as counties of similar size, even though the virus hit the area particularly hard. In April, outbreaks began tearing through a Cargill meatpacking plant and a local factory there. By late May, the health department confirmed 12 positive cases at a local jail.

Tara Brewer, Saline’s health department administrator, said phone lines were ringing off the hook, jamming the system. Eventually, several department employees handed out their personal cellphone numbers to take calls from residents looking to be tested or seeking care for coronavirus symptoms.

“Everything fell behind,” Brewer said.

The school vaccination clinic in April was canceled, and a staffer who works as a Spanish translator for the Women, Infants and Children nutritional program was enlisted to contact-trace for additional COVID-19 exposures. All food inspections stopped.

It was late July when $250,000 in federal CARES Act money finally reached the 11-person health department, Brewer said — four months after Congress approved the spending and three months after the county’s first outbreak.

That was far too late for Brewer to hire the army of contact tracers that might have helped slow the spread of the virus back in April. She said the money already has been spent on antibody testing and reimbursements for groceries and medical equipment the department had bought for quarantined residents.

Another problem: Some local health officials say that the laborious process required to qualify for some of the federal aid discourages overworked public health officials from even trying to secure more money and that funds can be uneven in arriving.

Volunteers work at a medical station on Aug. 15, 2020, near the location where George Floyd died in police custody in Minneapolis. Dr. Jackie Kawiecki organized the effort to help people at the site, an area that at times has drawn thousands of people per day. She says the city did not do enough free, easy-to-access COVID-19 testing in its neighborhoods this summer. (AP Photo/Craig Lassig)

Lisa Macon Harrison, public health director for Granville Vance Public Health in rural Oxford, North Carolina, said it’s tough to watch major hospital systems — some of which are sitting on billions in reserves — receive direct deposits, while her department received only about $122,000 through three grants by the end of July. Her team filled out a 25-page application just to get one of them.

She is now waiting to receive an estimated $400,000 more. By contrast, the Duke University Hospital System, which includes a facility that serves Granville, already has received over $67.3 million from the federal Provider Relief Fund.

“I just don’t understand the extra layers of onus for the bureaucracy, especially if hundreds of millions of dollars are going to the hospitals and we have to be responsible to apply for 50 grants,” she said.

The money comes from dozens of funds, including several programs within the CARES Act. Nebraska alone received money from 76 federal COVID relief funding sources.

Robert Miller, director of health for the Eastern Highlands Health District in Connecticut, which covers 10 towns, received $29,596 of the $2.5 million the state distributed to local departments from the CDC fund and nothing from CARES. It was only enough to pay for some contact tracing and employee mileage.

Miller said that he could theoretically apply for a little more from the Federal Emergency Management Agency, but that the reporting requirements — which include collecting every receipt — are extremely cumbersome for an already overburdened department.

So he wonders: “Is the squeeze worth the juice?”

Back in Minneapolis, Musicant said the new money from CARES allowed the department to run a free COVID-19 testing site Saturday, at a church that serves the Hispanic community about a mile from the site of Floyd’s killing.

It will take more money to do everything the community needs, she says, but with Congress deadlocked, she’s not sure they’ll get it anytime soon.

AP writers Camille Fassett and Steve Karnowski contributed to this report.

[khn_slabs syndicated=”863440″ view=”pull-right” /]
[khn_slabs slabs=”260982″ view=”pull-right” /]

Cuando el coronavirus comenzó a propagarse por Minneapolis esta primavera, la comisionada de salud Gretchen Musicant ajustó su presupuesto y encontró dinero para combatir la crisis. Dinero para los kits de prueba. Dinero para rastreadores de contactos. Dinero para un servicio que ayudara a comunicarse con los residentes en docenas de idiomas.

Cuando Musicant reubicaba a trabajadores de prevención de la violencia y otros programas básicos, los funcionarios estatales debatían cómo distribuir los $1,87 mil millones que Minnesota había recibido en ayuda federal.

Mientras esperaba, el zoológico de Minnesota obtuvo $6 millones en dinero federal para continuar sus operaciones, y una compañía de cobro de deudas fuera de Minneapolis recibió al menos $5 millones del Programa de Protección de Cheques de Pago federal, según datos federales.

No fue hasta el 5 de agosto —meses después de que el Congreso aprobara la ayuda para el coronavirus— que el departamento de Musicant finalmente recibió $1,7 millones, el equivalente a $4 por cada residente de la ciudad.

Desde que comenzó la pandemia, el Congreso ha reservado miles de millones para aliviar la crisis. Una investigación conjunta de Kaiser Health News y Associated Press encuentra que muchas comunidades con grandes brotes han gastado poco de ese dinero federal en los departamentos locales de salud pública para trabajos como pruebas y rastreo de contactos. Otras, como Minnesota, tuvieron respuestas lentas.

Por ejemplo, los estados, territorios y 154 grandes ciudades y condados que recibieron asignaciones del Fondo de Alivio para el Coronavirus de $150 mil millones informaron haber gastado sólo el 25% de ese dinero hasta el 30 de junio, según informes que los destinatarios presentaron al Departamento del Tesoro de los Estados Unidos.

La doctora Jackie Kawiecki posa fuera de su casa el sábado 15 de agosto, su día libre de su trabajo en una estación médica en Richfield, Minnesota, cerca del lugar donde George Floyd fue asesinado. “Todavía no creo que la cantidad de pruebas que se ofrecen sea adecuada, desde el punto de vista de la salud pública”, dice Kawiecki.(AP PHOTO/CRAIG LASSIG)

Muchas localidades han utilizado más dinero desde la fecha límite de presentación de informes del 30 de junio, y tanto los gobernadores republicanos como los demócratas dicen que necesitan más para evitar despidos y recortes en servicios estatales vitales.

Aún así, a medida que los casos en los Estados Unidos superan los 5,4 millones y las muertes confirmadas se elevan a más de 171,000, los republicanos en el Congreso señalan la lentitud del gasto para argumentar en contra del envío de más dinero a los gobiernos estatales y locales para ayudar en su respuesta a la pandemia.

El líder de la mayoría republicana del Senado, Mitch McConnell, dijo el martes 11 de agosto que los esfuerzos de los demócratas del Congreso para conseguir más dinero para los estados “no se basan en las matemáticas. No se basan en la pandemia”.

Las negociaciones sobre un nuevo proyecto de ley de ayuda se rompieron hace pocos días, en parte porque los demócratas y los republicanos no se pusieron de acuerdo sobre la financiación de los gobiernos estatales y locales.

KHN y AP solicitaron desgloses detallados de los gastos a los receptores del dinero del Fondo de Ayuda contra el Coronavirus —creado en marzo como parte de la Ley CARES de 1,9 mil millones— y recibieron respuestas de 23 estados y 62 ciudades y condados. Esas entidades dedicaron, hasta junio, el 23% de sus gastos del fondo a la salud pública y el 7% a la salud pública y a la seguridad de la nómina.

Un 22% adicional fue transferido a los gobiernos locales, algunos de los cuales eventualmente lo pasarán a los departamentos de salud.

La lentitud de la ayuda se debe a muchas razones, incluyendo la burocracia, la política y la falta de personal que dificulta a los departamentos navegar por el sistema.

“No tiene sentido para mí que alguien piense que ésta es la manera de hacer las cosas”, dijo E. Oscar Alleyne, jefe de programas y servicios de la Asociación Nacional de Funcionarios de Salud del Condado y la Ciudad.

Voluntarios trabajan el 15 de agosto, cerca del lugar en donde murió George Floyd bajo custodia policial en Minneapolis. (AP PHOTO/CRAIG LASSIG)

El Congreso ordenó que el Fondo de Alivio para el Coronavirus se distribuyera a los gobiernos estatales y locales en función de la población. Minneapolis, con 430,000 residentes, no alcanzó el umbral de 500,000 personas que le hubiera permitido recibir dinero directamente.

El estado de Minnesota recibió $1,87 mil millones, una parte de los cuales estaba destinada a ser enviada a las comunidades locales. Los legisladores inicialmente enviaron algo de dinero del estado para ayudar a las comunidades hasta que el dinero federal llegara. El departamento de salud de Minneapolis recibió unos $430,000 en dinero estatal.

Sin embargo, cuando llegó el momento de decidir cómo utilizar el dinero del CARES Act, los legisladores de Minnesota no se pusieron de acuerdo.

Entonces la policía de Minneapolis mató a George Floyd, y la ciudad estalló en protestas por la injusticia racial, haciendo la situación aún más difícil.

Finalmente, el gobernador demócrata Tim Walz decidió repartir el dinero utilizando una fórmula basada en la población, desarrollada anteriormente por los líderes legislativos republicanos y demócratas, que no tenía en cuenta los casos de COVID-19 ni las disparidades raciales.

El estado envió entonces cientos de millones de dólares a las comunidades locales. Aún así, incluso después que el dinero llegara a Minneapolis hace un mes, Musicant esperó a que los líderes de la ciudad decidieran cómo gastarlo.

Una coalición que incluye a la Asociación Nacional de Gobernadores ha culpado de los retrasos en el gasto al gobierno federal, diciendo que la orientación final sobre cómo los estados podrían gastar el dinero no llegó hasta finales de junio. La coalición comunicó que los gobiernos estatales y locales habían actuado “de manera expeditiva y responsable” para utilizar el dinero.

Algunas ciudades recibieron grandes subsidios federales, entre ellas Louisville, en Kentucky, cuyo departamento de salud obtuvo $42 millones en abril, lo que duplicó con creces su presupuesto.

Pero a mediados de julio en Missouri, al menos 50 departamentos de salud locales aún no habían recibido el dinero federal que habían solicitado, según una encuesta estatal. El dinero debe fluir primero a través de los comisionados locales del condado, algunos de los cuales no están dispuestos a enviar dinero a las agencias de salud pública que cerraron los negocios.

El condado rural de Saline, en Missouri, recibió los mismos fondos que los condados de tamaño similar, a pesar de que el virus golpeó la zona con especial dureza, con brotes en una planta de empaquetado de carne y en una fábrica.

Fue a finales de julio cuando $250,000 en dinero de la Ley Federal CARES finalmente llegaron al departamento de salud de 11 personas —demasiado tarde para contratar al ejército de rastreadores de contacto que podrían haber frenado el virus en abril, señaló Tara Brewer, administradora del departamento de salud de Saline.

Algunos funcionarios de salud locales dijeron que el laborioso proceso requerido para calificar para alguna de las ayudas federales también es un problema.

Lisa Harrison, directora de salud pública de Granville Vance Public Health en la zona rural de Carolina del Norte, comentó que resulta duro ver cómo importantes sistemas hospitalarios como la Universidad de Duke reciben decenas de millones de dólares en depósitos directos, mientras que su departamento sólo recibió unos $122,000 a través de tres subvenciones a finales de julio. Su equipo rellenó una solicitud de 25 páginas sólo para conseguir una de ellas.

En Minneapolis, Musicant dijo que el nuevo dinero de CARES permitió al departamento hacer pruebas gratuitas de COVID-19 en una iglesia, a una milla del lugar donde tuvo lugar el asesinato de Floyd.

Hará falta más dinero para hacer todo lo que la comunidad necesita, aseguró Musicant; pero con el Congreso estancado, no está segura de que lo consigan pronto.

Smith es periodista de The Associated Press, y Weber, Recht y Ungar son periodistas de KHN. Los periodistas de AP Camille Fassett y Steve Karnowski colaboraron con este informe.

Esta historia es una colaboración entre The Associated Press y KHN, que es un servicio de noticias sin fines de lucro que cubre temas de salud. Es un programa editorialmente independiente de la Kaiser Family Foundation. KHN no está afiliada a Kaiser Permanente.

Pennsylvania is rolling out its new “Pennie” this fall: a state-run insurance exchange that officials say will save residents collectively millions of dollars on next year’s health plan premiums.

Since the Affordable Care Act’s marketplaces opened for enrollment in fall 2013, Pennsylvania, like most states, has used the federal www.healthcare.gov website for people buying coverage on their own.

But in a move defying the usual political polarization, state lawmakers from both parties last year agreed the cost of using the federal marketplace had grown too high and the state could do it for much less. They set up the Pennsylvania insurance exchange (nicknamed “Pennie”), designed to pass on expected savings to policyholders. Although the final rates for 2021 are not yet set, insurers have requested about a 3% average drop in premiums.

Pennsylvania is one of six states shifting in the next several years from the federal insurance exchange to run their own online marketplaces, which determine eligibility, assist with enrollment and connect buyers with insurance companies. They will join 12 states and the District of Columbia with self-contained exchanges.

The transitions come amid mounting evidence that state marketplaces attract more consumers, especially young adults, and hold down prices better than the federal exchange. They’ve also been gaining appeal since the Trump administration has cut the enrollment period on healthcare.gov and slashed funds for advertising and helping consumers.

State policymakers say they can run their own exchanges more cheaply and efficiently, and can better respond to residents’ and insurers’ needs.

“It comes down to getting more bang for your buck,” said Rachel Schwab, a researcher at Georgetown University’s Center on Health Insurance Reforms in Washington, D.C.

The importance of state-run exchanges was highlighted this year as all but one of them held special enrollment periods to sign up hundreds of thousands of people hurt financially by COVID-caused economic turmoil. The federal exchange, run by the Trump administration, refused to do so, although anyone who has lost workplace insurance is able to buy coverage anytime on either the state or federal exchange.

Like Pennsylvania, New Jersey expects to have its state-run exchange operational for the start of open enrollment on Nov. 1.

In fall 2021, New Mexico plans to launch its own marketplace and Kentucky is scheduled to fully revive its state-run exchange, which was dismantled by its Republican governor in 2015. Maine has also announced it will move to set up its own exchange, possibly in fall 2021.

Virginia’s legislature passed an exchange bill this year and hopes to start it in 2022 or 2023.

Nationwide, about 11 million people get coverage through the state and federal exchanges, with more than 80% receiving federal subsidies to lower their insurance costs.

“Almost across the board, states with their own exchanges have achieved higher enrollment rates than their federal peers, along with lower premiums and better consumer education and protection,” according to a study published this month in the Journal of Health Politics, Policy and Law.

Controlling ‘Their Own Destiny’

Since 2014, states using the federal marketplaces have had a rise in premiums of 87% while state exchanges saw 47% growth, the study found.

In one key metric, from 2016 to 2019 the number of young enrollees in state exchanges rose 11.5%, while states using the federal marketplace recorded an 11.3% drop, a study by the National Academy for State Health Policy found.

Attracting younger enrollees, who tend to be healthy, is vital to helping the marketplaces spread the insurance risk to help keep premiums down, experts say.

When the Affordable Care Act was debated, Republicans and some Democrats in Congress were cautious about a one-size-fits-all approach to insurance and accusations about a federal takeover of health care. So the law’s advocates gave states more control over selling private health coverage. The law’s framers included a provision that allowed states to use millions in federal dollars to launch their own insurance exchanges.

Initially, 49 states took the money. But in 2011, conservative groups convinced Republican-controlled states that forgoing state-run exchanges would help undermine Obamacare.

As a result, most GOP-controlled states defaulted to the federal marketplace.

In the ensuing years, several states that had started their own marketplaces, such as Oregon, Nevada and Hawaii, reverted to the federal exchange because of technological problems. Nevada relaunched its exchange last fall.

“States want to control their own destiny, and the instability of healthcare.gov in the Trump administration has frustrated states,” said Joel Ario, managing director for the consulting firm Manatt Health Solutions and a former Obama administration official, who helped set up the exchanges. States running their own platform can use data to target enrollment efforts, he said.

An Effort to Hold Down Premium Increases

Marlene Caride, New Jersey commissioner of Banking and Insurance, said that “the beauty of [a state-based exchange] is we can tailor it to New Jersey residents and have the ability to help [them] when they are in dire need.”

About 210,000 New Jersey residents enrolled in marketplace health plans for this year.

New Jersey has been spending $50 million a year in user fees for the federal exchange. After startup costs, the state estimates, it will cost about $7.6 million a year to run its own exchange enrollment platform and $7 million a year for a customer service center.

Open enrollment on the New Jersey exchange — called Get Covered NJ — will run from Nov. 1 to Jan. 31.

New Jersey plans to provide additional government subsidies for lower-income enrollees. Those would supplement federal subsidies.

Kentucky officials said insurers there were paying $15 million a year in user fees for healthcare.gov, a cost passed on to policyholders. When the state switches to its own operation, it plans to collect $5 million in its first year to cover the startup costs to revive its Kynect exchange and another $1 million to $2 million in annual administrative costs. So insurers will pay lower fees and those savings will help cut premium costs, said Eric Friedlander, secretary of the Kentucky Cabinet for Health and Family Services.

States using the federal marketplace this year paid either a 2.5% or 3% surcharge to the federal government on premiums collected.

In Pennsylvania, where about 330,000 residents buy coverage through an exchange plan, those fees accounted for $90 million a year. State officials estimate they can run their own exchange for about $40 million and will use the savings for a reinsurance program that pays insurers to help cover the cost of extremely expensive health care needed by some customers. Removing those costs from the insurers’ responsibility allows them to drop premiums by 5% to 10%, the state projects.

“When we talk about bringing something back to state control, that is a real narrative that can appeal to both sides of the aisle,” said Jessica Altman, the state’s insurance commissioner. “There is nothing political about making health insurance more affordable.” (Altman is the daughter of Drew Altman, CEO of KFF. KHN is an editorially independent program of KFF.)

Without the savings from running its own exchange, Pennsylvania would not have been able to come up with the more than $40 million needed for the reinsurance program, state officials said.

In addition, Pennsylvania has extended its enrollment period to run an extra month, until Jan. 15 (federal marketplace enrollment ends Dec. 15). Pennie also plans to spend three to four times the $400,000 that the federal government allocated to the state for navigators to help with enrollment, said Zachary Sherman, who heads Pennie.

“We think increased outreach and marketing will bring in a healthier population and broaden enrollment,” 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.

USE OUR CONTENT

This story can be republished for free (details).

Thousands of letters stuffed with money flooded Jonas Salk’s mailbox the week after his polio vaccine was declared safe and effective in 1955. Everybody wanted his vaccine. Desperate parents clogged doctors’ phone lines in search of the precious elixir; drug companies and doctors diverted doses to the rich and famous.

Some of the first batches of the vaccine were disastrously botched, causing 200 cases of permanent paralysis. That barely dented public desire for the preventive. Marlon Brando even asked to play Salk in a movie.

Eight years later, with polio a fading threat, the first measles vaccines went on sale. Measles had killed more than 400 children the year before and caused permanent brain damage in thousands more. Interest in the vaccine was modest. Its creator, Maurice Hilleman, was never lionized as Salk had been.

“People felt, ‘What’s the big deal? I had measles; why does my kid need a vaccine?’ It was a very difficult sell,” said Walter Orenstein, an Emory University professor who headed the national immunization program at the Centers for Disease Control and Prevention from 1988 to 2004.

When a coronavirus vaccine becomes available, will it be met with a roaring ovation, like the polio vaccine, or communal yawning, like the measles shot? Or some strange hybrid of the two? Americans’ trust in authority, affordable access to the vaccine and a sense of solidarity will determine the result, said Orenstein and other public health veterans and historians.

Perceptions of particular diseases — and vaccines — reflect the seriousness of the diseases themselves, but popular values, culture, human risk assessment and politics all play important roles. Acceptance of public health measures — be they face masks or vaccines — is never entirely determined through a rational balancing of risk and benefit.

We can see that in the history of national campaigns for new vaccines meant to vanquish a scourge. No disease was more feared in the mid-20th century than polio. With the possible exception of AIDS, no disease since has been as feared until the arrival of COVID-19.

The polio vaccine was one of the few the public greeted eagerly. Diseases like measles and whooping cough were familiar childhood afflictions. In most years they killed more children than polio, but polio, which put people in iron lungs and leg braces, was visible in ways that an infant’s death certificate, tucked away in a drawer, could never be.

Vaccines are often a hard sell, since they prevent rather than cure disease and seem scary even though they are generally quite safe. Since vaccines must be widely used to prevent outbreaks, successful vaccination campaigns rely heavily on trust in those who sell, recommend and administer the medicines. And trust in science, government and business has not always been in steady supply.

In the late 1800s and early 1900s, when public health laws were in flux, authorities battling smallpox epidemics would often send vaccinators out with police to enforce the jab. They’d enter factories where cases had been reported, lock the doors and frog-march the workers through a vaccination line. The workers’ resistance was not unmerited; the vaccine sometimes caused swollen arms, fever and bacterial infections. Vaccination could cost a week’s missed wages.

Authorities had learned their lesson by the 1920s, when the diphtheria vaccine came on the scene, as James Colgrove notes in his book “State of Immunity: The Politics of Vaccination in Twentieth-Century America.” Diphtheria was a much-feared killer of children, and publicity campaigns run by public health officials, insurance companies and charities sought to educate and persuade rather than coerce.

Polio terrified Americans, peaking in 1952 with more than 57,000 cases. In 1938, President Franklin D. Roosevelt, himself a polio patient, had begun a national scientific program to battle the disease, backed by millions of Americans’ contributions through the March of Dimes.

The result of this national quest, uniting government and the people, was Jonas Salk’s inactivated polio vaccine. It cemented a powerful post-World War II trust in the U.S. scientific and medical establishment that would endure for many years.

Social solidarity was also important.

Vaccines prevent the circulation of a disease among the unvaccinated via what scientists call herd immunity — if enough people are vaccinated. When a reliable rubella vaccine became available in 1969, states quickly required childhood vaccination, even though rubella was practically harmless in children. They wanted to protect a vulnerable population — pregnant women — to prevent a repeat of the 1963-64 congenital rubella epidemic, which resulted in 30,000 fetal deaths and the birth of more than 20,000 babies with severe disabilities.

The embrace of the rubella vaccine, as historian Elena Conis of the University of California-Berkeley notes in her book, “Vaccine Nation: America’s Changing Relationship With Immunization,” marked the first time a vaccine had been deployed that offered no direct benefit to those who were vaccinated.

Still, it took a combination of fear, solidarity — and coercion — for Orenstein and his colleagues at the CDC and state public health agencies to drive childhood vaccination rates for measles, whooping cough, rubella and diphtheria to 90% and above in the 1990s to assure herd immunity.

Shame was also a tool. Orenstein remembered testifying to the Florida Legislature when it was considering a tougher vaccine mandate. He showed them that disease rates were lower in neighboring states that had tighter mandates. It worked.

What’s different now? In a politically divided nation, trust in science is low and experts are distrusted, politicians more so. Childhood vaccination efforts are already beset by large numbers of hesitant parents. And efforts to fight the COVID epidemic in the United States have been clumsy and chaotic at best, leaving Americans to doubt the competence of their governments and institutions.

There is still fear. “Maybe I’m an old-fashioned fool, but I think that most people will welcome a vaccine, if the rollout is done right,” said David Oshinsky, a professor of history at New York University and author of “Polio: An American Story,” a Pulitzer Prize-winning history. “Most people are desperately afraid of COVID. A minority thumb their noses, many of them for political reasons. How will this change when there’s a vaccine that [hopefully] changes the health risk equation to some degree?”

Recent surveys show as few as half of Americans are determined to be vaccinated against COVID-19. Those numbers could change depending on a number of hard-to-predict factors, said Conis of Berkeley.

“A lot of people will be really eager to get it,” she said. “A lot will be hesitant, not only because of misinformation but because of a lack of trust in the current administration.”

When a coronavirus vaccine is introduced, it may be sold as personal protection, even for young, healthy people. But those who suffer most from the virus are usually older or sicker. An effective vaccination campaign may try to instill a sense of solidarity, or altruism, as well as a more general sense that without vaccination, the economy can’t get back on its feet.

“I’m not clear if people accept that solidarity,” Orenstein said. “People look more for what’s good for themselves than what’s good for society.” That said, the risk of COVID-19 to young people is “not zero. That’s one of the major ways to sell this, in a sense.”

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.

USE OUR CONTENT

This story can be republished for free (details).

MEDFORD, Ore. — From the outside, it appears to be just another suburban allergy clinic, a tidy, tan brick-and-cinder-block building set back from a busy highway and across the road from an auto parts store.

But inside the offices of the Clinical Research Institute of Southern Oregon, Dr. Edward Kerwin and his staff are part of the race to save the world.

Kerwin, 63, was tapped this spring to lead one of the nearly 90 U.S. clinical trial sites taking part in the large-scale, phase 3 test of a vaccine produced by biotech startup Moderna to fight the virus that causes COVID-19.

Starting in late July, Kerwin’s clinic, set in a working-class region roughly halfway between Seattle and San Francisco, began enrolling up to 40 participants a day for the two-year study. He hopes to recruit as many as 700 volunteers by the end of August.

They’ll join the 30,000 test subjects needed nationwide to determine whether the Moderna vaccine can tame a disease that has infected 5.4 million Americans and claimed the lives of more than 170,000. Another vaccine, produced by Pfizer and BioNTech, a German company, is being tested in nearly 30,000 more recruits.

“It’s a perfect opportunity for science to come to the rescue,” said Kerwin, a lanky figure in a bright-blue shirt and khaki pants. He led visitors to a conference room, took a chair well outside social-distancing range and doffed his mask, the better to explain the magnitude of this moment.

He acknowledged “it may seem like a surprise” that Medford is the site of a clinical trial to halt the world’s biggest medical challenge in a century. But Kerwin, who worked as a NASA scientist before heading to medical school and a career in allergy, asthma and immunology, has led more than 750 clinical trials over the past quarter-century, mostly focused on asthma, lung disease and skin disorders.

He moved to southern Oregon in 1993, choosing the rural Rogue Valley because of its beauty and cultural opportunities, such as the Oregon Shakespeare Festival in Ashland. As his medical expertise grew, he built a top-enrolling clinical trial site that coexists with a clinic that treats asthma and allergy patients. Along the way, he established deep roots in the valley, where he founded Bel Fiore, a $10 million winery and vineyard that features a 19,000-square-foot chateau.

Even with his experience, however, testing a vaccine to halt a global pandemic is a challenge like no other, Kerwin said. When the call came from Velocity Clinical Research — the North Carolina-based company that operates Kerwin’s clinic, known as CRISOR, and more than a dozen other COVID trial sites across the U.S. — he paused for a moment.

“You take a big gasp and say, ‘Do we have the resources to do this?’” Kerwin said. “You definitely do it, but you want to do your homework.”

So far, the testing is going well, he said. Unlike most clinical trials, for which it’s difficult to recruit enough volunteers, the COVID effort has attracted intense interest. All of Velocity’s sites are paying participants $1,962 for the two-year trial, but Kerwin’s staff of two dozen didn’t advertise widely at first.

“We would worry our phone would ring off the hook,” Kerwin said.

The Medford clinic is the only COVID vaccine clinical trial site in Oregon, so participants have come from as far as Portland, nearly 300 miles north.

It’s a prime example of the gamble drugmakers and federal trial sponsors take when deciding where to host large-scale COVID clinical trials. To gauge whether the vaccine works, you need to know there’s a good chance participants will be exposed to the virus in the environment. Ethically, in traditional phase 3 trials, you can’t deliberately infect people with COVID, a disease with no treatment or cure, though some propose doing just that in controversial human challenge trials.

Southern Oregon has not been a hot spot for COVID, with fewer than 500 confirmed cases and two deaths in Jackson County, which includes Medford. But, Kerwin said, it’s at risk of becoming one, offering the opportunity to vaccinate trial participants before the virus becomes widespread.

“It’s almost too late in New York and Arizona,” he said.

In the meantime, he’s trying to shift the odds that trial volunteers will be exposed to COVID-19 by reaching out to people at greater risk of infection.

So Kerwin’s team has contacted businesses in industries such as agriculture and food production, where the disease has been known to spread with particular virulence. Locally, that includes employers such as Harry & David, the food retailer famous for its fruit-of-the-month shipments, and Amy’s Kitchen, the maker of vegetarian frozen meals, which operates a production plant in the area.

The Medford trial site is also emphasizing enrollment of elder volunteers, those age 65 and up, who are at higher risk of serious illness or death from the coronavirus.

One of the first volunteers was Trish Malone, a 68-year-old cultural anthropologist who lives in Ashland. Like many of the other participants, she has enlisted in Kerwin’s previous clinical trials of devices to treat asthma. When clinic staffers reached out to ask whether she’d participate in the COVID trial, she didn’t hesitate.

“I said, ‘Wow, yes,’” Malone recalled. “It’s because of [Kerwin] and his expertise. Little Medford gets to have this testing.”

Participating is a way to “give back” to her community, said Malone, who sat, calm and still, on a recent Thursday as study coordinator Audrey Kuehl sank the injection into Malone’s left shoulder.

“She was fast. It was no pain, and it was fine,” Malone said.

Half of the patients in the trial will receive two doses, 28 days apart, of the Moderna vaccine, called mRNA-1273. It uses a snippet of the genetic code of the coronavirus, not the virus itself, to instruct cells to produce a protein that triggers an immune response to protect against infection. The other half will receive a placebo, or saline dummy shot.

Three study coordinators at the Medford clinic, Kuehl among them, know which patients receive which dose, but the information is kept from volunteers and other staff members — including Kerwin, the principal investigator.

Participants who receive the vaccine may experience some side effects, such as redness at the injection site, muscle soreness, fatigue or headache, Kerwin said. “It’s a sign the vaccine is working with your immune system,” he said.

Four days after her first injection, Malone was disappointed to report no reaction at all. “I am bummed, totally bummed,” she said. “I have no symptoms. I think I got the placebo.”

That may not be true, of course. Even if it is, Malone said, she’s happy to participate in an effort that may help stop the deadly virus.

“This a global pandemic,” she said. “What can I do to help?”

The study will run for two years so that investigators can track the longer-term effects of the vaccine. Malone will keep a diary of her temperature and symptoms, if any, and have regular blood tests to determine whether she has antibodies to the virus.

Kerwin is optimistic about the chances the Moderna vaccine will work, agreeing with Dr. Anthony Fauci, the nation’s top infectious disease expert, who predicted the study could demonstrate efficacy by November or December. Kerwin estimates that the vaccine could prove 90% effective, though outside infectious disease experts said it’s far too soon to tell.

Even if the trial shows the vaccine is successful, it would take months longer to produce and deliver enough injections for the U.S. and beyond.

As he enrolls patients and awaits data, Kerwin said, he’s mindful of the real-world implications of his work. His mother, in her 90s, lives in a Denver nursing home where, so far, there have been no cases of COVID-19. But the threat looms.

The tragedy of the pandemic has underscored the promise of science — and the interconnectedness of people far beyond this small corner of Oregon.

“Immunology has never been more fascinating than it is today,” he said. “This is a year that reminds us we cannot live in isolation and do not live in isolation from the world.”

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.

USE OUR CONTENT

This story can be republished for free (details).

Shortages of personal protective equipment and medical supplies could persist for years without strategic government intervention, officials from health care and manufacturing industries have predicted.

Officials said logistical challenges continue seven months after the coronavirus reached the United States, as the flu season approaches and as some state emergency management agencies prepare for a fall surge in COVID-19 cases.

Although the disarray is not as widespread as it was this spring, hospitals said rolling shortages of supplies range from specialized beds to disposable isolation gowns to thermometers.

“A few weeks ago, we were having a very difficult time getting the sanitary wipes. You just couldn’t get them,” said Dr. Bernard Klein, chief executive of Providence Holy Cross Medical Center in Mission Hills, California, near Los Angeles. “We actually had to manufacture our own.”

This same dynamic has played out across a number of critical supplies in his hospital. First masks, then isolation gowns and now a specialized bed that allows nurses to turn COVID-19 patients onto their bellies — equipment that helps workers with what can otherwise be a six-person job.

“We’ve seen whole families come to our hospital with COVID, and several members hospitalized at the same time,” said Klein. “It’s very, very sad.”

Testing supplies ran short as the predominantly Latino community served by Providence Holy Cross was hit hard by COVID, and even as nearby hospitals could process 15-minute tests.

“If we had a more coordinated response with a partnership between the medical field, the government and the private industry, it would help improve the supply chain to the areas that need it most,” Klein said.

Klein said he expected to deal with equipment and supply shortages throughout 2021, especially as flu season approaches.

“Most people focus on those N95 respirators,” said Carmela Coyle, CEO of the California Hospital Association, an industry group that represents more than 400 hospitals across one of America’s hardest-hit states.

She said she believed COVID-19-related supply challenges will persist through 2022.

“We have been challenged with shortages of isolation gowns, face shields, which you’re now starting to see in public places. Any one piece that’s in shortage or not available creates risk for patients and for health care workers,” said Coyle.

At the same time, trade associations representing manufacturers said persuading customers to shift to American suppliers had been difficult.

“I also have industry that’s working only at 10-20% capacity, who can make PPE in our own backyard, but have no orders,” said Kim Glas, CEO of the National Council of Textile Organizations, whose members make reusable cloth gowns.

Manufacturers in her organization have made “hundreds of millions of products,” but, without long-term government contracts, many are apprehensive to invest in the equipment needed to scale up the business and eventually lower prices.

“If there continues to be an upward trajectory of COVID-19 cases, not just in the U.S. but globally, you can see those supply chains breaking down again,” Glas said. “It is a health care security issue.”

For the past two decades, personal protective equipment was supplied to health care institutions in lean supply chains in the same way toilet paper was to grocery stores. Chains between major manufacturers and end users were so efficient, there was no need to stockpile goods.

But in March, the supply chain broke when major Asian PPE exporters embargoed materials or shut down just as demand increased exponentially. Thus, health care institutions were in much the same position as regular grocery shoppers, who were trying to buy great quantities of a product they never needed to stockpile before.

“I am very concerned about long-term PPE shortages for the foreseeable future,” said Dr. Susan Bailey, president of the American Medical Association.

“There’s no question the situation is better than it was a couple of months ago,” said Bailey. However, many health care organizations, including her own, have struggled to obtain PPE. Bailey practices at a 10-doctor allergy clinic and was met with a 10,000-mask minimum when they tried to order N95 respirators.

“We have not seen evidence of a long-term strategic plan for the manufacture, acquisition and distribution of PPE” from the government, said Bailey. “The supply chain needs to be strengthened dramatically, and we need less dependence on foreign goods to manufacture our own PPE in the U.S.”

Some products have now come back to be made in the U.S. — although factories are not expected to be able to reach demand until mid-2021.

“A lot has been done in the last six months,” said Rousse. “We are largely out of the hole, and we have planted the seeds to render the United States self-sufficient,” said Dave Rousse, president of the Association of the Nonwoven Fabrics Industry.

In 2019, 850 tons of the material used in disposable masks was made in the U.S. Around 10,000 tons is expected to be made in 2021, satisfying perhaps 80% of demand. But PPE is a suite of items — including gloves, gowns and face shields — not all of which have seen the same success.

“Thermometers are becoming a real issue,” said Cindy Juhas, chief strategy officer of CME, an American health care product distributor. “They’re expecting even a problem with needles and syringes for the amount of vaccines they have to make,” she said.

Federal government efforts to address the supply chain have foundered. The Federal Emergency Management Agency, in charge of the COVID-19 response, told congressional interviewers in June it had “no involvement” in distributing PPE to hot spots.

Project Airbridge, an initiative headed by Jared Kushner, President Donald Trump’s son-in-law, flew PPE from international suppliers to the U.S. at taxpayer expense but was phased out. And the government has not responded to the AMA’s calls for more distribution data.

Arguably, Klein is among the best placed to weather such disruptions. He is part of a 51-hospital chain with purchasing power, and among the institutions that distributors prioritize when selling supplies. But tribulations continue even in hospitals, as shortages have pushed buyers to look directly for manufacturers, often through a swamp of companies that have sprung up overnight.

Now distributors are being called upon not just by their traditional customers — hospitals and long-term care homes — but by nearly every segment of society. First responders, schools, clinics and even food businesses are all buying medical equipment now.

“There’s going to be lots of other shortages we haven’t even thought about,” said Juhas.

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.

USE OUR CONTENT

This story can be republished for free (details).