Governors continue to open indoor dining and other activities before vaccinations become widespread. Experts warn this could create superspreading playgrounds for dangerous variants and squander our best shot at getting the pandemic under control.
This article was published on Saturday, February 6, 2021 in ProPublica.
On Jan. 29, New York Gov. Andrew Cuomo was promoting “marital bliss” at a coronavirus news conference.
Announcing that indoor dining would reopen at 25% capacity in New York City on Valentine’s Day, and wedding receptions could also resume with up to 150 people a month after, Cuomo suggested: “You propose on Valentine’s Day and then you can have the wedding ceremony March 15, up to 150 people. People will actually come to your wedding because you can tell them, with the testing, it will be safe. … No pressure, but it’s just an idea.”
Cuomo isn’t alone in taking measures to loosen pandemic-related restrictions. Michigan Gov. Gretchen Whitmer allowed indoor dining to resume at 25% capacity starting Feb. 1. Idaho Gov. Brad Little increased limits on indoor gatherings from 10 to 50 people. Massachusetts Gov. Charlie Baker is raising business capacity from 25% to 40%, including at restaurants and gyms. California Gov. Gavin Newsom lifted stay-at-home orders on Jan. 25.
To justify their reopening decisions, governors point to falling case counts. “We make decisions based on facts,” Cuomo said. “New York City numbers are down.”
But epidemiologists and public health experts say a crucial factor is missing from these calculations: the threat of new viral variants. One coronavirus variant, which originated in the United Kingdom and is now spreading in the U.S., is believed to be 50% more transmissible. The more cases there are, the faster new variants can spread. Because the baseline of case counts in the U.S. is already so high — we’re still averaging about 130,000 new cases a day — and because the spread of the virus grows exponentially, cases could easily climb past the 300,000-per-day peak we reached in early January if we underestimate the variants, experts said.
Furthermore, study after study has identified indoor spaces — particularly restaurants, where consistent masking is not possible — as some of the highest-risk locations for transmission to occur. Even with distanced tables, case studies have shown that droplets can travel long distances within dining establishments, sometimes helped along by air conditioning.
We’re just in the opening stage of the new variants’ arrival in the United States. Experts say we could speed viruses’ spread by providing them with superspreading playgrounds or slow them down by starving them of opportunities to replicate.
“We’re standing at an inflection point,” said Sam Scarpino, assistant professor at Northeastern University and director of the school’s Emergent Epidemics Lab. Thanks to the arrival of vaccines, he said, “we finally have the chance right now to bring this back under control, but if we ease up now, we may end up wasting all the effort we put in.”
Dr. Luciana Borio, an infectious disease physician who was a member of the Biden-Harris transition team’s COVID-19 advisory board, put it more bluntly at a congressional hearing on Feb. 3. “Our worst days could be ahead of us,” she said.
I interviewed 10 scientists for this story and was surprised by the vehemence of some of their language. “Are you sure it could be that bad?” I asked, over and over.
They unanimously said they expected B.1.1.7, the variant first discovered in the U.K., to eventually become the dominant version of coronavirus in the U.S. The Centers for Disease Control and Prevention has estimated that B.1.1.7 will become dominant in March, using a model that presumes it’s 50% more transmissible than the original “wildtype” coronavirus. The model’s transmission rate was based on experience in the U.K., which first detected B.1.1.7 in September and saw an increase in cases that became apparent in December, straining hospitals despite stringent closures and stay-at-home orders. So while our country appears relatively B.1.1.7-free right now, the situation could look drastically different in a matter of months.
Experts are particularly concerned because we don’t have a handle on exactly how far B.1.1.7 has spread. Our current surveillance system sequences less than 1% of cases to see whether they are a variant.
Throwing an even more troubling wrench into the mix is that B.1.1.7 is continuing to morph. Just this week, scientists discovered that some B.1.1.7 coronaviruses in Britain had picked up a key change, known as the E484K mutation. That mutation had previously been found in the B.1.351 variant, which was first discovered in South Africa. Scientists have hypothesized that it’s the E484K mutation that has reduced the efficacy of some vaccines in South African trials, so this is incredibly worrying news.
“It’s really hard to thread this needle without sounding like a prophet of doom,” said Angela Rasmussen, a virologist at Georgetown University’s Center for Global Health Science and Security. While vaccines bring hope, she said, governors who are moving to expand indoor dining are “completely reckless”; if they don’t course correct, “I don’t think it’s hyperbolic to say the worst could be yet to come.”
The choices that our federal and state leaders make right at this moment will determine if we can bend the curve once and for all and start ending the pandemic, or if we ride the rollercoaster into yet another surge, this one fueled by a viral enemy harder to fight than ever before.
All of us have agency in deciding this narrative, Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, stressed. “Certainly you need to be prepared for the possibility that things might get worse in the light of the variants, but that is not inevitable because there are things that we can do to mitigate against it,” he said in an interview. “We're not helpless observers of our own fate."
Fauci urged states to “double down on your public health measures … to have virtually everybody wear masks, to have everyone maintain social distance, to have everybody avoid congregate settings, and to have everybody wash their hands very frequently.”
And don’t wait until it’s too late, warned Michael Osterholm, director of the Center for Infectious Disease Research and Policy at the University of Minnesota.
“We are so good at pumping the brakes after we’ve wrapped the car around the tree,” he said. The new variants aren’t being complacent. “There’s still a lot of human wood out there for this coronavirus to burn.”
To understand the epidemiologists’ warnings, it helps to understand what variants are, how they have been behaving and our limitations in knowing exactly how far they have spread.
People have a bad habit of anthropomorphizing the coronavirus: ascribing human-like intentions to it, as if a microbe can discern that we finally have a vaccine and try to evade it. But viruses don’t really have any schemes; they just reproduce. “Coronaviruses are a single strand of RNA in a sac of fat,” epidemiologist Larry Brilliant reminded me. “They’re preprogrammed to replicate and continue replicating. That’s their job.”
Once in a while, when a virus replicates, a mistake occurs, and a letter in the strand of RNA is copied inaccurately. That’s called a mutation. Many times, those mutations are neutral. Sometimes they are detrimental to the virus, and that lineage will quickly die off. Other times, they’re beneficial to the virus in some way, such as by making it more transmissible. When a version of the virus becomes functionally different, that’s when scientists consider it a variant.
As of Feb. 4, according to the CDC, the U.S. has found 611 cases of B.1.1.7, the variant first discovered in the United Kingdom, five cases of B.1.351, first identified in South Africa, and two cases of P.1., first identified in Brazil. But that’s almost certainly an undercount.
Part of the reason why epidemiologists are advocating for us to stay hunkered down is because the U.S. doesn’t know exactly where all the variant cases are.
The term that public health uses is “surveillance.” I like to think of it as having eyes on the virus. In order to have good eyes on where coronavirus infections are in general, all you need is the regular swab tests that we’re all familiar with. But in order to tell whether a positive case is the wildtype coronavirus or one of the more nasty variants, an additional step is needed: genomic sequencing. For that, the sample needs to be sent on to a lab that has specialized machinery capable of conducting sequencing.
Until recently, sequencing in the U.S. was a patchwork effort, conducted by a mix of academic and public health agency labs keen to track the evolution of the coronavirus. Though the CDC hosted a weekly call where those scientists already conducting sequencing could compare notes, there was no dedicated federal funding or coordination to ensure that samples were routinely gathered from across the country.
Today, the U.S. sequences less than 1% of its total cases. This is a pittance compared to the U.K., which sequences around 8-10% of its positive test results. But volume alone isn’t the only thing that matters. Representation, meaning where the samples come from, is another crucial factor. Since most of the sequencing so far has come from voluntary efforts, the U.S. has suffered from uneven visibility, with a whole bunch of eyeballs in parts of the country that are biotechnology and academic hubs, like Boston, San Francisco and San Diego, and less in “surveillance deserts” like North and South Dakota. There, barely any samples have been sequenced at all, even when those states had explosions of COVID-19 cases.
Dr. Phil Febbo is chief medical officer at Illumina, one of the world’s biggest sequencing technology companies. Like so many parts of the coronavirus response, keeping a lookout for variants has suffered from a lack of federal leadership, Febbo said. As early as March of last year, Illumina representatives began meeting with federal agencies, advocating for a national genomic surveillance system.
“We talked to any three-lettered agency we could,” Febbo said. “Those conversations were cordial: They said they heard what we were saying, but then they’d say, ‘But we need more tests, but can you do it in five minutes, can it be point-of-care?’” It wasn’t until Dec. 18, when B.1.1.7 was taking off in the United Kingdom, that Illumina finally got a call from the CDC offering to sign a contract with the company. (Since December, CDC has engaged Illumina to do surveillance work by signing twocontracts potentially worth up to $4.6 million.)
Today, Illumina sequences positive samples that are passed on from a diagnostic testing company, Helix. Each RNA strand of the SARS-CoV-2 virus has about 30,000 nucleotides, each represented by one of four letters. Illumina’s sequencers read through each sample’s code and compare each letter to a reference sequence, looking for significant changes. The data gets passed back to the CDC, which uses location data stripped of personal identifiers to map the spread of any variants that Illumina has picked up.
The CDC said it has contracted with several large commercial companies with the goal of sequencing up to 6,000 samples a week by mid-February. Through another program, called the National SARS-CoV-2 Strain Surveillance System, state public health labs are supposed to send a total of 1,500 samples to the agency every other week. This program went into effect on Jan. 25 and is still ramping up, according to a CDC spokesperson.
Febbo says more can be done to increase surveillance. He notes that the Biden administration, while clearly more invested in variant surveillance than the Trump administration, hasn’t set a public target in the same way it has for vaccinations with its “100 million shots” campaign. Illumina estimates that sequencing 5% of all samples would allow us to be confident that we are catching all variants of concern, and he would like the Biden administration to make that a public goal. It can be done, Febbo says: “It hasn’t been the lack of capacity, it’s been the lack of will.”
Having clearer information about where variants are would give governors and local officials actual information with which to make decisions. Then they could say with confidence, “We can open indoor dining because we know that the variants aren’t circulating in our community.” Absent that information, the only thing we can do is act like the variants are here.
The good news is that so far, the vaccines that have been made available to the public appear to be reasonably effective against the coronavirus variants. They may be slightly less effective against B.1.351, the variant discovered in South Africa, but none of the variants are total “escapes,” so a vaccine should offer you at least partial protection against any form of the coronavirus you encounter.
All of the available shots give your immune system some familiarity with the virus, allowing it to be more prepared to meet the bug in the wild, whether it’s the original strain or a variant. Having a savvier immune system, in turn, means that even if you do get infected, you’re less likely to need to be hospitalized, and less likely to die.
“Regardless of what’s happening with this variant, we’re much better with [people’s immune systems] seeing SARS-CoV-2 after seeing the vaccine than not,” said Derek Cummings, a biology professor at the University of Florida’s Emerging Pathogens Institute.
However, we’re not very far along with vaccinations yet. As of Feb. 4, only 2.1% of the U.S. population had been reported to have received both doses of the vaccine; 8.5% had received one dose. That means we’re in a precarious moment right now where the vast majority of the U.S. hasn’t had a chance to get protected, and the variants have a window to multiply. (Of course, those who have already gotten sick with COVID-19 have natural immunity, but some scientists are concerned that those who develop only mild symptoms may not gain as much innate immunity as those who receive a vaccine.)
Of the scientists I talked to, Caitlin Rivers, a computational epidemiologist at Johns Hopkins Center for Health Security, was the most optimistic about a potential variant-fueled surge. “I do think that B.1.1.7 has the possibility to precipitate a wave, but it probably won’t be as bad as the last wave, because we have a lot of preexisting immunity and we are rolling out the vaccines,” she said. Thanks to the vaccines, the U.S. will have more population immunity by March, when the CDC predicts B.1.1.7 will become dominant, than the U.K. did when the variant hit there late last year. “It’s a low likelihood that we will have a gigantic fourth wave, but not impossible,” she said.
Still, Rivers said, “now is not the time to relax.” She, too, was critical of state policies to loosen restrictions. “When you create the same conditions that allowed the last surge, you should expect the same results,” she said. “Our main move should be to reduce transmission as much as possible while we vaccinate as much as possible.”
Time is not on our side, as the morphing B.1.1.7 variant showed us when it picked up the E484K mutation. While we are lucky that our vaccines still work against the current variants, we have to keep in mind that in this race between vaccines and variants, the variants aren’t staying static.
The big fear is that eventually, a variant will come along that provides the virus with a complete immune escape, preventing our vaccines from working against it. Even though we can update our vaccines, that would take time. The only way to guarantee that the virus won’t mutate into a variant that our current vaccines don’t cover is to lower transmission significantly, said genomic epidemiologist Alli Black: “The virus will continue to mutate as it continues to spread. We’re not going to stop that biological fact unless transmission stops.” And vaccinating everyone quickly is one key way to make it harder for the coronavirus to get from person to person in the first place.
“We need to start responding like the variants are going to take over and they are one of the biggest threats,” said Cummings, “or we won’t have vaccinated enough people when this rolls through.”
Throughout this pandemic, the U.S. has often been in the fortunate position of not being first when it comes to novel viral encounters. We weren’t the country where SARS-CoV-2 originated. We weren’t the place where B.1.1.7 was spawned. We’ve had the opportunity to look to other countries and learn from them, if only we’d choose to.
Epidemiologist after epidemiologist pointed out that the U.K., Denmark and Portugal required drastic measures — the dreaded L word, “lockdown” — to get B.1.1.7 under control. “We’ve seen that multiple different countries in Europe have had to close schools after making it a policy that schools would be the last to close,” Rivers, from Johns Hopkins, noted.
If we don’t want the same fate to befall the U.S., now is the time to act, the scientists urged.
Improving surveillance can help. Utah Public Health Laboratory has a robust state sequencing program, analyzing a random sample of cases sent by the state’s two largest hospital groups. Kelly Oakeson, its chief scientist for next generation sequencing and bioinformatics, has set a goal of sequencing 10% of all cases in the state; his lab is currently doing about 3%. They could do more, he said. The only problem is that they don’t have enough pipette tips due to a national shortage. Oakeson said he’s hoping that the Biden administration will leverage the Defense Production Act to produce more pipette tips so he can increase his state’s surveillance capabilities.
“We can’t get transmission down through vaccination alone,” said Rasmussen, the Georgetown virologist. “We need to be encouraging leadership, both at the state and federal levels, to protect people, to have paid sick leave for people if they become symptomatic.”
A restaurant server in New York City, who was laid off early in the pandemic from a high-end steakhouse, told me he understood what the epidemiologists were saying from a scientific point of view. But, he asked, “if you want to shut everything down, who’s going to pay the bills?”
He continued, “In order to do what the epidemiologists want to get done, you can only do that with policies to support the people and make it worth their while to do it.” He’s job hunting, and he said that if he was offered a position that put him indoors on Valentine’s Day, “I would have to take it.” He’d put on a double mask and go to work.
Whenever we have options, though, individual decisions can make a difference. Black, the genomic epidemiologist, encouraged everyone to limit travel as much as possible: “It just really facilitates introductions of these circulating variants.”
Hang in there, urged Scarpino, the Northeastern professor, painting a hopeful picture: “Cases are coming down, vaccines are going up. Let’s pretend that politicians wake up and don’t reopen restaurants and we avoid a big wave in March. Then we’re running downhill on the vaccines because the pipeline gets better and better. Then we can get our lives back.”
That sounded so tantalizing. Dream-worthy. Just a matter of good science-based public policy and collective compliance driving down the case counts until those little mindless RNA-filled fat sacs have nowhere to go, no one to infect, no way to replicate, no chances to mutate. I imagine them bumping around, lost without crowded indoor spaces to breed in, thwarted by vaccine-boosted immune cells, unable to find a host, dwindling, going, gone.
Private equity firm Leonard Green and other investors extracted $645 million from Prospect Medical before announcing a deal to sell it and leave it with $1.3 billion in financial obligations. Four states approved it — but Rhode Island is holding out.
This article was published on Thursday, February 4, 2021 in ProPublica.
In a David-and-Goliath battle, a group of Rhode Island officials and a union for hospital workers have so far stymied a multi-billion-dollar private equity fund's attempt to unload its controlling stake in a national for-profit hospital chain.
Investors led by the private equity firm, Leonard Green & Partners, previously extracted $645 million in dividends from the investment, and the firm now seeks to leave behind another $1.3 billion in financial obligations at the chain.
In the face of more than a year of often-vehement public opposition in Rhode Island, the hospital chain suddenly agreed in the final days of December to pay $27.25 million to resolve a group of lawsuits they had previously refused to settle. But a Jan. 29 deadline for the state to approve the deal has been extended indefinitely and other obstacles remain.
Leonard Green and the hospital chain, Prospect Medical Holdings, were the subject of a ProPublica investigation in September that explored Prospect's history of patient-care violations — including some that posed "immediate jeopardy" to patients, according to multiple government findings — along with complaints about deteriorating facilities, broken financial commitments and allegations of Medicare fraud surrounding the company. These problems surfaced over the past decade, after the private equity firm purchased the company in 2010. Prospect has defended its quality of care and denied any improprieties.
Leonard Green, which owns about 60% of the hospital chain, announced plans in October 2019 to sell its stake to Prospect CEO Sam Lee and his longtime business partner for $12 million plus the assumption of $1.3 billion in lease obligations. The $12 million is to be paid by the company, not the two executives. As Prospect previously told ProPublica, "In effect, the company's money is their money." At the time the deal was announced, Prospect said it expected the sale to close by the spring of 2020.
The transaction breezed past regulators in four states where Prospect owns a total of 15 hospitals. But not so in Rhode Island, where Prospect owns its other two hospitals. The sale of the two Rhode Island hospitals — and thus the entire deal — requires approval from the state's health department and attorney general, which first must conduct a review process to assure the transaction meets nine statutory criteria.
The Rhode Island officials have subjected the transaction to a high level of scrutiny. There have been multiple rounds of public hearings and questions to both Prospect and Leonard Green, generating thousands of pages of submissions in response. The state has sought details on topics such as COVID-19's impact on the company's finances and has requested interviews with multiple company officials, including the CEO.
As criticism of Prospect grew during 2020, Rhode Island officials first delayed their decision on the sale to November, citing missing documents and unanswered questions, then extended it again to the end of January 2021. On Jan. 18, the health department and attorney general wrote to Prospect confirming that the Jan. 29, 2021 deadline would be "extended," and advised the company, "as of this date, we do not have a new deadline for completing the review."
Proposed legislation in Rhode Island threatens to further stall the deal. The bill comes from state senate president Dominick Ruggerio, a Democrat, who previously wrote a letter urging regulators to subject the Prospect sale to "the utmost scrutiny" and warning that approval posed "a probability of serious harm to the health and welfare of all Rhode Islanders." On Jan. 12, Ruggerio introduced a bill, citing Prospect's two Rhode Island hospitals, that would impose a one-year moratorium on all hospital ownership transfers "involving a for-profit corporation as acquiree or acquiror." The bill has nine co-sponsors.
Prospect and Leonard Green declined to comment on the bill. Responding to questions through an outside spokesman, they said they have no intention of abandoning their plans for the company's sale. "Based on our communications with RI regulators," they stated, "we expect to complete the transaction in the coming months."
Prospect has managed to silence one prominent group of Rhode Island critics by reversing course and, on Dec. 30, agreeing to settle multiple fraud lawsuits with a $27.25-million payment. The money is part of a broader settlement with the court-appointed receiver for the employee retirement plan at Our Lady of Fatima hospital, one of Prospect's two facilities in the state. The plan was declared insolvent and placed in receivership in 2017. The receiver then sued the company, asserting that Prospect had misled the public and 2,700 current and past hospital employees about the pension fund's financial health. The receiver demanded that Prospect help make the fund whole. The company denied the claims, pointing out that its 2014 purchase of the hospitals included contract language absolving it of any future liability for the retirement plan.
The settlement, subject to multiple court approvals that will take several months, will end the receiver's public opposition to Prospect's pending sale. As late as Dec. 10, the receiver's special counsel told a public hearing that Lee and his partner were "predators," using the hospitals "as their private piggy banks." A financial consultant for the receiver also warned in a report that Prospect's financial statements through fiscal year 2019 (even preceding the financial stress caused by the COVID-19 pandemic) revealed a worsening "state of insolvency" and "imminent" bankruptcy, absent a big capital infusion. (A Prospect spokesman disputed the claim, insisting that the company had "ample liquidity." The company's 2020 financial results have not been made public yet.)
The settlement agreement explicitly requires the receiver to notify state regulators that his objections to the sale are withdrawn. It also bars "any statements to media which would reasonably be expected to cause the reader or hearer thereof to question the solvency or honesty of, or the quality of care or other services provided by" Prospect.
Other Prospect critics remain undeterred. They include United Nurses & Allied Professionals, the union for hospital workers at Our Lady of Fatima; elected officials, including five Democratic members of the U.S. Congress, Rhode Island's state treasurer and its senate majority leader; and the Private Equity Stakeholder Project, a union-backed research group that has produced critical reports about Leonard Green's conduct and lobbied the firm's public pension fund investors.
Prospect has conducted a public relations counter-offensive. After the retirement plan settlement was announced, the company took out a large ad in The Providence Journal, stating that by making the $27 million payment, it was "helping our retirees and employees," and doing so "because we are fully committed to Rhode Island." A second ad solicited support for the company's sale: "Today, Prospect seeks state approval to allow its founders to buy out the outside investors in Prospect. With all that Prospect has done for Rhode Island, and will continue to do, we hope the state will recognize the benefits and approve this request." The company issued a press release noting that an outside monitor for the state had found that Prospect had met the commitments it had made for capital spending at the two hospitals.
The union is responding to Prospect's claims with a postcard that is being mailed this week to 4,000 state opinion-makers. It warns: "RHODE ISLANDERS BEWARE! PROSPECT MEDICAL HOLDINGS IS A WOLF IN SHEEP'S CLOTHING." The mailer urges recipients to press state officials to reject the proposed sale.
Chris Callaci, general counsel for the Fatima hospital union, said his group is also considering running a radio ad to boost public opposition to the sale. The union, which initially welcomed Prospect's acquisition of the two hospitals in 2014, has waged a series of battles with company management in the years since.
Callaci told ProPublica that attorneys representing Prospect approached him to explore what it would take to get the union to drop its opposition, but that the discussions went nowhere. "We can't find anything that will make us feel comfortable they'll be good stewards of these safety-net hospitals in Rhode Island," he said. "As far as the union's concerned, they're not welcome in Rhode Island."
At least part of the delay in approving the sale in Rhode Island appears to be self-inflicted by Prospect. In late October, the company — which has a lengthy history of litigation — threatened to sue an accounting firm hired by Rhode Island to assess the deal because a former accountant at the firm made critical comments to ProPublica about a company that Prospect CEO Lee had been involved with more than a decade ago. In response, Rhode Island terminated the accounting firm's contract to avoid any "perception of impropriety, motivation, and influence." The state informed Prospect that the termination would delay the review process as Rhode Island needed to hire a new accounting firm. That in turn led Prospect to retract its threat of legal action and say, in effect, never mind.
It was too late. Prospect's about-face, a Rhode Island official responded, couldn't remove "the initial taint of the original receipt of threatened litigation." (Prospect declined to comment on this matter.)
Peter Elkind is a senior reporter covering the Trump administration.
A key House subcommittee cited reports by ProPublica and other news outlets in launching an investigation into how the country's meatpacking companies handled the pandemic, which has killed hundreds of workers to date.
This article was published on Thursday, February 4, 2021 in ProPublica
By Bernice Yeung and Michael Grabell A key congressional panel launched an investigation this week into the wave of COVID-19 infections that killed hundreds of workers at meatpacking plants nationwide last year and highlighted longstanding hazards in the industry.
Since the start of the pandemic, the meat industry has struggled to contain the virus in its facilities, and plants in Iowa, South Dakota and Kansas have endured some of the biggest workplace outbreaks in the country.
The meat companies' employees, many of them immigrants and refugees, slice pig bellies or cut up chicken carcasses in close quarters. Many of them don't speak English and aren't granted paid sick leave. To date, more than 50,000 meatpacking workers have been infected and at least 250 have died, according to a ProPublica tally.
The congressional investigation, opened by the House Select Subcommittee on the Coronavirus Crisis, will examine the role of JBS, Smithfield Foods and Tyson Foods, three of the nation's largest meat companies, which, the subcommittee said, had "refused to take basic precautions to protect their workers" and had "shown a callous disregard for workers' health."
The subcommittee is chaired by Rep. James E. Clyburn of South Carolina, the No. 3 Democrat in the House.
In response to the subcommittee's announcement, officials for JBS and Tyson said that the companies had spent hundreds of millions of dollars to implement coronavirus protections and to temporarily increase pay and benefits, and they looked forward to discussing their pandemic safety efforts with the panel. Smithfield said in a statement that it had also taken "extraordinary measures" to protect employees from the virus, spending more than $700 million on workplace modifications, testing and equipment.
The House subcommittee noted that reports from a variety of news organizations had illuminated problems with how the meatpacking companies handled the pandemic, and with the Occupational Safety and Health Administration's enforcement efforts. The subcommittee cited ProPublica's reporting on how meat companies blindsided local public health departments, and on Nebraska Gov. Pete Ricketts' efforts to intervene when local health officials tried to temporarily shutter a JBS plant amid an outbreak.
ProPublica has also documented how meat companies ignored years of warnings from the federal government about how a pandemic could tear through a food processing facility, and chronicled the role that meatpacking plants like a Tyson pork facility in Waterloo, Iowa, have played in spreading the virus to the surrounding community.
The subcommittee's inquiry will also scrutinize the federal government's shortcomings in protecting meatpacking workers. "Public reports indicate that under the Trump Administration, the Occupational Safety and Health Administration (OSHA) failed to adequately carry out its responsibility for enforcing worker safety laws at meatpacking plants across the country, resulting in preventable infections and deaths," according to the subcommittee's letter to OSHA.
The subcommittee also said that the agency had issued only a "few meager fines" and "failed to show urgency in addressing safety hazards at the meatpacking facilities it inspected." The letter noted that OSHA had received complaints about JBS and Smithfield plants months before the agency conducted inspections.
The council has announced a package of bills to reshape the NYPD and improve officer accountability. A City Council member cited a "direct line" from ProPublica's coverage to the proposals.
David Seligman, a lawyer who helped meatpacking workers in Pennsylvania file a lawsuit against OSHA during the pandemic, said he hopes the subcommittee's efforts are "just one of the initial steps" to holding companies accountable and ensuring workers are safe. "The harm inflicted on meat-processing workers during this pandemic, in service of the profits of corporate meat-packing companies and under a government that seemed happy to turn a blind eye, is a grave scandal," Seligman wrote in an email.
In a statement, a Department of Labor spokesperson said that the subcommittee's inquiry is "focused on the Trump administration's actions surrounding the protection of workers from COVID-19 related risks," and the agency is committed to protecting workers, and that new guidance on coronavirus enforcement that was issued in late January will serve as a "first step."
In its Feb. 1 letters to OSHA, JBS, Tyson and Smithfield, the subcommittee has requested documents related to government inspections at meatpacking plants and COVID-19 complaints lodged with the companies. OSHA was asked to brief the subcommittee by Feb. 15.
Michael Grabell writes about economic issues, labor, immigration and trade. In 2019, he was part of a team that was a finalist for the Pulitzer Prize for public service.
The VA and FEMA agreed to pay a first-time vendor in a desperate search for protective equipment. Now Robert Stewart admits he defrauded three federal agencies and lied about being in the Marine Corps.
This article was published on Thursday, February 4, 2021 in ProPublica
An amateur mask broker who was awarded more than $38 million in federal contracts to provide N95 masks has pleaded guilty to defrauding three different federal agencies as part of a scheme to profit from the COVID-19 pandemic.
Robert Stewart Jr., 35, pleaded guilty to three counts of making false statements, wire fraud and theft of government funds Wednesday in U.S. District Court in the Eastern District of Virginia, including charges that he lied to the Department of Veterans Affairs in April in order to win a $34.5 million no-bid deal to supply personal protective equipment to nurses and doctors in a sprawling health system serving 9 million veterans. He similarly acknowledged lying to the Federal Emergency Management Agency when he stated he had masks "stored securely in our climate control warehouse located in VA and PA," according to his plea agreement.
Stewart was a key figure in a ProPublica investigation published in May in which he invited a reporter to tag along on a doomed mask deal, which produced zero masks for the VA and revealed that Stewart had none and had no plan for finding them or financing a purchase. Stewart's hapless journey provided the first details of a shadowy network of brokers and investors who were pursuing billions in loosely monitored contracts from government agencies desperately trying to deal with the virus.
"Mr. Stewart made intentionally false statements to the VA and to FEMA in order to be awarded lucrative contracts," U.S. Attorney William Fitzpatrick, head of the district's Financial Crimes and Public Corruption Unit, told the court Wednesday.
"At the time, Mr. Stewart made these representations, he well knew he didn't possess the masks."
Stewart and his Arlington, Virginia-based business, Federal Government Experts LLC, were not ultimately paid by the VA for masks because none were delivered.
Federal agencies have hired contractors with no experience to find respirators and masks, fueling a black market filled with price gouging and multiple layers of profiteering brokers. One contractor called them "buccaneers and pirates."
But Stewart did collect a huge payday from another government program responding to the pandemic, the Paycheck Protection Program, or PPP. Stewart pleaded guilty to wire fraud and a scheme to defraud the Small Business Administration, which guaranteed $350 billion in loans to help struggling businesses stay afloat, many of which could be forgiven.
Federal prosecutors alleged that Stewart, trying to collect federally backed bank loans, provided false tax forms showing his business employed 37 people for a total quarterly payroll of $960,000, when his business actually employed nine people. Celtic Bank approved Federal Government Experts' PPP loan of $805,000, most of which Stewart has repaid to the bank, according to court filings.
Stewart also pleaded guilty to collecting about $261,000 on false pretenses from another small business loan program, the Economic Injury Disaster Loan Program, which provides low-interest financing to struggling small businesses during disasters.
The prosecutor told the judge that Stewart gave about $60,000 of that cash to himself as wages and also spent lavishly, including renting a private jet to hunt down masks, which ProPublica reported last spring.
"There was definitely some extravagant spending," the prosecutor said.
Stewart, who declined comment in the courtroom Wednesday, is an Air Force veteran, a designation which gave him an edge when seeking federal contracts, especially from the VA. But prosecutors said that in a separate scheme, he claimed to be a decorated veteran of the Marine Corps, which was untrue.
From September 2013 to October 2020, Stewart collected nearly $74,000 in medical and educational benefits from the VA by falsely claiming he had been honorably discharged at the rank of Marine corporal. Stewart also pleaded guilty to that charge, which carries a maximum penalty of 10 years in prison and a fine of $250,000.
Last year, when ProPublica asked Stewart to explain what designated his business as owned by a disabled veteran, which gives an edge in contract competition, he declined to provide a specific disability.
As Stewart entered his plea, Judge Rossie Alston Jr. at one point turned to him and said, "I was inclined after reading what you did to lock you up."
But prosecutors did not object to Stewart's request that he remain free under court supervision while his lawyer negotiates terms for him to aid in a separate congressional investigation into the failed federal coronavirus response.
Stewart's sentencing is scheduled for June. He faces a maximum penalty of 35 years in prison.
An audit found that the time it takes the Louisiana Department of Environmental Quality to issue penalties to polluters has doubled. Some companies that have been known to violate air quality rules were able to keep at it for years, or even decades.
This article was published on Friday, January 29, 2021 in ProPublica.
By Mark Schleifstein
The Louisiana Department of Environmental Quality needs to do a better job of identifying industrial polluters that don't properly report emission violations, and it should enforce those violations more aggressively, according to a new management audit by the Louisiana Legislative Auditor’s office.
Many of the audit's findings tracked those of a 2019 investigation by The Times-Picayune, The Advocate and ProPublica.
The newsrooms showed how emissions of cancer-causing chemicals from clusters of large industrial facilities in seven parishes along the lower Mississippi River combine to increase overall air toxicity for nearby residents. Overall, the analysis found that a crush of new industrial plants will increase the levels of cancer-causing chemicals in the air of predominantly Black and poor communities.
The auditor’s report found that the time it took for the LDEQ to issue enforcement actions after a known violation more than doubled between fiscal year 2015 and 2019, from nearly 10 months to nearly 20 months.
Auditors also found it could take as long as nine years from the time a company was cited for violating emission standards before it was ordered to pay a fine or was required by a settlement to pay for a mitigation project.
“Overall, we found DEQ could strengthen its monitoring and enforcement processes by identifying violations and issuing enforcement actions in a timelier manner,” Legislative Auditor Daryl Purpera said in a cover letter to the report.
“As a result, there is a risk that facilities may have violations that remain uncorrected for years,” an audit summary said. “Best practices state that effective enforcement includes swift and predictable responses to violations.”
The DEQ also needs to do a better job identifying facilities that fail to submit self-monitoring reports on emissions, and to speed its review of the reports for violations, the audit said. The auditors also found the agency doesn’t adequately track the penalties it has assessed or whether the penalties were paid.
Part of the agency’s enforcement problems can be traced to DEQ’s reduced number of employees, employees’ high workloads, frequent staff turnover “and ineffective data systems,” the audit said.
“Louisiana has the highest toxic air emissions per square mile of any state,” the report said, based on data gathered by the U.S. Environmental Protection Agency's 2018 Toxics Release Inventory, a self-reported measurement of toxic chemicals released into the air, land or water by individual facilities.
Based on TRI data, the audit said, in 2018, Louisiana had an average of 1,239 pounds of toxic air releases per square mile. Ohio, the state with the second-highest air emissions rate, averaged 899 pounds per square mile.
The audit also pointed to the EPA’s most recent National Air Toxics Assessment, from 2014, which identified a number of Louisiana locations where emissions from nearby manufacturing facilities are linked to a high potential for cancer risks or high respiratory illness hazards.
But the audit also pointed out that its criticisms come amid better news about some forms of air pollution in Louisiana. It pointed out that the EPA’s AirNow website’s daily reports of air pollution issues — mostly ground-level ozone and particulate matter — indicated that “good air quality” days in Louisiana had increased by 21% between 2008 and 2018, and the number of “unhealthy days for sensitive groups” had decreased by 71%.
The audit noted that several areas of the state “are highly industrialized and have high concentrations of air pollution” involving chemicals not measured by AirNow. The EPA does not regularly monitor cancer-causing chemicals such as chlorine and ethylene oxide, which the 2019 investigation by ProPublica, The Times-Picayune and The Advocate highlighted as being elevated in certain parts of Louisiana’s industrial river corridor.
The report included 11 major recommendations. A response included in the report from DEQ Secretary Chuck Carr Brown said the agency generally agreed with 10 of them.
The only one they’re at odds over is a recommendation that DEQ inspectors take photographs or gather other hard evidence that will show inspections actually take place. Brown pointed out that inspectors fill out a field interview form during the inspection that is left at the facility, and that copies are signed by both the inspectors and facility employees.
But the audit report pointed out that the DEQ had to notify both the state legislative auditor and the EPA’s inspector general that a former employee had falsified at least three compliance investigations.
The facilities involved were not named in the report.
A spokesman for the DEQ said the skipped inspections were the fault of an employee who left the agency before they were discovered.
In his response included in the audit, Brown said DEQ is developing its own software to allow the staff to better track violations. When complete, it should also issue notices to staffers if reports aren’t submitted on time or if a new violation shows up in a company’s records. Brown did not say when the software would be ready.
Other findings of the audit include:
The DEQ should vary when it inspects facilities so the inspections are less predictable. DEQ agreed.
DEQ should develop goals for how long it should take to issue enforcement actions and track their progress. Again, DEQ agreed.
DEQ should establish a process requiring facilities to submit settlement offers within a certain time frame, such as six months, and draft a penalty amount for those who do not comply. This recommendation is aimed at shortening the time between when a company is notified of a penalty and when the agency issues a final penalty decision, a span that now often lasts several years. DEQ mostly agreed, but it pointed out that compliance orders and notices of potential penalty are subject to appeal, which can delay the process.
DEQ management should determine whether staffing levels are sufficient and, if not, should request funding for additional staff. DEQ agreed to consider moving staff within its divisions, but said requesting more money was likely to be a problem.
The Legislative Auditor’s office has produced a podcast explaining the highlights of its report for members of the Legislature.
A report by New York Attorney General Letitia James says that a survey of dozens of nursing homes suggests the number of residents who died of COVID-19 could be a huge undercount.
This article was published on Thursday, January 28, 2021 in ProPublica.
Thousands more New York state nursing home residents may have died of COVID-19 than Gov. Andrew Cuomo’s administration has publicly acknowledged, according to a report issued Thursday by the state’s attorney general.
The report by Attorney General Letitia James said a survey of dozens of nursing homes conducted by her staff suggested the state’s failure to include in its official counts residents who died in hospitals after being sickened by COVID-19 in facilities had led to an undercount of as much as 50%. To date, the state Health Department says some 8,400 nursing home residents in New York have died of COVID-19.
The Cuomo administration’s failure to make public deaths of nursing home residents who perished in hospitals has for almost a year enraged local and national lawmakers who have accused the administration of hiding the true death toll to avoid accountability. New York state Health Commissioner Howard Zucker testified before lawmakers last summer that his department was actively working to accurately tabulate the loss of life, but five months later, the department has remained silent.
The attorney general’s report said the office had contacted 62 nursing homes, about a tenth of the state’s total, to better understand how many residents had truly been lost to COVID-19. At a single home last spring, 29 more residents had died of COVID-19 when deaths at hospitals were included than were reflected in the state’s count. At another, the undercount was 25 deaths.
In a statement, the Health Department did not dispute the finding that thousands of nursing home residents died of COVID-19 after being taken to the hospital, and that those totals were not reflected in the state’s public tally of nursing home deaths. It offered no explanation for why it chose not to include the hospital deaths and once more claimed it was still trying to accurately count exactly how many residents had died of the virus in hospitals.
“DOH has consistently made clear that our numbers are reported based on the place of death,” the statement said. “DOH does not disagree that the number of people transferred from a nursing home to a hospital is an important data point, and is in the midst of auditing this data from nursing homes.”
When ProPublica in October had asked the Health Department why the count of hospital deaths was taking so long to be made public, Jonah Bruno, a department spokesman, said, “We are carefully reviewing all previous data, as the commissioner committed to, and we’re also requiring confirmatory and post mortem testing for anybody who may have had COVID-19 or flu symptoms, or exposure to someone who did, to ensure data integrity.”
The claim was widely ridiculed by lawmakers and health officials, who said counting hospital deaths of nursing home residents was not a complicated undertaking.
“Attorney General Tish James validates the cover-up of nursing home deaths, and the only question remains is why this administration chose to lie to the public for months,” said Ron Kim, a state legislator from Queens whose district’s nursing homes were battered by the pandemic.
The attorney general’s report cited a wide array of failings as accounting for the extraordinary death toll, nearly 9% of the state’s entire population of nursing home residents. Nursing homes had inadequate protective equipment, failed to implement effective infection control procedures and communicated poorly with the families of residents, many of whom feared for their loved ones and were unable to visit in person to check on their welfare.
The report also said another Cuomo administration policy requiring nursing homes to take in patients from hospitals who had COVID-19 and were stable enough to be discharged had likely contributed to the loss of life. The administration, which reversed the policy last May after six weeks, has said homes that could not safely handle patients with COVID-19 were not required to admit them.
Late last year, ProPublica noted that the true death toll among nursing home residents was not mentioned in Cuomo’s much-publicized memoir on his leadership successes handling the pandemic.
The attorney general’s investigation also turned up evidence that the state had undercounted some number of nursing home deaths that had taken place inside the facilities and that the state Health Department had made public.
Bill Hammond, a health care policy analyst at the Empire Center, an Albany think tank, said those findings raise “new questions about the accuracy of the limited numbers the department has released.” He said there was much to still learn about the true dimensions of the human loss in New York during the pandemic, and he criticized the administration for not releasing additional data even when subpoenaed by Congress.
“It’s shocking that the Cuomo administration continues to withhold basic information about a major public health crisis that New Yorkers urgently want to know and clearly have a right to know,” Hammond said.
Trump ultimately fell short on many of his signature promises, but his administration’s successes in cutting taxes, rolling back regulations and reshaping the judiciary will cast a long shadow.
This article was published on Wednesday, January 27, 2021 in ProPublica.
Donald Trump was elected president in 2016 following a campaign of pledges to build a wall along the border with Mexico, repeal and replace his predecessor’s signature health care legislation, “drain the swamp” of special interests in Washington, D.C., and cut through the federal government’s bureaucracy, all to “Make America Great Again.”
Trump ultimately fell short on many of his signature promises, but his administration’s successes in cutting taxes, rolling back regulations and reshaping the judiciary will cast a long shadow, with the national debt reaching historic highs, weakened federal agencies and conservative judges who will remain in position for decades.
President Joe Biden has begun undoing some inherited policies via executive orders, yet much of what the new administration ultimately hopes to achieve cannot be accomplished by presidential fiat. Like Trump when he was reversing Obama-era regulations, Biden will need cooperation from Congress, including compromises with at least some Republicans in the Senate, to enact significant swaths of his agenda, and he faces a ticking clock to undo some of Trump’s “midnight” rules.
Here are some of the most important ways Trump changed Washington and the federal government:
Renovating the Swamp
From the start of his term, Trump staffed his administration with lobbyists — hundreds of them, by our count — some of whom remain in career positions. He signed an executive order on ethics that was supposed to bar his political appointees from lobbying their former agencies for five years after they left government, though ProPublica found in 2018 that the order was not being enforced. Then, one of his final acts as president was to rescind that order, calling into question whether the swamp was drained or if Trump had built a yacht club along its murky waters.
The new administration will almost certainly have to employ one of the tools Trump used to halt or undo former President Barack Obama’s regulations: a little-known law called the Congressional Review Act.
The law, passed in 1996 by a GOP majority in the House, which was led by Speaker Newt Gingrich, gave Congress the ability to pass a simple resolution of disapproval and thereby reject any new major regulation implemented by a president. It also permanently prevents these voided regulations from being resurrected in any similar form without a subsequent act of Congress. In the two decades after it was enacted, the CRA was only used successfully once.
Then came Trump.
His 2016 election resulted in a flood of regulatory rollbacks — 15 in the first year of his term alone.
Now that the Congressional Review Act has been established as a political power tool, Biden and a Democratic-led House and Senate will likely use it to repeal as many of the Trump administration’s midnight regulations as they possibly can in the limited window of time available to them.
Among federal institutions, the judicial branch will remain in Trump’s shadow the longest. The one-term president was responsible for installing more than 225 federal judges and three Supreme Court justices to lifetime appointments. A ProPublica analysis highlighted the relative youth of Trump’s judicial appointments. Given the age of many of these judges, they are likely to remain in their positions for 30 years or more before retiring.
The Senate’s then-majority leader, Mitch McConnell, handed Trump a gift by refusing to hold hearings in 2016 for Obama’s nominee to fill a Supreme Court vacancy. In April 2017, that seat was filled by Neil Gorsuch, who, at age 49, was the youngest justice on the court.
The subsequent appointments of Brett Kavanaugh (53 when confirmed) and Amy Coney Barrett (47 when confirmed) made clear Trump’s goal of placing young, deeply conservative justices into lifetime appointments.
According to a ProPublica analysis, all three Trump-appointed justices could remain with the court until 2050 or beyond by simply staying through or slightly beyond the average age of retirement for the court.
Trump’s relative success with Supreme Court nominations was only part of the GOP strategy to remake the federal courts. McConnell and Republican leadership deliberately held back on confirming Obama’s judge nominations in hopes of the White House changing parties after 2016. In his last two years in office, Obama only saw two of his appellate nominees confirmed to the bench. By contrast, Trump seated a cavalcade of judges during his term — 19 appeals court spots and nearly 50 U.S. district court judges in 2018 alone.
In one four-year term, Trump placed 54 judges in federal appellate courts, and seated 174 district court judges. By contrast, Obama and former President George W. Bush seated 55 and 62 appellate judges, respectively, over the course of their eight-year stays in office.
Following the death of liberal Supreme Court Justice Ruth Bader Ginsburg in 2020, the issue of “packing the court” by adding more justices became a talking point for both progressives who supported the idea and for Trump, who claimed Biden would use the strategy to change the court’s ideological balance. However, Biden has not publicly supported this idea, and it would be unlikely to succeed in Congress.
The Constitution prescribes no specific number of justices for the Supreme Court, which over the years has had as few as six justices and as many as 10. The current nine-justice court was established in 1869, though there have been multiple proposals to expand the court, most notably in 1937, when President Franklin D. Roosevelt made a failed plan to expand the Supreme Court to as many as 15 justices.
The Democrats’ win of both Georgia Senate seats in January means Biden should be able to fill vacancies in the judiciary, with Republicans unable to block hearings and Vice President Kamala Harris acting as the tiebreaker for any 50-50 confirmation votes. However, finding nominees that satisfy all 48 Democrats and the 2 independents who caucus with them may prove to be a challenge.
There is also the question of how many Supreme Court seats Biden will have the opportunity to fill. Stephen Breyer is the only justice currently above the typical retirement age. Justice Clarence Thomas, the longest tenured of the nine, is 72. According to the ProPublica analysis, if he stays on the bench through typical retirement age, he would remain in place through 2029.
Long-tenured district and appellate court judges who meet specific age and experience requirements can declare "senior” status, which allows for their seats to be filled by the president while they continue working. There are currently dozens of judges eligible for this designation. On Inauguration Day, District Court Judge Victoria Roberts of Michigan’s Eastern District announced her intention to transition into senior status. It remains to be seen how many others will choose this path.
A Win for the Wealthy, a Loss for the Uninsured
Even though Trump began his term with Republicans in control of both chambers, the GOP was unable to pass major bills on issues like immigration and abortion because it couldn’t get the 60 votes it needed to end debate in the Senate and get to a final vote. The two signature Trump legislative efforts — on health care and tax cuts — were expedited by using the budget reconciliation process, which limits what can be put into the legislation but means the bill is not subject to a cloture vote.
In his public remarks, Trump sold the Republicans’ 2017 tax reforms as mainly benefiting the middle class and creating jobs.
Yet the new tax law’s cap on deductions for state and local taxes, along with the elimination of some mortgage deductions, resulted in a trillion-dollar drop in overall home values nationwide — “a very big deal to families whose biggest financial asset is the equity they have in their homes,” wrote ProPublica’s Allan Sloan.
ProPublica has reported on a number of ways in which the 2017 tax cuts benefited America’s wealthiest, including some Trump appointees. Similarly, the plan’s Opportunity Zone tax breaks, which were purportedly intended to spur investment in lower-income neighborhoods, have repeatedly gone to billionaire investors and developers for projects that were not new or are of dubious value, like a Florida superyacht marina.
Critics warned the cuts would raise the national debt, which then stood at around $20 trillion. Trump insisted otherwise, telling Fox News’ Sean Hannity in 2018 that when the bill “really kicks in, we’ll start paying off that debt like it’s water.”
Despite Trump’s pledge that the revenue lost from the tax cuts would be recouped by tariffs and increased productivity, the national debt continued to rise, even before the COVID-19 pandemic. The $1.563 trillion budget deficit from 2019 was higher than it had been in all but one year under the Obama administration, which spent $1.652 trillion in 2010 in an effort to end the economic downturn that resulted from the crash of the housing market. More than a year after signing the tax law, Trump’s own White House referred to the then-$22 trillion national debt as a “grave threat to our economic and societal prosperity.”
During the 2020 campaign, Biden proposed income tax increases on individuals earning more than $400,000 annually, repealing the cap on state and local tax deductions, and raising the corporate tax rate from 21% to 28%, splitting the difference between Trump’s level and the 35% rate that was in place before 2017.
As experts have noted, the new president may face an uphill battle trying to sell any tax hike while the economy remains troubled. While the Democratic Party now controls both chambers of Congress, Biden cannot afford even a single defector in the Senate if he hopes to succeed there. Additionally, Biden hopes to push through a $1.9 trillion stimulus package in the early part of 2021, which will further inflate the debt.
Undoing Obamacare
On the day of his inauguration in 2017, Trump signed Executive Order 13765, instructing the Secretary of Health and Human Services and the heads of other relevant federal bodies to try to “waive, defer, grant exemptions from, or delay the implementation” of any part of the Affordable Care Act if they deemed that it “would impose a fiscal burden on any State or a cost, fee, tax, penalty, or regulatory burden on individuals, families, healthcare providers, health insurers, patients, recipients of healthcare services, purchasers of health insurance, or makers of medical devices, products, or medications.”
While the House passed its version of a health care plan, dubbed the American Health Care Act, in May 2017, what followed was a series of failed attempts to craft a Senate version of the bill. The process came to an end in July 2017 with the Health Care Freedom Act, dubbed a “skinny repeal” bill with no real replacement plan. That too failed in the Senate, when Sen. John McCain of Arizona, with a now-famous thumbs-down gesture, joined fellow Republican Sens. Lisa Murkowski of Alaska and Susan Collins of Maine and all Democrats in voting “no.”
The closest Trump would come to repealing the ACA came later in 2017, when — as part of the Republican tax bill — he effectively negated the individual mandate, which required individuals to carry a minimum level of healthcare coverage or face an annual penalty of up to $695; the tax bill reduced the amount of that penalty to $0. The Trump administration also cut back on marketing for the ACA’s open enrollment periods and expanded the availability of short-term limited-duration insurance policies, which are generally less expensive than those that meet ACA requirements but offer fewer protections, particularly for preexisting conditions. Despite repeated promises from the president that a true ACA replacement was in the offing, it never materialized.
Though Obama’s legislation remains on the books, its initial surge in coverage numbers began to reverse itself after 2017. According to a 2020 Kaiser Family Foundation report, there were 28.9 million uninsured nonelderly Americans by the end of 2019, an increase of 2.2 million since the beginning of 2017, with the number expected to continue rising in 2020 due to the historic levels of unemployment resulting from pandemic-related layoffs and closings.
In addition to resulting in more uninsured Americans, the Obamacare repeal campaign set the tone of bluster, partisanship and misinformation that would come to define many aspects of the Trump years. As ProPublica reported in May 2017, backers of the repeal legislation had engaged in a campaign of inaccurate information, misleading euphemisms and a curated online discussion bubble in which members of Congress blocked critical comments from their constituents.
Biden and the new Democratic-led Congress could reinstate the individual mandate, but financial penalties for uninsured Americans will be difficult for the White House and legislators to sell to a public living through mass unemployment. Rather, as part of his $1.9 trillion COVID-19 relief package, the new president hopes to maintain insurance rolls by increasing the value of the Premium Tax Credit — a refundable credit that helps eligible taxpayers afford insurance coverage — so that their net cost of insurance premiums is no more than 8.5% of an individual’s yearly income.
The new White House will face pressure from within its own party as progressive Democrats push to replace traditional insurance plans with a single-payer “Medicare for All” plan. Support for this concept is increasing among the general public. According to a September 2020 report from Pew Research, 63% of Americans support at least some mix of government and private insurance plans, up 4 percentage points from the previous year. Support for a single national government program was up 6 percentage points year-over-year, rising from 30% to 36%. During the campaign, Biden did not push for a Medicare for All plan, but rather for expansion of the ACA marketplace via the “public option,” meaning government-run insurance plans that would compete with private insurers.
The Wall
In early 2018, with nothing to show for his campaign promises and no indication that Mexico wanted any involvement in funding the border wall, Trump floated to then-Defense Secretary James Mattis the idea of using money earmarked for the armed forces to build it.
It would be nearly a year before Trump moved forward with this plan, setting off a slew of legal challenges, some involving the Supreme Court. Opponents said Trump did not have the authority to reallocate billions of congressionally appropriated military funds. The standoff over money for the wall resulted in the longest shutdown in U.S. government history. Congress, now with a Democratic majority in the House, eventually agreed to give Trump part of what he requested, but with some restrictions. The president was also allowed to use billions that had previously been allocated for the military’s counter-narcotics efforts.
After construction on the wall finally began in earnest, a ProPublica/Texas Tribune investigation found that costs for the structure were running significantly higher than expected. For example, the Army Corps of Engineers issued two contracts worth $788 million for construction of one 83-mile stretch of wall. In less than a year, the value of those contracts increased by more than $1 billion. Within a year, after the length of the wall segments in those contracts was extended by 63% to 135 miles, the total cost more than tripled to $3 billion. ProPublica and the Tribune found multiple instances where the value of border wall contracts was increased through the use of supplemental contracts without any competitive bidding.
While more than 400 miles of wall were constructed by the end of Trump’s term, only about 80 miles involved building a barrier where none had existed before, according to newsreports. The Washington Post reported that Biden may be obligated to build more than 200 additional miles of wall.
On his first day in office, Biden issued an executive order describing the wall as a “waste of money that diverts attention from genuine threats to our homeland security.” The order pauses construction and spending on the wall “to the extent permitted by law,” leaving open the possibility that construction could continue or that money will continue to be spent on the project. Our investigation confirmed that some wall contracts come with hefty termination fees. One agreement stipulates a cancellation fee of nearly $15 million.
The Erosion of Trust
The legacy of the Trump administration will be one of erosion, both of norms and of trust in government. Arguably the strongest example is Trump’s yearslong campaign to convince the American people that their elections are not secure.
Trump became president by winning the electoral college in 2016, but he repeatedly insisted without evidence that he’d only lost the popular vote to Democratic candidate Hillary Clinton because of widespread election fraud.
“I won the popular vote if you deduct the millions of people who voted illegally,” Trump tweeted on Nov. 27, 2016, despite all evidence to the contrary. The next day, he added, “Serious voter fraud in Virginia, New Hampshire and California - so why isn’t the media reporting on this? Serious bias - big problem!” Again, his claims were not backed up by the facts.
His zeal for the voter fraud myth did not cool after taking office. A May 11, 2017, executive order created the Presidential Advisory Commission on Election Integrity to investigate, among other things, issues “that could lead to improper voter registrations and improper voting, including fraudulent voter registrations and fraudulent voting.”
In the end, the commission only met three times before Trump summarily dissolved it in January 2018, amid internecine legal squabbles and other troubles. Though the administration said the Department of Homeland Security would continue the commission’s work, the Trump White House never unearthed any actual evidence of substantial voter fraud.
The commission was a failure, but it thrust members like Hans von Spakovsky into the spotlight. Von Spakovsky, a prominent purveyor of discredited voter fraud claims, would go on to become a central figure in some Republican efforts to restrict mail-in and early voting during the 2020 election.
As Trump and his surrogates stoked unfounded fears of dead people and undocumented migrants voting, Americans grew concerned about interference in elections. A Gallup poll released in early 2020 found that nearly 3 in 5 Americans no longer had confidence in the election process, an inversion from only a decade earlier when that same poll found that almost 3 in 5 Americans were confident in the integrity of their elections.
With the 2020 election drawing near, Trump preemptively claimed that if he lost on Election Day it would have to be the result of fraud.
"The Democrats are also trying to rig the election by sending tens of millions of ballots using the China virus as the excuse for allowing people not to go to the polls," Trump said during a June 2020 campaign event in Phoenix, Arizona. He later predicted, "This will be, in my opinion, the most corrupt election in the history of our country, and we cannot let this happen."
The volume of ominous statements from Trump soared in the weeks leading up to the November election. According to The Washington Post’s tally of Trump’s false and misleading claims, the president made more than 1,500 such statements about the election between July 1 and Nov. 2, 2020.
Even after Trump’s legal team and his unofficial legal supporters failed more than 60 times to convince courts to overturn election results in multiple states, and after the Jan. 6 Stop the Steal rally escalated into an insurrection at the Capitol that left at least five people dead, a large number of Americans still believe in the fiction of a stolen election.
According to a CNN/SSRS poll taken after the violence at the Capitol, 32% of Americans said they think Biden did not legitimately win the election. Nearly one-quarter of all respondents believe there is “solid evidence” that Biden actually lost. Three-quarters of Republican respondents said they had little or no confidence that elections reflect the will of American voters.
The 2020 election will not be the end of outrageous voter fraud myths. The longer-term effect is only just being seen, as state legislatures around the country reconvene for their new sessions, with a number of Republican-led assemblies already moving to restrict or repeal efforts to make voting easier.
"Far too many residents of Pennsylvania are questioning the validity of their votes or have doubt that the process was conducted fairly, securely and produced accurate results," state Sen. Jake Corman, who had voted for the 2019 election reforms, said about the commission in December. His statement echoed an argument similar to that made by U.S. Sen. Ted Cruz on Jan. 6, only minutes before insurrectionists breached the Capitol.
Similarly, Minnesota state Sen. Scott Newman, a Republican, recently introduced a bill to require photo identification from voters. Like Corman, he did not cite any evidence of specific fraud that would merit ID checks, just stated that “millions of American citizens believe there was widespread fraud during the last election, and their loss of faith in the integrity of our election system alone justifies incorporating photo ID into our voting system.”
COVID-19 relief was meant to give a lifeline to hospitals, especially the small, rural facilities that struggled to stay open before 2020. But in states like Oklahoma, problems created by confusing guidelines could cause harm long after the pandemic.
This article was published on Tuesday, January 26, 2021 in ProPublica.
By Brianna Bailey, The Frontier
A federal economic relief package passed by Congress in March promised to provide a lifeline for hospitals, particularly those in rural communities where many facilities struggled to survive even before the coronavirus pandemic.
But over the past 10 months, the distribution of more than $100 billion in CARES Act funding for healthcare providers has been plagued by a dizzying rollout and, at times, contradictory guidelines for how to use the funding.
The result has been a patchwork of problems for rural hospitals, which were already at far greater risk of closure than other healthcare facilities and in dire need of help, The Frontier and ProPublica found. The scope of those problems is clearly visible in Oklahoma.
One hospital used more than $1 million in federal aid to pay off its years-old debt to a management company that left before Oklahoma's first coronavirus case was diagnosed, a potential violation of federal guidelines that could require the hospital to return the money, according to experts.
Three Oklahoma hospitals that were purchased last year after filing for bankruptcy were unable to access more than $6 million in funds deposited by the Department of Health and Human Services, the agency in charge of the rollout for healthcare providers. The money was instead deposited into accounts tied to the previous owners, leaving the new owners with few options as they tried to keep the facilities from becoming insolvent.
And administrators at yet other hospitals have left millions in relief aid untouched, spiraling deeper into debt for fear that the wrong decision could force them to return money.
"Every day we have new rules, new guidelines, and it's a struggle," said Shelly Dunham, CEO of Okeene Municipal Hospital in western Oklahoma. Dunham said she used only $50,000 of the $3 million the hospital received in April and May because of concerns that the facility would have to return the money. "I can't say we need more money right now. We just need to be able to keep what they've given us."
Under the CARES Act, funding can be used to prevent, prepare for and respond to the coronavirus or to help with expenses or losses caused by COVID-19. The problem is in the details, which Congress left to HHS.
HHS has primarily managed concerns by publicly releasing responses to more than 100 frequently asked questions. Those responses have sometimes contradicted previous guidance from the agency, leaving healthcare providers confused about how money can be used and what the agency would seek to claw back. The whipsawing guidance has covered a range of topics, including how healthcare providers could calculate losses from the pandemic and whether they could use the money to pay for long-term capital improvement projects such as new heating, ventilating and air conditioning systems.
"Hospitals' challenge right now is keeping their doors open and paying their debts," said Carrie Cochran-McClain, vice president of government affairs and policy for the National Rural Health Association. "There is not enough flexibility to help providers really use the funds as Congress intended for the kinds of things that they need to address for COVID."
Rural hospitals across Oklahoma and the country are disappearing at an alarming pace that could hasten without help from the federal government, Cochran-McClain said. In 2019, the year before the coronavirus pandemic, rural hospital closures reached a record high, with 18 nationwide. Texas led the country with three closures. Tennessee, Kansas and Oklahoma followed with two each.
Last year, despite the infusion of federal funding, another 17 rural hospitals shuttered, bringing the total number of closures since 2005 to 176.
Unlike larger, wealthier facilities, rural hospitals often have only a few weeks' worth of cash on hand to operate with. Experts have warned that even with the federal relief aid, many hospitals would struggle. But without it, they would surely fail.
"There was a tussle between the desire early on to get funds out quickly into the hands of people and providers who need it first, and also a compelling need to have oversight of where the money is going," said James Cosgrove, healthcare director for the Government Accountability Office. After the first distribution of $50 billion in April, the GAO found that the federal government had sent $558,000 to four closed hospitals that either declined or returned the money.
The Frontier and ProPublica found six other hospitals that closed in 2019 but received more than $3.2 million combined in federal relief payments. More than half of the money went to a hospital in Ellwood City, Pennsylvania, that closed in December 2019 after state inspectors found unsafe conditions for patients.
The relief money was being used for security and to respond to medical records requests until Ellwood City Medical Center could be sold, a bankruptcy trustee said in a December 2020 court filing. The trustee did not respond to requests for comment.
An HHS official said the agency is "in the process of recovering payments'' from hospitals that permanently closed before Jan. 31, 2020, but would not say how much it was pursuing or identify any closed facilities that had received aid. Officials said they could not comment specifically on the six hospitals identified by The Frontier and ProPublica because the agency does not release information on individual facilities.
The distribution of funding for healthcare providers is just one example of complications with the sweeping $2 trillion CARES Act. More than $174 billion in temporary tax breaks benefited mostly wealthy people and large companies. The Paycheck Protection Program, another effort aimed at helping small businesses stay afloat, drew widespread criticism after large companies, including the restaurant chains Ruth's Chris and Shake Shack, qualified for loans, while smaller struggling businesses were shut out. Ruth's Chris and Shake Shack later agreed to return the money.
The hospital rescue program similarly helped wealthier facilities pad their bottom lines, while poorer hospitals struggled. In the first round of funding, wealthier hospitals received a larger share of the $50 billion than poor and rural hospitals, according to a report from the Kaiser Family Foundation, a health policy research organization. The report found that those hospitals with a larger share of revenue coming from private insurers received about $44,000 per bed, while poor, rural hospitals got about half that amount.
Subsequently, HHS set aside billions more for rural healthcare providers and for hospitals with a higher percentage of COVID-19 patients. But that wasn't enough to make up for the inequities, said Karyn Schwartz, a senior fellow for Kaiser.
"I think they (HHS) were under a lot of pressure to do it quickly, and so they prioritized a quick and simple formula over really targeting the money towards the providers who might be most vulnerable," Schwartz said.
HHS officials said they have repeatedly made improvements to the system in response to feedback from Congress and healthcare providers. The agency has changed the way it distributes money, seeking a formal application instead of releasing funding to all hospitals. A new $900 billion pandemic relief package passed in December also gave hospitals more flexibility in calculating revenue losses from the pandemic.
"HHS has balanced the need for flexibility in use of funds to stabilize the healthcare system with program integrity requirements and the responsible use of taxpayer dollars," the agency said in a statement released before President Joe Biden took office.
"We're Doomed"
As rural communities across Oklahoma began experiencing an uptick in COVID-19 cases, the new owner of the only hospital in the small Oklahoma town of Prague fought for access to part of $3.2 million in federal relief aid.
The Prague Community Hospital was one of three that in June asked U.S. Bankruptcy Court Judge Joseph Callaway to help them solve what appeared to be an intractable problem.
The facilities, which included the Fairfax Community Hospital and the Haskell County Community Hospital, were among 11 that entered bankruptcy in 2019 amid accusations that the company that owned them, EmpowerHMS, had engaged in fraud. In a federal indictment unsealed in June, prosecutors accused the company's owner, Jorge Perez, and nine others of a scheme that allowed rural hospitals to bill at higher rates for blood and urine tests performed elsewhere. The case is set to go to trial in September 2021. Perez and eight other defendants have pleaded not guilty. A tenth defendant has not yet appeared in court.
The CDC says health facilities should report unused and spoiled COVID-19 vaccines, but many are failing to do so. At a time when there aren't enough shots to meet demand, significant numbers may be going in the trash.
Each Oklahoma hospital owned by the company was auctioned off by a bankruptcy trustee in charge of settling financial debts incurred under EmpowerHMS.
After unexpected revenue losses from the pandemic, the new owners banked on federal funding from the hospital relief package. But when the money was dispersed, they got nothing.
HHS had instead deposited a total of $6.4 million into accounts connected to the hospitals' previous owners and managed by bankruptcy trustee Thomas Waldrep.
Since federal rules prevented the money from being transferred, it had to be returned to HHS, Department of Justice attorney Michael Quinn said during a June bankruptcy court hearing.
The new owners would have to wait for another round of relief, Quinn said. Even then, they may not qualify because the money was distributed using the hospitals' 2019 tax identification numbers and none of the current owners controlled the facilities at the time.
"This is not specific to this case, this is a response to an enormous program of unprecedented size that rolled out billions of dollars on an emergency basis to provide relief and used estimated data to get the money out the door as fast as possible," Quinn said during the court hearing. "As soon as that happens though, that creates an expectation that, in some cases, the money will not go and land in the correct place. And here, it happened to land in the middle of a corporate sale of an asset."
Waldrep, the bankruptcy trustee, later said in an interview that he believed the new owners should get a portion of the relief aid but he was hamstrung by the federal rules. The trustee also wanted to use a portion of the money to pay some of the hospitals' debts from before the sale, including his fee and charges from the management company that operated the facilities during the transition.
"This puts our clients in a very bad position in terms of the continued delivery of care in these very critical needed areas," Hugh Robert, an attorney for Transcendental Union with Love and Spiritual Advancement, said during the hearing. The Tulsa-based nonprofit that purchased the Prague Community Hospital in May.
Attorneys for the new owners of the three hospitals and for Waldrep asked the judge to allow them to use the money despite objections from the federal government. During the hearing, Callaway grew increasingly irritated at what he viewed as the federal government's failure to help the clearly struggling hospitals.
The lack of guidance and flexibility from the federal government endangered hospitals instead of helping communities keep them open, Callaway said.
"We don't do things like this around here," he said. "All I hear are reasons from the government of why it can't be done, instead of reasons why it can be done."
The judge eventually allowed Waldrep to reach agreements with the hospitals. As part of the final plan, Waldrep could use about $750,000 to pay his fees and expenses for overseeing the bankruptcy cases. He would use another $1.4 million to pay Cohesive Healthcare Management and Consulting, which operated the hospitals in bankruptcy.
Some of the money would also go to expenses that were incurred before the sale but were directly related to COVID-19.
The Fairfax and Prague hospitals would each then receive a portion of the remaining $4 million. But because the federal government threatened to later take back money it determined was misused, the hospitals would have to obtain a line of credit that would protect the previous owner from any collection attempts.
Dr. Vishal Aggarwal, who founded the nonprofit that purchased the Prague hospital, said he was never able to secure the financing that would serve as collateral because of the facility's poor financial state.
"If a second wave hits us, we are doomed," Aggarwal said in an interview.
Coming to Collect
During the pandemic, hospitals were forced to forgo elective surgeries and other nonessential services that help drive the minimal revenue that rural facilities bring in annually. The losses, coupled with the added costs of preparing hospitals for the pandemic, heightened the urgency of obtaining federal relief.
Some Oklahoma rural hospitals received federal relief aid before the coronavirus pandemic spread to their small towns and immediately began using the money without considering how expenses could later be justified.
In May, Cimarron Memorial Hospital, in the Oklahoma Panhandle, was two weeks away from closing. It had fallen behind on state taxes and was working to settle a lawsuit filed months earlier by the electric company after the hospital failed to pay its several bills. It also owed $1.2 million in past-due fees to NewLight Healthcare, a management company that ran the hospital for nearly a decade before abruptly departing in January 2020.
The hospital received $3.5 million in federal relief payments and loans.
Tim Beard, Cimarron's chief executive officer, used nearly a third of the relief aid to pay off NewLight Healthcare, a decision that experts say could force the hospital to repay the federal government. HHS has called it "highly unusual" that the relief aid could be used for expenses incurred before Jan. 1, 2020.
For nearly a decade, NewLight provided loans to the Cimarron hospital and deferred management fees, under a contract that allowed it to charge interest on the past-due amounts. The company then placed a lien on the hospital's incoming payments. If NewLight chose to enforce the lien, as it had already done in another Oklahoma town, the hospital would be required to pay the company before it paid employees or covered bills for medical supplies.
Lee Hughes, an executive vice president for NewLight, declined an interview and did not respond to detailed written questions. In a statement, Hughes said that the company acted in good faith by settling for less than what it was owed.
"NewLight did this both to resolve all past indebtedness owed by the hospital, but also as a gesture of good will," Hughes said.
The hospital had run out of options to settle its debts, said Beard, adding that he believed there were no restrictions on the coronavirus relief money.
"If I didn't do things as I should have then we will pay the price for that but we got the community taken care of for eight months longer than we were looking at," Beard said in an email.
Hospitals will be required to start reporting how they spent the federal relief aid, but HHS officials said no deadline has been set. Those that received at least $750,000 must undergo audits that HHS will use to determine whether money must be returned.
"I think there's probably many in the industry optimistic that the government doesn't want to recoup this money, and they're going to come up with a way to allow the hospitals to keep it," said Eric Shell, a rural hospital finance expert with the healthcare consulting firm Stroudwater Associates.
By the time COVID-19 arrived in Cimarron County, the hospital had already used $2 million in federal funds. Aside from the payment to NewLight, Beard said he used $250,000 to replace the hospital's broken CT scanner, $81,000 to settle its debt to the electric company and another $750,000 to cover payroll and other bills.
The hospital still has $1 million in provider relief funds, according to Beard, who did not provide detailed financial records requested by The Frontier and ProPublica. Beard said he hadn't compiled the information because it doesn't have to be reported to the federal government until this year.
"If they take back the money or what we have in savings, we won't survive," Beard said in an email to The Frontier and ProPublica.
Another Shot at Relief Funding
Despite vastly different problems with the rollout of the federal program, hospital administrators share a fear that money they thought would save them could now accelerate their closure.
This month, Dunham started using more of the $3 million she had been holding on to. The hospital, she said, needs the money. But Dunham said she hasn't stopped worrying about the crushing financial situation the hospital will face if the federal government disagrees with how the money is spent and asks for it to be returned.
The Prague hospital has now changed hands. City officials who purchased the hospital this month for $1.3 million say they are not concerned about whether the government will claw back federal funds. Instead, they're worried about getting access to the money in the first place.
The 25-bed hospital has been operating at or near capacity since Thanksgiving, when Oklahoma experienced a spike in COVID-19 cases that continues to grow. The city loaned the hospital $236,000 from its emergency reserves to pay employee salaries in November and December, according to city officials. And the hospital still needs to make various improvements, including replacing an antiquated system that supplies oxygen to patients.
Prague's mayor, Cliff Bryant, acknowledged the risk the city took in buying the hospital, given the facility's history of financial problems and the additional pressures from the ongoing pandemic. But, he said, the move was necessary to ensure residents had access to quality healthcare.
"It's either that or shut it down, so it's not a real good choice," Bryant said.
Bryant said the city plans to apply for another round of relief money, probably early this year, but he worries about another denial. HHS has an estimated $24 billion left to allocate. The agency has not released details about which providers will qualify and how much they will receive.
Meanwhile, the $1.7 million in relief money intended to help the Prague hospital weather the pandemic is still sitting in a bank account controlled by the bankruptcy trustee. He's unsure what will happen to the money.
"I think one possibility is that it would just get sent back to the government," Waldrep said.
A much-needed check-in with health care reporter Caroline Chen as we examine the toll COVID-19 has taken on the country and what to expect from a new president.
This article was published on Saturday, January 23, 2021 in ProPublica.
In May of last year, ProPublica health care reporter Caroline Chen reflected on the first 100,000 lives lost to COVID-19 and posed an important question: “How do we stop the next 100,000?” Eight months later, with 300,000 additional American lives lost and the chaotic distribution of the vaccine underway, Chen shares her thoughts on where we are and what happens next.
In your 100,000 lives lost piece, you wrote about questions we needed to ask at that moment: “How do we prevent the next 100,000 deaths from happening? How do we better protect our most vulnerable in the coming months? Even while we mourn, how can we take action, so we do not repeat this horror all over again?” It’s been almost eight months since then. What are the biggest questions we need to be asking now?
I’m afraid that we did end up repeating this horror all over again — and again — and again. There’s no way of dancing around this: We’ve failed to protect our most vulnerable. We’ve let the virus spread out of control across America. We’ve let the worst happen.
So here’s the question on my mind now: How are we going to end the pandemic? We have a vaccine in hand, and I’m so grateful for it. It is, truly, a game changer. But there are different ways that this story can go from this moment in January. We can end the pandemic as quickly as possible, with rapid distribution and uptake of the vaccine, with everyone doing their best to maintain best practices (social distancing, etc.) while they wait their turn, prioritizing those who need the vaccine most, doing whatever we can to alleviate the pressure on exhausted health care workers and public health officials.
Or we can drag it out, with a chaotic and sputtering vaccine rollout, exacerbating inequities in society by letting those who have connections, or money, or power get the vaccine first, and continue to ignore what science tells us, so we have so many more COVID-19 cases that we give the virus evermore chances to mutate away from our currently effective vaccine. We are the authors of the final chapters of this story. How are we going to determine its ending?
You also wrote about choices our nation’s leaders have had to make. What choices are the most pressing right now for the Biden administration?
Biden’s administration does not have the luxury of doing one thing at a time. I’ve watched America lurch from one pandemic theme du jour to another. For a while contact tracing was really hot. Then we all got into antibody testing. Now the hype is about vaccines. This virus is incredibly wily, it’s spreading out of control and front-line workers are exhausted. The administration really needs to be able to work on multiple fronts, bringing in funding, staffing and supplies to sustain public health officials who are trying to do testing while conducting contact tracing interviews while also setting up vaccine clinics.
We can’t rush to vaccinate then drop the testing ball. We still do not have a clear strategy for testing asymptomatic people. I’d love to see a nationwide sharing of sequencing data so we can track and evaluate variants more robustly. Every single health care staff — and hey, what about meatpacking workers and other front-line laborers — should have access to N95s. It’s insane to me that I am still told by some nurses that they have to reuse their masks for two weeks. Last but not least: Clear, consistent and transparent communication from the White House, the Department of Health and Human Services, the Centers for Disease Control and Prevention, the Food and Drug Administration and all branches of government would be desperately welcome.
We’re hearing a lot about mutations and new variants of the virus that spread more quickly. Should we be changing our behavior?
Viruses are constantly mutating; it’s just what viruses do. A lot of these mutations aren’t actually meaningful, and it’s only when they have some sort of functional difference that we consider them a new variant, like the B.1.1.7 variant (also known as the U.K. variant). When a new variant is detected, the question is always, what’s the significance? In the case of the B.1.1.7 variant, it’s pretty clear now that it’s more transmissible, but there isn’t enough data so far to say whether it causes more severe disease.
Still, a more transmissible variant will result in the virus spreading faster, meaning more cases, more overloaded hospitals, diminished therapeutic resources and thus probably a worse outcome if you do get sick — not because you got more severely ill in the first place, but because you didn’t get as good care as you would have otherwise if hospitals weren’t stretched so thin. So far, some B.1.1.7 cases have been found in the U.S., but it doesn’t appear to be dominant. And we need to make sure that doesn’t happen. Epidemiology Professor Andrew Lover at the University of Massachusetts Amherst told me he thinks we’re in a critical period right now — with hospitals still recovering from post-holiday surges, vaccine protection yet to kick in and pandemic fatigue at an all time high. “The vaccine is on the horizon, but it’s really challenging to message that it won’t have a major impact for months,” he said.
Epidemiologist Marc Lipsitch at the Harvard T.H. Chan School of Public Health has argued that contact tracers should prioritize any case that involves a B.1.1.7 variant, because those cases will spread faster. To be able to do that, testing resources — specifically the type of tests that can identify B.1.1.7 — need to be ramped up and widely distributed. As for individuals, however, there’s nothing you need to change about your behavior if you’re worried about variants. You already know what to do, you just have to fight the fatigue and do it. Wash your hands. Wear a mask. Social distance. Seek the outdoors. Get your vaccine when it’s your turn. Do whatever you can to not be a case.
Of all of the great reporting you and other science reporters have done on the pandemic, most people experience only a swath of what the big picture of the pandemic is — the bigger picture that you as a reporter have. You’ve reported on some of these smaller swaths, individual stories and experiences, but also the larger systemic failures. What do we lose sight of with the big picture, and what do we lose sight of with the small picture?
Sometimes when I’m looking at the charts, I have to remind myself what the numbers mean. It’s become so easy after months and months of this to become numb. For example, even though the case count is finally starting to go down in Los Angeles County, and that is good news, it’s not just a trend line. Those are people. And even if I can be happy on one level that the tide seems to be turning in LA County, I should also keep in mind that that’s still 7,900 individuals who were diagnosed with COVID-19 yesterday, and close to 200 people who died. Each person — as my May essay said — was somebody’s everything. I have to remember that, so I don’t ever treat the numbers like just numbers in my reporting.
On the flip side, when I’m listening to people’s stories, I always keep in mind that one person’s experience may not speak for the whole. There are a lot of vaccine snafus happening across the country right now. Some of them are dysfunctions unique to that particular vaccine site, and as a national reporter, they’re not my story to tell. So I talk to a lot of people and gather as many stories as I can. And when I start to hear the same themes repeat over and over, that’s when I start to think, Hmmm, there’s something going on here. It’s not a good sign when clinics across the country are all canceling appointments on the same day. That’s when I swing into action to try and find out the Why. That’s a ProPublica story.
You wrote eight months ago: “I refuse to succumb to fatalism, to just accepting the ever higher death toll as inevitable. I want us to make it harder for this virus to take each precious life from us. And I believe we can.” What were you feeling then that fueled you to write about refusing to succumb to fatalism, and what are you feeling now?
What was I feeling? Oh, boy. I was leaking tears and writing at the same time because our brilliant visuals editor Andrea Wise was sending me her selections for that essay and I was looking at the images just thinking how awful it was for people to have to be going through this: not just to be sick and die, but in so many cases to have to die alone — or to have a loved one in the hospital and not be able to be by their side. There’s one image in there of a funeral home in New Jersey with the spaced out chairs that seemed so bleak to me. Even after your loved one’s death, you couldn’t lean close to a friend or relative for comfort.
I didn’t want people to just roll over and accept that more people would die. It angered me that some people were ignoring the guidance of public health officials and what science told us could help reduce cases. I wanted people to realize that there’s accountability at all levels: from federal policies all the way down to your own actions, every day.
And now? I’m tired. I miss my family so much (they’re mostly overseas). But I still haven’t given up. I remind myself that I can’t solve the world’s problems, but I can do my little bit as a health reporter and hope it helps, somehow. And now there’s a new administration. I don’t think it’ll be perfect by any means, but I am hopeful to see that President Biden takes the pandemic seriously and I look forward to seeing what actions his administration takes in the coming weeks.
Well for starters, we have a vaccine that works! Two, in fact, and potentially another on the way (Johnson & Johnson’s). As a former biotech reporter, I know that drug development is a slog, so the fact that we have two very efficacious vaccines that made it to market in under a year is truly amazing.
But of course, shots in the vial are pointless if they don’t get to people’s arms. So where am I seeing hope? So far, production appears to be going OK. There obviously isn’t as much available vaccine as the demand, but there haven’t been any major manufacturing snafus, so I expect Pfizer and Moderna to continue to ramp up as planned.
I am also hoping that as more vaccines become available, this should (fingers crossed) coincide with federal, state and local entities sorting out the logistical issues that have plagued the rollout so far. Ideally, things will go more smoothly when the bulk of the supply becomes available. I’ll stay optimistic, while looking out for everything that may be going wrong, of course. That’s my job.
The CDC says health facilities should report unused and spoiled COVID-19 vaccines, but many are failing to do so. At a time when there aren't enough shots to meet demand, significant numbers may be going in the trash.
This article was published on Thursday, January 21, 2021 in ProPublica.
As reports emerge across the country of health facilities throwing out unused and spoiled COVID-19 vaccines, some state governments are failing to track the wastage as required by the Centers for Disease Control and Prevention, leaving officials coordinating immunization efforts blind to exactly how many of the precious, limited doses are going into the trash and why.
In Washington, a health facility allegedly threw out some COVID-19 vaccine doses at the end of workers’ shifts because staff believed state guidelines blocked them from giving unused shots to people below the top priority tier. In Maryland, workers appear to have tossed thawed doses when they ran out of time to administer them safely. How many doses, exactly, have been wasted in those states is unknown because neither state is tracking unused or wasted vaccines.
In Indiana, where hospitals have told the media about discarding some shots, the state Health Department said it requires wastage to be reported but wasn’t able to tell ProPublica how many doses have been tossed statewide. Nonetheless, it asserted that “wastage has been minimal.”
Experts say that waste reporting is essential during a vaccination campaign to encourage careful handling and the use of every viable dose and, more importantly, to identify potential problems in the shipping and cold storage operations. With inconsistent reporting requirements and no enforcement of a federal mandate to report wastage, vaccine providers have little incentive to acknowledge wasting vaccines, said Dr. Ashish Jha, dean of the School of Public Health at Brown University.
Jha said he thinks that the true number of wasted doses across the country is far higher than a handful. After he detailed one anecdote he heard about an ER physician forced to waste vaccine doses in a thread on Twitter, his phone quickly filled with more than a dozen messages from other medical workers, confirming what he suspected: At a time when the U.S. is desperately short on vaccines, a significant number of doses are ending up in the trash.
Clinics and hospitals have “gotten slammed” when the media has learned of them wasting even a few doses, he said. “And the signal to everybody else is, if you have waste, don't report it. Because if you do, you're gonna get into a lot of trouble. That combination means, at least in my assessment, there's a lot of waste and a lot of underreporting of that waste."
The CDC requires all organizations that administer the vaccine to report the number of vaccine doses “that were unused, spoiled, expired, or wasted as required by the relevant jurisdiction.” The CDC also asked states to describe their wastage monitoring method during the distribution planning process.
Vaccine providers, such as pharmacies and hospitals, are supposed to provide data on wasted doses to their state health agencies, which then send the information to the CDC. Like many parts of the vaccine rollout, that has not gone according to plan. State by state, ProPublica found, reporting requirements vary and are not reliably communicated to vaccine providers. Even when the rules are clear, they are not regularly enforced, nor are numbers reported to the public.
Maryland’s Hospital Association said wastage data “is not systematically collected,” while the state’s Health Department said that “unless they are reported to us, MDH does not track specific instances of accidental vaccine wastage at the local level.”A Washington State Health Department spokesperson said that the state “does not systematically capture wasted dose information.” The spokesperson added that providers are encouraged to use up all of the shots they receive and that “if a provider doesn’t have enough qualifying employees under” the top priority group, “they can help vaccinate workers who aren’t receiving vaccine directly from their employers.”
Michigan’s Department of Health and Human Services said, “We have not asked that vaccine providers report this data,” though it said that 10 wasted doses had been reported to it as of Jan. 13.In some cases, states said they were aware of specific instances of wastage. New Jersey said that it was “aware of 16 vials that had to be discarded because they arrived broken when the boxes were open.”
While a spokesperson noted that providers are instructed to give vaccines to people on waitlists to minimize the chances of vaccine being discarded, the spokesperson didn’t respond to questions about whether providers were mandated to report wasted doses.
Other states do have wastage reporting mandates. Pennsylvania, for example, said it requires providers to report any doses that are received and are not able to be used and was able to give a percentage — 0.1% of doses received for injections as of Jan. 11 — that had to be disposed of. “The majority of discarded vaccine is related to vials broken in handling and syringe issues, such as bent or broken needles or clients refusing after the vaccine dose was drawn,” said Department of Health spokesman Barry Ciccocioppo.
Colorado also said that waste is being tracked. “The state is aware that Pueblo Local Public Health rendered 300 doses of the Pfizer vaccine unusable after a portable vaccine storage unit malfunction,” a spokesperson from the state’s Joint Information Center said. “The state’s goal is to use every single available vaccine, acknowledging that emergencies may occur infrequently in the distribution process.”
In every mass vaccination effort, some share of doses unavoidably goes into the trash rather than arms. However, data on wasted shots — especially in large quantities — is an essential tool for federal and state health agencies trying to spot problems in how the vaccine is being shipped, stored and given to the public.
State vaccine officials monitor wastage numbers to determine if providers are mishandling shipments or improperly maintaining the temperature of their vials, said Dr. Kelly Moore, deputy director of the Immunization Action Coalition and former head of Tennessee’s immunization program. "Are they tracking things and responding appropriately, if you're seeing extremely low wastage rates and everything is always perfect?" Moore said. "When things look too good to be true, they usually are."
The two vaccines currently authorized, made by Moderna and Pfizer-BioNTech, both must be used within six hours of leaving cold storage, reaching room temperature and being opened. If there are no-shows for vaccination appointments, pharmacists have to quickly find replacements before the thawed vaccines expire.
Complicating the count is the fact that the number of doses available in a vial sometimes exceeds the amount prescribed on the label — pharmacists have commonly found that they can squeeze a sixth dose out of Pfizer’s vials, even though they are labeled as containing five. That means that a vaccine site could be allocated a certain number of doses on paper, have a few extra ones left that need to be tossed and still come out net positive. In that situation, it is unclear if the discarded doses should count as waste.
Data on wasted doses is routinely monitored in childhood immunizations in large part because it is required by the federal Vaccines For Children program, which provides innoculations to millions of children not covered by private health insurance, said Dr. Sean O'Leary, a professor of pediatric infectious diseases at University of Colorado Medicine. “Practices that are participating in that program, which are the vast majority of pediatric practices and a lot of family medicine practices, are used to keeping track very carefully of their vaccine inventory.”
There isn't a federal program overseeing most adult vaccinations, so any wastage reporting for adult shots, like the flu shot, would be managed state by state.
While collecting wastage data is a good business practice, O’Leary said it is most useful as a deterrent against vaccine providers mishandling or discarding doses irresponsibly.
"It's being tracked as a disincentive to letting [wastage] happen,” he said, “for accountability for people who are delivering the vaccines that they are doing their best to give the vaccines and store them properly."
However, there is also a danger in stigmatizing the waste of vaccine doses, said Moore, the immunization coalition deputy director. Accidents and normal human error are going to make some vials unfit to use on patients. Doses compromised by unsafe temperatures or contamination need to be thrown out, not injected into people. “You never, ever want to have clinics feel pressured not to waste vaccine that needs to be wasted,” Moore said. “If you say, ‘No one should ever damage vaccine,' you're really going to be in trouble.”
The CDC says vaccine providers should avoid wastage and disclose when it happens.
“If there is excess vaccine, clinic staff should do everything possible to avoid wasting the dose. If vaccine wastage occurs, it should be reported into CDC’s Vaccine Tracking System (VTrckS),” said CDC spokeswoman Kristen Nordlund. “We are working to figure out how to provide this data online in the future when the data is more complete."
In the meantime, federal officials have begun to urge that priority guidelines not get in the way of using vaccines. “It’s more important to get people vaccinated than to perfectly march through each prioritized group,” Alex Azar, secretary of health and human services under President Donald Trump, said at a briefing on Jan. 6.
This means that a pharmacist should use a dose that’s about to expire on any available person — even someone who isn’t in a priority group — rather than letting it go in the trash. “There’s always someone in line. The whole nation is in line,” said Lori Freeman, chief executive officer of the National Association of County and City Health Officials. “There’s no reason for any vaccine to go to waste.”
Dr. Mysheika Roberts, health commissioner of Columbus, Ohio, said in an interview last week that her local vaccination site hasn’t had to waste a single dose of vaccine so far. Initially, if there were extra doses at the end of the day, they used them on their own staff, she said. After that, the mayor allowed them to put police officers on the waitlist — even though only health care providers were technically eligible at the time — so the vaccinators could call the station if they had extra doses. Managing a waitlist is complicated, Roberts said, because you need to have people who want the vaccine and have both the transportation and flexibility to get to the vaccine clinic within about 30 minutes, but so far it has worked out. The vaccine clinic has also managed to further reduce potential waste by getting appointment confirmations and defrosting vaccine vials close to appointment times, she said.
An Ohio Department of Health spokesperson said the state requires providers to report waste, and that 165 doses of the vaccine had been recorded as wastage as of Jan. 15.
“I hope to never be in a position where I have to waste a dose,” Roberts added. “I’d go on a street corner and find someone to give the vaccine to before I have to throw it away.”