As the novel coronavirus emerged in the news in January, Sarah Keeley was working as a medical scribe and considering what to do with her biology degree.
By February, as the disease crept across the U.S., Keeley said she found her calling: a career in public health. "This is something that's going to be necessary," Keeley remembered thinking. "This is something I can do. This is something I'm interested in."
In August, Keeley began studying at the University of Illinois at Urbana-Champaign to become an epidemiologist.
Public health programs in the United States have seen a surge in enrollment as the coronavirus has swept through the country, killing more than 246,000 people. As state and local public health departments struggle with unprecedented challenges — slashed budgets, surging demand, staff departures and even threats to workers' safety — a new generation is entering the field.
Among the more than 100 schools and public health programs that use the common application — a single admissions application form that students can send to multiple schools — there was a 20% increase in applications to master's in public health programs for the current academic year, to nearly 40,000, according to the Association of Schools and Programs of Public Health.
Some programs are seeing even bigger jumps. Applications to Brown University's small master's in public health program rose 75%, according to Annie Gjelsvik, a professor and director of the program.
Demand was so high as the pandemic hit full force in the spring that Brown extended its application deadline by over a month. Seventy students ultimately matriculated this fall, up from 41 last year.
"People interested in public health are interested in solving complex problems," Gjelsvik said. "The COVID pandemic is a complex issue that's in the forefront every day."
It's too early to say whether the jump in interest in public health programs is specific to that field or reflects a broader surge of interest in graduate programs in general, according to those who track graduate school admissions. Factors such as pandemic-related deferrals and disruptions in international student admissions make it difficult to compare programs across the board.
Magnolia E. Hernández, an assistant dean at Florida International University's Robert Stempel College of Public Health and Social Work, said new student enrollments in its master's in public health program grew 63% from last year. The school has especially seen an uptick in interest among Black students, from 21% of newly admitted students last fall to 26.8% this year.
Kelsie Campbell is one of them. She's part Jamaican and part British. When she heard in both the British and American media that Black and ethnic minorities were being disproportionately hurt by the pandemic, she wanted to focus on why.
"Why is the Black community being impacted disproportionately by the pandemic? Why is that happening?" Campbell asked. "I want to be able to come to you and say 'This is happening. These are the numbers and this is what we're going to do.'"
The biochemistry major at Florida International said she plans to explore that when she begins her MPH program at Stempel College in the spring. She said she hopes to eventually put her public health degree to work helping her own community.
"There's power in having people from your community in high places, somebody to fight for you, somebody to be your voice," she said.
Public health students are already working on the front lines of the nation's pandemic response in many locations. Students at Brown's public health program, for example, are crunching infection data and tracing the spread of the disease for the Rhode Island Department of Health.
Some students who had planned to work in public health shifted their focus as they watched the devastation of COVID-19 in their communities. In college, Emilie Saksvig, 23, double-majored in civil engineering and public health. She was supposed to start working this year as a Peace Corps volunteer to help with water infrastructure in Kenya. She had dreamed of working overseas on global public health.
The pandemic forced her to cancel those plans, and she decided instead to pursue a master's degree in public health at Emory University.
"The pandemic has made it so that it is apparent that the United States needs a lot of help, too," she said. "It changed the direction of where I wanted to go."
These students are entering a field that faced serious challenges even before the pandemic exposed the strains on the underfunded patchwork of state and local public health departments. An analysis by AP and KHN found that since 2010, per capita spending for state public health departments has dropped by 16%, and for local health departments by 18%. At least 38,000 state and local public health jobs have disappeared since the 2008 recession.
And the workforce is aging: Forty-two percent of governmental public health workers are over 50, according to the de Beaumont Foundation, and the field has high turnover. Before the pandemic, nearly half of public health workers said they planned to retire or leave their organizations for other reasons in the next five years. Poor pay topped the list of reasons. Some public health workers are paid so little that they qualify for public aid.
Brian Castrucci, CEO of the de Beaumont Foundation, which advocates for public health, said government public health jobs need to be a "destination job" for top graduates of public health schools.
"If we aren't going after the best and the brightest, it means that the best and the brightest aren't protecting our nation from those threats that can, clearly, not only devastate from a human perspective, but from an economic perspective," Castrucci said.
The pandemic put that already-stressed public health workforce in the middle of what became a pitched political battle over how to contain the disease. As public health officials recommended closing businesses and requiring people to wear masks, many, including Dr. Anthony Fauci, the U.S. government's top virus expert, faced threats and political reprisals, AP and KHN found. Many were pushed out of their jobs. An ongoing count by AP/KHN has found that more than 100 public health leaders in dozens of states have retired, quit or been fired since April.
Those threats have had the effect of crystallizing for students the importance of their work, said Patricia Pittman, a professor of health policy and management at George Washington University's Milken Institute School of Public Health.
"Our students have been both indignant and also energized by what it means to become a public health professional," Pittman said. "Indignant because many of the local and the national leaders who are trying to make recommendations around public health practices were being mistreated. And proud because they know that they are going to be part of that front-line public health workforce that has not always gotten the respect that it deserves."
Saksvig compared public health workers to law enforcement in the way they both have responsibility for enforcing rules that can alter people's lives.
"I feel like before the coronavirus, a lot of people didn't really pay attention to public health," she said. "Especially now when something like a pandemic is happening, public health people are just on the forefront of everything."
KHN Midwest correspondent Lauren Weber and KHN senior correspondent Anna Maria Barry-Jester contributed to this report.
This story is a collaboration between The Associated Press and KHN.
Faculty members and student activists around the country have long called for medical schools to increase the number of students and instructors from underrepresented backgrounds to improve treatment and build inclusivity.
This article was published on Tuesday, November 17, 2020 in Kaiser Health News.
By Elizabeth Lawrence Betial Asmerom, a fourth-year medical student at the University of California-San Diego, didn't have the slightest interest in becoming a doctor when she was growing up.
As an adolescent, she helped her parents — immigrants from Eritrea who spoke little English — navigate the healthcare system in Oakland, California. She saw physicians who were disrespectful to her family and uncaring about treatment for her mother's cirrhosis, hypertension and diabetes.
"All of those experiences actually made me really dislike physicians," Asmerom said. "Particularly in my community, the saying is, 'You only go to the doctor if you're about to die.'"
But that changed when she took a course in college about health disparities. It shocked her and made her realize that what her Eritrean family and friends saw was happening to other communities of color, too. Asmerom came to believe that as a doctor she could help turn things around.
Faculty members and student activists around the country have long called for medical schools to increase the number of students and instructors from underrepresented backgrounds to improve treatment and build inclusivity. But to identify racism's roots and its effects in the health system, they say, fundamental changes must be made in medical school curriculums.
Asmerom is one of many crusaders seeking robust anti-racist education. They are demanding that the schools eliminate the use of race as a diagnostic tool, recognize how systemic racism harms patients and reckon with some of medicine's racist history.
This activism has been ongoing — White Coats for Black Lives (WC4BL), a student-run organization fighting racism in medicine, grew out of the 2014 Black Lives Matter protests. But now, as with countless other U.S. institutions since the killing of George Floyd in Minneapolis in May, medical schools and national medical organizations are under even greater pressure to take concrete action.
Debunking Race as a Diagnostic Tool
For many years, medical students were taught that genetic differences among the races had an effect on health. But in recent years, studies have found race does not reliably reflect that. The National Human Genome Research Institute notes very little genetic variation among races, and more differences among people within each race. Because of this, more physicians are embracing the idea that race is not an intrinsic biological difference but instead a social construct.
Dr. Brooke Cunningham, a physician and sociologist at the University of Minnesota Medical School, said the medical community is conflicted about abandoning the idea of race as biological. It's baked into the way doctors diagnose and measure illness, she said. Some physicians claim it is useful to take race into account when treating patients; others argue it leads to bias and poor care.
When race is factored into medical calculations, it can lead to less effective treatments and perpetuate race-based inequities. One such calculation estimates kidney function (eGFR, or the estimated glomerular filtration rate). The eGFR can limit Black patients' access to care because the number used to denote Black race in the formula provides a result suggesting kidneys are functioning better than they are, researchers recently reported in the New England Journal of Medicine. Among another dozen examples they cite is a formula that obstetricians use to determine the probability of a successful vaginal birth after a cesarean section, which disadvantages Black and Hispanic patients, and an adjustment for measuring lung capacity using a spirometer, which can cause inaccurate estimates of lung function for patients with asthma or chronic obstructive pulmonary disease.
In the face of this research, medical students are urging schools to rethink curricula that treat race as a risk factor for disease. Briana Christophers, a second-year student at Weill Cornell Medical College in New York, said it makes no sense that race would make someone more susceptible to disease, although economic and social factors play a significant role.
Naomi Nkinsi, a third-year student at the University of Washington School of Medicine in Seattle, recalled sitting in a lecture — one of five Black students in the room — and hearing that Black people are inherently more prone to disease.
"It was very personal," Nkinsi said. "That's my body, that's my parents, that's my siblings. Every time I go into a doctor's office now, I'll be reminded that they're not just considering me as a whole person but as somehow physically different than all other patients just because I have more melanin in my skin."
Nkinsi helped in a successful campaign to exclude race from the calculation of eGFR at UW Medicine, joining a small number of other health systems. She said the achievement — announced officially in late May — was largely due to Black students' tireless efforts.
Acknowledging Racism's Adverse Effects on Health
The Liaison Committee on Medical Education, the official accrediting body for medical schools in the U.S. and Canada, said faculty must teach students to recognize bias "in themselves, in others, and in the healthcare delivery process." But the LCME does not explicitly require accredited institutions to teach about systemic racism in medicine.
This is what students and some faculty want to change. Dr. David Acosta, the chief diversity and inclusion officer of the American Association of Medical Colleges, said about 80% of medical schools offer either a mandatory or elective course on health disparities. But little data exists on how many schools teach students how to recognize and fight racism, he said.
An anti-racist curriculum should explore ways to mitigate or eliminate racism's harm, said Rachel Hardeman, a health policy professor at the University of Minnesota.
"It's thinking about how do you infuse this across all of the learning in medical education, so that it's not this sort of drop in the bucket, like, one-time thing," she said. Above all, the courses that delve into systemic racism need to be required, Hardeman said.
Edwin Lindo, a lecturer at the University of Washington School of Medicine, said medicine should embrace an interdisciplinary model, allowing sociologists or historians to lecture on how racism harms health.
Acosta said the AAMC has organized a committee of experts to develop an anti-racism curriculum for every step of medical education. They hope to share their work publicly this month and talk to the LCME about developing and implementing these standards.
"Our next work is how do we persuade and influence the LCME to think about adding anti-racist training in there," Acosta said.
Recognizing Racism in Medical Education's Past and Present
Activists especially want to see their institutions recognize their own missteps, as well as the racism that has accompanied past medical achievements. Dereck Paul, a student at the University of California-San Francisco School of Medicine, said he wants every medical school to include lectures on people like Henrietta Lacks, the Black woman who was dying of cancer when cells were taken without her consent and used to develop cell lines that have been instrumental in medical research.
Asmerom said she wants to see faculty acknowledge medicine's racist past in lessons. She cited an introductory course on anatomy at her school that failed to note that in the past, as scientists sought to study the body, Blacks and other minorities were mistreated. "It's like, OK, but you're not going to talk about the fact that Black bodies were taken out of graves in order to have bodies to use for anatomy lab?" she said.
While Asmerom is glad to see her medical school actively listening to students, she feels administrators need to own up to their mistakes in the recent past. "There needs to be an admission of how you perpetuated anti-Black racism at this institution," Asmerom said.
Asmerom, who is one of the leaders of the UCSD Anti-Racism Coalition, said the administration has responded favorably so far to the coalition's demands to pour time and money into anti-racist initiatives. She's cautiously hopeful.
"But I'm not going to hold my breath until I see actual changes," she said.
Faculty members and student activists around the country have long called for medical schools to increase the number of students and instructors from underrepresented backgrounds to improve treatment and build inclusivity.
This article was published on Tuesday, November 17, 2020 in Kaiser Health News.
Betial Asmerom, a fourth-year medical student at the University of California-San Diego, didn’t have the slightest interest in becoming a doctor when she was growing up.
As an adolescent, she helped her parents — immigrants from Eritrea who spoke little English — navigate the health care system in Oakland, California. She saw physicians who were disrespectful to her family and uncaring about treatment for her mother’s cirrhosis, hypertension and diabetes.
“All of those experiences actually made me really dislike physicians,” Asmerom said. “Particularly in my community, the saying is, ‘You only go to the doctor if you’re about to die.’”
But that changed when she took a course in college about health disparities. It shocked her and made her realize that what her Eritrean family and friends saw was happening to other communities of color, too. Asmerom came to believe that as a doctor she could help turn things around.
Faculty members and student activists around the country have long called for medical schools to increase the number of students and instructors from underrepresented backgrounds to improve treatment and build inclusivity. But to identify racism’s roots and its effects in the health system, they say, fundamental changes must be made in medical school curriculums.
Asmerom is one of many crusaders seeking robust anti-racist education. They are demanding that the schools eliminate the use of race as a diagnostic tool, recognize how systemic racism harms patients and reckon with some of medicine’s racist history.
This activism has been ongoing — White Coats for Black Lives (WC4BL), a student-run organization fighting racism in medicine, grew out of the 2014 Black Lives Matter protests. But now, as with countless other U.S. institutions since the killing of George Floyd in Minneapolis in May, medical schools and national medical organizations are under even greater pressure to take concrete action.
Debunking Race as a Diagnostic Tool
For many years, medical students were taught that genetic differences among the races had an effect on health. But in recent years, studies have found race does not reliably reflect that. The National Human Genome Research Institute notes very little genetic variation among races, and more differences among people within each race. Because of this, more physicians are embracing the idea that race is not an intrinsic biological difference but instead a social construct.
Dr. Brooke Cunningham, a physician and sociologist at the University of Minnesota Medical School, said the medical community is conflicted about abandoning the idea of race as biological. It’s baked into the way doctors diagnose and measure illness, she said. Some physicians claim it is useful to take race into account when treating patients; others argue it leads to bias and poor care.
When race is factored into medical calculations, it can lead to less effective treatments and perpetuate race-based inequities. One such calculation estimates kidney function (eGFR, or the estimated glomerular filtration rate). The eGFR can limit Black patients’ access to care because the number used to denote Black race in the formula provides a result suggesting kidneys are functioning better than they are, researchers recently reported in the New England Journal of Medicine. Among another dozen examples they cite is a formula that obstetricians use to determine the probability of a successful vaginal birth after a cesarean section, which disadvantages Black and Hispanic patients, and an adjustment for measuring lung capacity using a spirometer, which can cause inaccurate estimates of lung function for patients with asthma or chronic obstructive pulmonary disease.
In the face of this research, medical students are urging schools to rethink curricula that treat race as a risk factor for disease. Briana Christophers, a second-year student at Weill Cornell Medical College in New York, said it makes no sense that race would make someone more susceptible to disease, although economic and social factors play a significant role.
Naomi Nkinsi, a third-year student at the University of Washington School of Medicine in Seattle, recalled sitting in a lecture — one of five Black students in the room — and hearing that Black people are inherently more prone to disease.
“It was very personal,” Nkinsi said. “That’s my body, that’s my parents, that’s my siblings. Every time I go into a doctor’s office now, I’ll be reminded that they’re not just considering me as a whole person but as somehow physically different than all other patients just because I have more melanin in my skin.”
Nkinsi helped in a successful campaign to exclude race from the calculation of eGFR at UW Medicine, joining a small number of other health systems. She said the achievement — announced officially in late May — was largely due to Black students’ tireless efforts.
Acknowledging Racism’s Adverse Effects on Health
The Liaison Committee on Medical Education, the official accrediting body for medical schools in the U.S. and Canada, said faculty must teach students to recognize bias “in themselves, in others, and in the health care delivery process.” But the LCME does not explicitly require accredited institutions to teach about systemic racism in medicine.
This is what students and some faculty want to change. Dr. David Acosta, the chief diversity and inclusion officer of the American Association of Medical Colleges, said about 80% of medical schools offer either a mandatory or elective course on health disparities. But little data exists on how many schools teach students how to recognize and fight racism, he said.
An anti-racist curriculum should explore ways to mitigate or eliminate racism’s harm, said Rachel Hardeman, a health policy professor at the University of Minnesota.
“It’s thinking about how do you infuse this across all of the learning in medical education, so that it’s not this sort of drop in the bucket, like, one-time thing,” she said. Above all, the courses that delve into systemic racism need to be required, Hardeman said.
Edwin Lindo, a lecturer at the University of Washington School of Medicine, said medicine should embrace an interdisciplinary model, allowing sociologists or historians to lecture on how racism harms health.
Acosta said the AAMC has organized a committee of experts to develop an anti-racism curriculum for every step of medical education. They hope to share their work publicly this month and talk to the LCME about developing and implementing these standards.
“Our next work is how do we persuade and influence the LCME to think about adding anti-racist training in there,” Acosta said.
Recognizing Racism in Medical Education’s Past and Present
Activists especially want to see their institutions recognize their own missteps, as well as the racism that has accompanied past medical achievements. Dereck Paul, a student at the University of California-San Francisco School of Medicine, said he wants every medical school to include lectures on people like Henrietta Lacks, the Black woman who was dying of cancer when cells were taken without her consent and used to develop cell lines that have been instrumental in medical research.
Asmerom said she wants to see faculty acknowledge medicine’s racist past in lessons. She cited an introductory course on anatomy at her school that failed to note that in the past, as scientists sought to study the body, Blacks and other minorities were mistreated. “It’s like, OK, but you’re not going to talk about the fact that Black bodies were taken out of graves in order to have bodies to use for anatomy lab?” she said.
While Asmerom is glad to see her medical school actively listening to students, she feels administrators need to own up to their mistakes in the recent past. “There needs to be an admission of how you perpetuated anti-Black racism at this institution,” Asmerom said.
Asmerom, who is one of the leaders of the UCSD Anti-Racism Coalition, said the administration has responded favorably so far to the coalition’s demands to pour time and money into anti-racist initiatives. She’s cautiously hopeful.
“But I’m not going to hold my breath until I see actual changes,” she said.
Ben Barnes has slept in abandoned buildings, hallways and alleys. For the past year or so, he’s been staying at the city’s largest homeless shelter, Pacific Garden Mission, in the shadows of the famous skyline.
“I’ve always considered myself homeless because I don’t have a home,” he said on a recent crisp, fall day in the shelter’s sun-splashed courtyard. But he’s fortunate, said Barnes, 44. He’s never had to sleep outside when it was below zero or snowy. He always found a friend’s place, building or shelter to crash in. He knows others aren’t so lucky.
As winter approaches, hundreds — perhaps thousands — of people in this city of nearly 3 million are living on the streets: some in encampments, others hopping from corner to corner. And the numbers could grow without more federal aid and protections amid economic pressures from the pandemic.
This year, the coronavirus has forced homeless shelters to limit the number of beds they can offer. Pacific Garden Mission, for instance, is operating at roughly half its normal capacity of 740. And COVID-19 cases are rising as temperatures drop.
“What happens if we’re in the midst of a pandemic and a polar vortex happens?” said Doug Schenkelberg, executive director of the Chicago Coalition for the Homeless. “We’re trying to keep the contagion from spreading and keep people from dealing with hypothermia. Is there the infrastructure in place that can handle that type of dual crisis?”
Cold-weather cities across the nation are seeking creative ways to cautiously shelter homeless people this winter. Exposure to the elements kills individuals staying outside every year, so indoor refuges can be lifesaving. But fewer options exist nowadays, as coronavirus concerns limit access to libraries, public recreation facilities and restaurants. And in official shelters, safety precautions — spacing out beds and chairs, emphasizing masks and hand-washing, testing — are critical.
“The homeless check off most boxes in terms of being the most susceptible and most vulnerable to the COVID-19 pandemic, and most likely to spread and most likely to die from it,” said Neli Vazquez Rowland, founder of A Safe Haven Foundation, a Chicago nonprofit that has been operating a “medical respite” isolation facility for homeless individuals with the coronavirus.
Demand for shelter could grow. Stimulus checks helped stave off some of the pandemic’s initial economic pain, but Congress has stalled on additional relief packages. And though the Trump administration has ordered a moratorium on evictions for tenants who meet certain conditions through the end of the year, a group of landlords is suing to stop the ban. Some states have their own prohibitions on evictions, but only Illinois, Minnesota and Kansas do in the Midwest.
At the Guest House of Milwaukee, a publicly funded homeless shelter in Wisconsin, the pandemic complicates an already challenging situation.
“We’re like many communities. We never really have completely enough space for everybody who is in need of shelter,” said Cindy Krahenbuhl, its executive director. “The fact that we’ve had to reduce capacity, and all shelters have, has created even more of a burden on the system.”
She said outreach teams plan to connect individuals living outside with an open bed — whether at a shelter, a hotel or an emergency facility for homeless people at risk for COVID — and get them started with case management.
“The reality is we’ve got to make it happen. We’ve got to have space for folks because it’s a matter of life and death. You cannot be outside unsheltered in this environment too long,” said Rob Swiers, executive director of the New Life Center in Fargo, North Dakota, where the average high in January is 18 degrees.
His shelter, Fargo’s largest, plans to use an insulated, heated warehouse to provide roomy sanctuary for clients.
In Minnesota’s Ramsey County, home to St. Paul, an estimated 311 people are living on the streets, compared with “dozens” at this time in 2019, according to Max Holdhusen, the county’s interim manager of housing stability. The area just had a record snowfall for so early in the year.
The county has been using hotel rooms to make up for the reduction in shelter beds, and recently agreed to lease an old hospital to shelter an additional 100 homeless people.
The city of Chicago has set up emergency shelters in two unused public school buildings to replace beds lost to social distancing. As it does every winter, the city will also operate warming centers across Chicago, although this year with precautions such as spacing and masking.
In September, the city directed more than $35 million in funding — mostly from the federal CARES Act for coronavirus relief — to an “expedited housing” program aiming to get more than 2,500 people housed in the next few years. The initiative plans to financially incentivize landlords to take risks on renters they might normally avoid, such as those with criminal histories or poor credit. The nonprofit in charge, All Chicago, is also hosting “accelerated moving events,” in which its staffers descend on a shelter, encampment or drop-in center and work to house everyone in that facility.
“In the ideal world, we would have permanent housing for them,” said Dr. David Ansell, senior vice president of community health equity at Chicago’s Rush University Medical Center. “That is the only way we can protect people’s health. That’s the fundamental health issue. It’s a fundamental racial justice issue. It’s a fundamental social justice issue.”
Even though Black people make up only a third of Chicago’s population, they account for roughly three-fourths of those who are homeless, according to the city’s count.
Dr. Thomas Huggett, a family physician with Lawndale Christian Health Center on the city’s largely impoverished West Side, also called safely sheltering and housing people this winter a racial equity issue.
“We know that people who are African American have a higher prevalence of hypertension, of diabetes, of obesity, of smoking, of lung issues,” he said. “So they are hit harder with those predisposing conditions that make it more likely that if you get coronavirus, you’re going to have a serious case of it.”
Then add the cold. Dr. Stockton Mayer, an infectious disease specialist from the University of Illinois Hospital in Chicago, said hypothermia doesn’t increase the chances of contracting the virus but could aggravate symptoms.
As of Sept. 30, according to All Chicago, 778 people were unsheltered in the city. However, that number includes only people who are enrolled in homelessness services, and other estimates are even higher.
Some homeless people who plan to live outside this winter said they worry about staying warm, dry and healthy in the age of COVID-19. Efren Parderes, 48, has been on the streets of Chicago since he lost his restaurant job and rented room early in the pandemic. But he doesn’t want to go to a shelter. He’s concerned about catching the coronavirus and bedbugs, and doesn’t want to have to obey curfews.
He recently asked other unsheltered people what they do to keep warm during the winter. Their advice: Locate a spot that blocks the wind or snow, bundle up with many layers of clothing, sleep in a sleeping bag and use hand warmers.
“This is going to be the first time I’ll be out when it’s really cold,” he said after spending a largely sleepless night in the chilly October rain.
If the states cannot prove they have standing, the justices can toss their case without ruling on its merits.
This article was published on Monday, November 16, 2020 in Kaiser Health News.
By Phil Galewitz Attorneys for GOP-controlled states seeking to kill the Affordable Care Act told the Supreme Court last week that at least some of the 12 million people who newly enrolled in Medicaid signed up only because of the law's requirement that people have insurance coverage — although a tax penalty no longer exists.
The statement drew a rebuke from Justice Sonia Sotomayor, who said it belies reason. Several health experts also questioned the argument that poor people apply for Medicaid not because they need help getting healthcare but to meet the ACA's individual mandate for coverage.
The point is vital to the Republicans' case to overturn the ACA, an effort supported by the Trump administration. The states are trying to prove they were harmed by the 2010 health law — and thus have "legal standing" to challenge its constitutionality. They argue their Medicaid spending increased because of the mandate, even though Congress eliminated the tax penalty for not having health coverage in 2019. Even when the penalty existed, most poor people were exempt because of their low income.
Under the ACA, states can opt to expand Medicaid eligibility to all adults earning less than 138% of the federal poverty level, or about $17,600 for an individual. States and the federal government share the cost of their care.
If the states cannot prove they have standing, the justices can toss their case without ruling on its merits. The case also involves two individuals who purchased private insurance from Texas and are suing to have the law overturned.
The Medicaid costs issue was one of several ways Texas and other GOP-controlled states participating in the lawsuit say they were harmed by the ACA even after the individual mandate penalty was reduced to zero. Several justices, including conservatives Clarence Thomas and Amy Coney Barrett, posed questions about whether the states had standing.
The case heard last Tuesday, California v. Texas, was the third time the high court has taken up a major suit on the ACA. Republican attorneys general in 18 states and the Trump administration want the entire law struck down, a move that would threaten coverage for more than 20 million people, as well as millions of others with preexisting conditions, including COVID-19.
Even if the court rules the states have legal standing, the ACA opponents must prove the elimination of a penalty makes the entire law unconstitutional.
The Republican states assert that since the law was upheld under Congress' taxing powers by the Supreme Court in 2012, once the tax penalty is gone, the entire law must fall, too.
A group of Democratic-controlled states led by California and the Democratic House of Representatives are urging the court to keep the law in place.
Sotomayor raised serious doubts about the plaintiffs' Medicaid argument and whether the states had suffered injury.
"At some point, common sense seems to me would say: Huh?" Sotomayor told Kyle Hawkins, Texas' solicitor general, who is leading the GOP states' legal fight. She questioned whether it seemed reasonable that once Medicaid enrollees are told there is no tax penalty for people who don't have coverage they would "enroll now, when they didn't enroll when they thought there was a tax? Does that make any sense to you?"
Hawkins defended his case, saying states need to show that only one person signed up for Medicaid because of the individual mandate. "There's a substantial likelihood of at least one person signing up for a state Medicaid program, which, of course, would cause at least one dollar in injury and satisfy the standing requirement," he said.
He cited a Congressional Budget Office report issued in 2017, when lawmakers were considering the change in the penalty. It said some people would continue to buy insurance or seek coverage "solely because of a willingness to comply with the law," even if the individual mandate penalty were eliminated.
Few surveys have asked Medicaid enrollees why they signed up for the program.
One of them, by University of Michigan researchers that same year, posed the question to 1,750 adults who had become eligible for Medicaid in the state as a result of the ACA expansion. The most common reasons respondents gave for enrolling were that they had lost other health coverage and had a medical condition that required care. Just 2% of respondents cited the need to avoid the individual mandate tax penalty.
With the tax penalty eliminated, legal and health policy experts said, it's likely the share of respondents signing up for Medicaid because of the health coverage mandate has dropped closer to zero.
Richard Kay, a law professor emeritus at the University of Connecticut, said it's clear most people don't seek coverage because of the individual mandate — particularly since there is no longer a financial penalty. But there could be a few who still do.
"Do you stop at a stop sign if you are in the country and no one is around for miles?" he said. "It's not impossible that some people get insurance just because the law requires them."
Kay said there is no precise guidance on how courts decide whether a plaintiff has been penalized enough to prove it has legal standing. "It's a very confused area of the law," he said.
Pratik Shah, a Washington, D.C., attorney who represents America's Health Insurance Plans, a trade group fighting to preserve the law, said the plaintiffs in the case have not proved standing.
"It does not make logical sense," he said of the argument that state budgets were harmed by people signing up for Medicaid even after the individual mandate penalty was eliminated.
"It's hard to see how the 2017 amendment to the health law would have forced more people into Medicaid," he said. "If they weren't signed up before, they would be less likely to get it without the penalty."
The court is expected to rule on the case by the end of June.
Nursing homes and assisted living centers are holding memorials for people who've died, having chaplains and social workers help residents and staff, and bringing in hospice providers to offer grief counseling.
This article was published on Friday, November 13, 2020 in Kaiser Health News.
A tidal wave of grief and loss has rolled through long-term care facilities as the coronavirus pandemic has killed more than 91,000 residents and staffers — nearly 40% of recorded COVID-19 deaths in the U.S.
And it’s not over: Facilities are bracing for further shocks as coronavirus cases rise across the country.
Workers are already emotionally drained and exhausted after staffing the front lines — and putting themselves at significant risk — since March, when the pandemic took hold. And residents are suffering deeply from losing people they once saw daily, the disruption of routines and being cut off from friends and family.
In response, nursing homes and assisted living centers are holding memorials for people who’ve died, having chaplains and social workers help residents and staff, and bringing in hospice providers to offer grief counseling, among other strategies. More than 2 million vulnerable older adults live in these facilities.
“Everyone is aware that this is a stressful, traumatic time, with no end in sight, and there needs to be some sort of intervention,” said Barbara Speedling, a long-term care consultant working on these issues with the American Health Care Association and National Center for Assisted Living, an industry organization.
Connie Graham, 65, is corporate chaplain at Community Health Services of Georgia, which operates 56 nursing homes. For months, he’s been holding socially distant prayer services in the homes’ parking lots for residents and staff members.
“People want prayers for friends in the facilities who’ve passed away, for relatives and friends who’ve passed away, for the safety of their families, for the loss of visitation, for healing, for the strength and perseverance to hold on,” Graham said.
Central Baptist Village, a Norridge, Illinois, nursing home, held a socially distanced garden ceremony to honor a beloved nurse who had died of COVID-19. “Our social service director made a wonderful collage of photos and left Post-its so everyone could write a memory” before delivering it to the nurse’s wife, said Dawn Mondschein, the nursing home’s chief executive officer.
“There’s a steady level of anxiety, with spikes of frustration and depression,” Mondschein said of staff members and residents.
Vitas Healthcare, a hospice provider in 14 states and the District of Columbia, has created occasional “virtual blessing services” on Zoom for staffers at nursing homes and assisted living centers. “We thank them for their service and a chaplain gives words of encouragement,” said Robin Fiorelli, Vitas’ senior director of bereavement and volunteers.
Vitas has also been holding virtual memorials via Zoom to recognize residents who’ve died of COVID-19. “A big part of that service is giving other residents an opportunity to share their memories and honor those they’ve lost,” Fiorelli said.
On Dec. 6, Hospice Savannah is going one step further and planning a national online broadcast of its annual Tree of Light” memorial, with grief counselors who will offer healing strategies. During the service, candles will be lit and a moment of silence observed in remembrance of people who’ve died.
“Grief has become an urgent mental health issue, and we hope this will help begin the healing process for people who haven’t been able to participate in rituals or receive the comfort and support they’d normally have gotten prior to COVID-19,” said Kathleen Benton, Hospice Savannah’s president and chief executive officer.
But these and other attempts are hardly equal to the extent of anguish, which has only grown as the pandemic stretches on, fueling a mental health crisis in long-term care.
“There is a desperate need for psychological services,” said Toni Miles, a professor at the University of Georgia’s College of Public Health and an expert on grief and bereavement in long-term care settings. She’s created two guides to help grieving staffers and residents and is distributing them digitally to more than 400 nursing homes and 1,000 assisted living centers in the state.
A recent survey by Altarum, a nonprofit research and consulting firm, highlights the hopelessness of many nursing home residents. The survey asked 365 people living in nursing homes about their experiences in July and August.
“I am completely isolated. I might as well be buried already,” one resident wrote. “There is no hope,” another said. “I feel like giving up. … No emotional support nor mental health support is available to me,” another complained.
Inadequate mental health services in nursing homes have been a problem for years. Instead of counseling, residents are typically given medications to ease symptoms of distress, said David Grabowski, a professor of health care policy at Harvard Medical School who has published several studies on this topic.
The situation has worsened during the pandemic as psychologists and social workers have been unable to enter facilities that limited outsiders to minimize the risk of viral transmission.
“Several facilities didn’t consider mental health professionals ‘essential’ health care providers, and many of us weren’t able to get in,” said Lisa Lind, president of Psychologists in Long-Term Care. Although some facilities switched to tele-mental health services, staff shortages have made those hard to arrange, she noted.
Fewer than half of nursing home staffers have health insurance, and those who do typically don’t have “minimal” access to mental health services, Grabowski said. That’s a problem because “there’s a real fragility right now on the part of the workforce.”
Colleen Frankenfield, president and chief executive officer of Lutheran Social Ministries of New Jersey, said what staffers need most of all is “the ability to vent and to have someone comfort them.” She recalls a horrible day in April, when four residents died in less than 24 hours at her organization’s continuing care retirement community in northern New Jersey, which includes an assisted living facility and a nursing home.
“The phone rang at 1 a.m. and all I heard on the other end was an administrator, sobbing,” she remembered. “She said she felt she was emotionally falling apart. She felt like she was responsible for the residents who had died, like she had let them down. She just had to talk about what she was experiencing and cry it out.”
Although Lutheran Social Ministries has been free of COVID-19 since the end of April, “our employees are tired — always on edge, always worried,” Frankenfield said. “I think people are afraid and they need time to heal. At the end of the day, all we can really do is stand with them, listen to them and support them in whatever way we can.”
Coming Monday: The Navigating Aging column will look at the grief faced by long-term care workers as COVID-19 cases and deaths mount.
Join Judith Graham for a Facebook Live event on grief and bereavement during the coronavirus pandemic on Monday, Nov. 16, at 1 p.m. ET. You can watch the conversation here and submit questions in advance here.
We’re eager to hear from readers about questions you’d like answered, problems you’ve been having with your care and advice you need in dealing with the health care system. Visit khn.org/columnists to submit your requests or tips.
It's already known that the coronavirus breaks into cells by way of a specific receptor, called ACE2, which is found all over the body. But scientists are still trying to understand how the virus sets off a cascade of events that cause so much destruction to blood vessels.
This article was published on Friday, November 13, 2020 in Kaiser Health News.
Whether it’s strange rashes on the toes or blood clots in the brain, the widespread ravages of COVID-19 have increasingly led researchers to focus on how the novel coronavirus sabotages blood vessels.
As scientists have come to know the disease better, they have homed in on the vascular system — the body’s network of arteries, veins and capillaries, stretching more than 60,000 miles — to understand this wide-ranging disease and to find treatments that can stymie its most pernicious effects.
Some of the earliest insights into how COVID-19 can act like a vascular disease came from studying the aftermath of the most serious infections. Those reveal that the virus warps a critical piece of our vascular infrastructure: the single layer of cells lining the inside of every blood vessel, known as the endothelial cells or simply the endothelium.
Dr. William Li, a vascular biologist, compares this lining to a freshly resurfaced ice rink before a hockey game on which the players and pucks glide smoothly along.
“When the virus damages the inside of the blood vessel and shreds the lining, that’s like the ice after a hockey game,” said Li, a researcher and founder of the Angiogenesis Foundation. “You wind up with a situation that is really untenable for blood flow.”
In a study published this summer, Li and an international team of researchers compared the lung tissues of people who died of COVID-19 with those of people who died of influenza. They found stark differences: The lung tissues of the COVID victims had nine times as many tiny blood clots (“microthrombi”) as those of the influenza victims, and the coronavirus-infected lungs also exhibited “severe endothelial injury.”
“The surprise was that this respiratory virus makes a beeline for the cells lining blood vessels, filling them up like a gumball machine and shredding the cell from the inside out,” Li said. “We found blood vessels are blocked and blood clots are forming because of that lining damage.”
It’s already known that the coronavirus breaks into cells by way of a specific receptor, called ACE2, which is found all over the body. But scientists are still trying to understand how the virus sets off a cascade of events that cause so much destruction to blood vessels. Li said one theory is that the virus directly attacks endothelial cells. Lab experiments have shown that the coronavirus can infect engineered human endothelial cells.
It’s also possible the problems begin elsewhere, and the endothelial cells sustain collateral damage along the way as the immune system reacts — and sometimes overreacts — to the invading virus.
Endothelial cells have a slew of important jobs; these include preventing clotting, controlling blood pressure, regulating oxidative stress and fending off pathogens. And Li said uncovering how the virus jeopardizes the endothelium may link many of COVID-19’s complications: “the effects in the brain, the blood clots in the lung and elsewhere in the legs, the COVID toe, the problem with the kidneys and even the heart.”
In Spain, skin biopsies of distinctive red lesions on toes, known as chilblains, found viral particles in the endothelial cells, leading the authors to conclude that “endothelial damage induced by the virus could be the key mechanism.”
Is Blood Vessel Damage Behind COVID Complications?
With a surface area larger than a football field, the endothelium helps maintain a delicate balance in the bloodstream. These cells are essentially the gatekeeper to the bloodstream.
“The endothelium has developed a distant early warning system to alert the body to get ready for an invasion if there’s trouble brewing,” said Dr. Peter Libby, a cardiologist and research scientist at Harvard Medical School. When that happens, endothelial cells change the way they function, he said. But that process can go too far.
“The very functions that help us maintain health and fight off invaders, when they run out of control, then it can actually make the disease worse,” Libby said.
In that case, the endothelial cells turn against their host and start to promote clotting and high blood pressure.
“In COVID-19 patients, we have both of these markers of dysfunction,” said Dr. Gaetano Santulli, a cardiologist and researcher at the Albert Einstein College of Medicine in New York City.
The novel coronavirus triggers a condition seen in other cardiovascular diseases called endothelial dysfunction. Santulli, who wrote about this idea in the spring, said that may be the “cornerstone” of organ dysfunction in COVID patients.
“The common denominator in all of these COVID-19 patients is endothelial dysfunction,” he said. “It’s like the virus knows where to go and knows how to attack these cells.”
Runaway Immune Response Adds a Plot Twist
A major source of damage to the vascular system likely also comes from the body’s own runaway immune response to the coronavirus.
“What we see with the SARS-CoV-2 is really an unprecedented level of inflammation in the bloodstream,” said Dr. Yogen Kanthi, a cardiologist and vascular medicine specialist at the National Institutes of Health who’s researching this phase of the illness. “This virus is leveraging its ability to create inflammation, and that has these deleterious, nefarious effects downstream.”
When inflammation spreads through the inner lining of the blood vessels — a condition called endothelialitis — blood clots can form throughout the body, starving tissues of oxygen and promoting even more inflammation.
“We start to get this relentless, self-amplifying cycle of inflammation in the body, which can then lead to more clotting and more inflammation,” Kanthi said.
Another sign of endothelial damage comes from analyzing the blood of COVID patients. A recent study found elevated levels of a protein produced by endothelial cells, called von Willebrand factor, that is involved in clotting.
“They are through the roof in those who are critically ill,” said Dr. Alfred Lee, a hematologist at the Yale Cancer Center who coauthored the study with Hyung Chun, a cardiologist and vascular biologist at Yale.
Lee pointed out that some autoimmune diseases can lead to a similar interplay of clotting and inflammation called immunothrombosis.
Chun said the elevated levels of von Willebrand factor show that vascular injury can be detected in patients while in the hospital — and perhaps even before, which could help predict their likelihood of developing more serious complications.
But he said it’s not yet clear what is the driving force behind the blood vessel damage: “It does seem to be a progression of disease that really brings out this endothelial injury. The key question is, what’s the root cause of this?”
After they presented their data, Lee said, Yale’s hospital system started putting patients who were critically ill with COVID-19 on aspirin, which can prevent clotting. While the best combinations and dosages are still being studied, research indicates blood thinners may improve outcomes in COVID patients.
Chun said treatments are also being studied that may more directly protect endothelial cells from the coronavirus.
“Is that the end-all-be-all to treating COVID-19? I absolutely don’t think so. There’s so many aspects of the disease that we still don’t understand,” he said.
COVID Is Often a Vascular ‘Stress Test’
Early in the pandemic, Dr. Roger Seheult, a critical care and pulmonary physician in Southern California, realized the patients he expected to be most vulnerable to a respiratory virus, those with underlying lung conditions such as chronic obstructive pulmonary disease and asthma, were not the ones ending up disproportionately in his intensive care unit. Seheult, who runs the popular medical education website MedCram, said, “Instead, what we are seeing are patients who are obese, people who have large BMIs, people who have Type 2 diabetes and with high blood pressure.”
Over time, all those conditions can cause inflammation and damage to the lining of blood vessels, he said, including a harmful chemical imbalance known as oxidative stress. Seheult said infection with the coronavirus becomes an added stress for people with those conditions that already tax the blood vessels: “If you’re right on the edge and you get the wind blown from this coronavirus, now you’ve gone over the edge.”
He said the extensive damage to blood vessels could explain why COVID patients with severe respiratory problems don’t necessarily resemble patients who get sick from the flu.
“They are having shortness of breath, but we have to realize the lungs are more than just the airways,” he said. “It’s an issue with the blood vessels themselves.”
This is why COVID patients struggle to fill their blood supply with oxygen, even when air is being pumped into their lungs.
“The endothelial cells get leaky, so instead of being like saran wrap, it turns into a sieve and then it allows fluid from the bloodstream to accumulate in the air spaces,” Harvard’s Libby said.
Doctors who treat COVID-19 are now keenly aware that complications such as strokes and heart problems can appear even after a patient gets better and their breathing improves.
“They are off oxygen, they can be discharged home, but their vasculature is not completely resolved. They still have inflammation,” he said. “What can happen is they develop a blood clot, and they have a massive pulmonary embolism.”
Patients can be closely monitored for these problems, but one of the big unknowns for doctors and patients is the long-term effects of COVID-19 on the circulatory system. The Angiogenesis Foundation’s Li puts it this way: “The virus enters your body and it leaves your body. You might or might not have gotten sick. But is that leaving behind a trashed vascular system?”
This story is part of a partnership that includes NPR and Kaiser Health News.
Dr. Megan Ranney has learned a lot about COVID-19 since she began treating patients with the disease in the emergency department in February.
But there's one question she still can't answer: What makes some patients so much sicker than others?
Advancing age and underlying medical problems explain only part of the phenomenon, said Ranney, who has seen patients of similar age, background and health status follow wildly different trajectories.
"Why does one 40-year-old get really sick and another one not even need to be admitted?" asked Ranney, an associate professor of emergency medicine at Brown University.
In some cases, provocative new research shows, some people — men in particular — succumb because their immune systems are hit by friendly fire. Researchers hope the finding will help them develop targeted therapies for these patients.
In an international study in Science, 10% of nearly 1,000 COVID patients who developed life-threatening pneumonia had antibodies that disable key immune system proteins called interferons. These antibodies — known as autoantibodies because they attack the body itself — were not found at all in 663 people with mild or asymptomatic COVID infections. Only four of 1,227 healthy individuals had the autoantibodies. The study, published on Oct. 23, was led by the COVID Human Genetic Effort, which includes 200 research centers in 40 countries.
"This is one of the most important things we've learned about the immune system since the start of the pandemic," said Dr. Eric Topol, executive vice president for research at Scripps Research in San Diego, who was not involved in the new study. "This is a breakthrough finding."
In a second Science study by the same team, authors found that an additional 3.5% of critically ill patients had mutations in genes that control the interferons involved in fighting viruses. Given that the body has 500 to 600 of these genes, it's possible researchers will find more mutations, said Qian Zhang, lead author of the second study.
Interferons serve as the body's first line of defense against infection, sounding the alarm and activating an army of virus-fighting genes, said virologist Angela Rasmussen, an associate research scientist at the Center of Infection and Immunity at Columbia University's Mailman School of Public Health.
"Interferons are like a fire alarm and a sprinkler system all in one," said Rasmussen, who wasn't involved in the new studies.
Lab studies show interferons are suppressed in some people with COVID-19, perhaps by the virus itself.
Interferons are particularly important for protecting the body against new viruses, such as the coronavirus, which the body has never encountered, said Zhang, a researcher at Rockefeller University's St. Giles Laboratory of Human Genetics of Infectious Diseases.
When infected with the novel coronavirus, "your body should have alarms ringing everywhere," said Zhang. "If you don't get the alarm out, you could have viruses everywhere in large numbers."
Significantly, patients didn't make autoantibodies in response to the virus. Instead, they appeared to have had them before the pandemic even began, said Paul Bastard, the antibody study's lead author, also a researcher at Rockefeller University.
For reasons that researchers don't understand, the autoantibodies never caused a problem until patients were infected with COVID-19, Bastard said. Somehow, the novel coronavirus, or the immune response it triggered, appears to have set them in motion.
"Before COVID, their condition was silent," Bastard said. "Most of them hadn't gotten sick before."
Bastard said he now wonders whether autoantibodies against interferon also increase the risk from other viruses, such as influenza. Among patients in his study, "some of them had gotten flu in the past, and we're looking to see if the autoantibodies could have had an effect on flu."
Scientists have long known that viruses and the immune system compete in a sort of arms race, with viruses evolving ways to evade the immune system and even suppress its response, said Sabra Klein, a professor of molecular microbiology and immunology at the Johns Hopkins Bloomberg School of Public Health.
Antibodies are usually the heroes of the immune system, defending the body against viruses and other threats. But sometimes, in a phenomenon known as autoimmune disease, the immune system appears confused and creates autoantibodies. This occurs in diseases such as rheumatoid arthritis, when antibodies attack the joints, and Type 1 diabetes, in which the immune system attacks insulin-producing cells in the pancreas.
Although doctors don't know the exact causes of autoimmune disease, they've observed that the conditions often occur after a viral infection. Autoimmune diseases are more common as people age.
In yet another unexpected finding, 94% of patients in the study with these autoantibodies were men. About 12.5% of men with life-threatening COVID pneumonia had autoantibodies against interferon, compared with 2.6% of women.
That was unexpected, given that autoimmune disease is far more common in women, Klein said.
"I've been studying sex differences in viral infections for 22 years, and I don't think anybody who studies autoantibodies thought this would be a risk factor for COVID-19," Klein said.
The study might help explain why men are more likely than women to become critically ill with COVID-19 and die, Klein said.
"You see significantly more men dying in their 30s, not just in their 80s," she said.
Akiko Iwasaki, a professor of immunobiology at the Yale School of Medicine, noted that several genes involved in the immune system's response to viruses are on the X chromosome.
Women have two copies of this chromosome — along with two copies of each gene. That gives women a backup in case one copy of a gene becomes defective, Iwasaki said.
Men, however, have only one copy of the X chromosome. So if there is a defect or harmful gene on the X chromosome, they have no other copy of that gene to correct the problem, Iwasaki said.
Bastard noted that one woman in the study who developed autoantibodies has a rare genetic condition in which she has only one X chromosome.
Scientists have struggled to explain why men have a higher risk of hospitalization and death from COVID-19. When the disease first appeared in China, experts speculated that men suffered more from the virus because they are much more likely to smoke than Chinese women.
Researchers quickly noticed that men in Spain were also more likely to die of COVID-19, however, even though men and women there smoke at about the same rate, Klein said.
Experts have hypothesized that men might be put at higher risk by being less likely to wear masks in public than women and more likely to delay seeking medical care, Klein said.
But behavioral differences between men and women provide only part of the answer. Scientists say it's possible that the hormone estrogen may somehow protect women, while testosterone may put men at greater risk. Interestingly, recent studies have found that obesity poses a much greater risk to men with COVID-19 than to women, Klein said.
Yet women have their own form of suffering from COVID-19.
Studies show women are four times more likely to experience long-term COVID symptoms, lasting weeks or months, including fatigue, weakness and a kind of mental confusion known as "brain fog," Klein noted.
As women, "maybe we survive it and are less likely to die, but then we have all these long-term complications," she said.
After reading the studies, Klein said, she would like to learn whether patients who become severely ill from other viruses, such as influenza, also harbor genes or antibodies that disable interferon.
"There's no evidence for this in flu," Klein said. "But we haven't looked. Through COVID-19, we may have uncovered a very novel mechanism of disease, which we could find is present in a number of diseases."
To be sure, scientists say that the new study solves only part of the mystery of why patient outcomes can vary so greatly.
Researchers say it's possible that some patients are protected by past exposure to other coronaviruses. Patients who get very sick also may have inhaled higher doses of the virus, such as from repeated exposure to infected co-workers.
Although doctors have looked for links between disease outcomes and blood type, studies have produced conflicting results.
Screening patients for autoantibodies against interferons could help predict which patients are more likely to become very sick, said Bastard, who is also affiliated with the Necker Hospital for Sick Children in Paris. Testing takes about two days. Hospitals in Paris can now screen patients on request from a doctor, he said.
Although only 10% of patients with life-threatening COVID-19 have autoantibodies, "I think we should give the test to everyone who is admitted," Bastard said. Otherwise, "we wouldn't know who is at risk for a severe form of the disease."
Bastard said he hopes his findings will lead to new therapies that save lives. He notes that the body manufactures many types of interferons. Giving these patients a different type of interferon — one not disabled by their genes or autoantibodies — might help them fight off the virus.
In fact, a pilot study of 98 patients published Thursday in the Lancet Respiratory Medicine journal found benefits from an inhaled form of interferon. In the industry-funded British study, hospitalized COVID patients randomly assigned to receive interferon beta-1a were more than twice as likely as others to recover enough to resume their regular activities.
Researchers need to confirm these findings in a much larger study, said Dr. Nathan Peiffer-Smadja, a researcher at Imperial College London who was not involved in the study but wrote an accompanying editorial. Future studies should test patients' blood for genetic mutations and autoantibodies against interferon, to see if they respond differently than others.
Peiffer-Smadja notes that inhaled interferon may work better than an injected form of the drug because it's delivered directly to the lungs. While injected versions of interferon have been used for years to treat other diseases, the inhaled version is still experimental and not commercially available.
And doctors should be cautious about interferon for now, because a study led by the World Health Organization found no benefit to an injected form of the drug in COVID patients, Peiffer-Smadja said. In fact, there was a trend toward higher mortality rates in patients given interferon, although this finding could have been due to chance. Giving interferon later in the course of disease could encourage a destructive immune overreaction called a cytokine storm, in which the immune system does more damage than the virus.
Around the world, scientists have launched more than 100 clinical trials of interferons, according to clinicaltrials.gov, a database of research studies from the National Institutes of Health.
Until larger studies are completed, doctors say, Bastard's findings are unlikely to change how they treat COVID-19.
Dr. Lewis Kaplan, president of the Society of Critical Care Medicine, said he treats patients according to their symptoms, not their risk factors.
"If you are a little sick, you get treated with a little bit of care," Kaplan said. "You are really sick, you get a lot of care. But if a COVID patient comes in with hypertension, diabetes and obesity, we don't say, 'They have risk factors. Let's put them in the ICU.'"
Millions of Americans have been dropped from their jobs and their employer-provided health insurance since March, when the coronavirus first ravaged the economy.
This article was published Thursday, November 12, 2020 inKaiser Health News.
Michelina Moen lost her job and health insurance in April. Only weeks earlier she had begun to feel ill and not her usual energetic self — in what she describes as a textbook case of "really bad timing."
The Orlando, Florida, resident sought treatment in May. After a series of tests, doctors told Moen she had a rare kidney condition that would require months of treatment.
"Losing the coverage ended up being worse than losing the job," said Moen, 36, a dancer who had worked for both Walt Disney World and Universal Studios. "It was very stressful."
Moen rushed to find replacement coverage. With help from a social service agency, she enrolled in a plan through healthcare.gov, the federal Affordable Care Act insurance marketplace. Because she and her husband, Brett, were not working — he had been laid off by Disney, too — they qualified for federal subsidies, so the coverage cost her just $35 a month. Most of her medical expenses, which involve traveling frequently to Jacksonville for specialty treatment, are covered.
Moen's husband recently found a job, however, and the increase in the couple's income likely means her subsidy will fall and she'll have to pay more for health insurance. Moen said she'll evaluate her options and may switch plans during this year's ACA open enrollment period, which began Nov. 1 and ends Dec. 15 for coverage starting Jan. 1.
"A priority is to continue seeing my medical team in Jacksonville," Moen said.
Moen is one of millions of Americans who have been dropped from their jobs and their employer-provided health insurance since March, when the coronavirus first ravaged the economy. Although no official tally exists, studies indicate that at least 10 million workers lost their insurance but that about two-thirds of them found alternative coverage — through a new job, Medicaid, a spouse's or parent's plan, or the ACA marketplaces.
That leaves at least 3 million people without coverage, the most added in a single year since accurate record-keeping began in 1968. And experts are worried that, as the virus continues to play havoc with the economy, new rounds of business closings and layoffs could add to that number.
Navigators Want More Resources
The unprecedented situation has health insurance counselors (called navigators), ACA marketplace staff members and insurers scrambling to assist a possible surge of people looking for health insurance during open enrollment.
For the 36 states that rely on the federal ACA enrollment platform — healthcare.gov — the Trump administration awarded grants totaling $10 million for marketing and outreach this year, the same level as in 2019. In 2016, the last year of the Obama administration, navigator grants totaled $63 million.
Many navigator organizations say they don't have the resources from the federal government to do the job as they would like.
"I'm trying not to panic," said Jodi Ray, executive director of Florida Covering Kids & Families. "We've seen substantially more people needing coverage and help in recent months compared to last year, and more are new to being uninsured."
Ray said her team is booked with appointments well into November. But she bemoans the fact that she has a third of the counselors she had a few years ago — 50, compared with 150 — and only a tiny ad budget.
Like Ray, Jeremy Smith, program director at First Choice Services in Charleston, West Virginia, said his team is expecting "tens of thousands more people" needing help compared with last year — but no bigger budget to serve them. First Choice provides telephone-based enrollment assistance in West Virginia, New Hampshire, Iowa and Montana with a federal grant of $100,000 per state.
"We are talking to a lot more people who have had job-based coverage for years," Smith said. "This is the first time they are having to find insurance elsewhere. They don't know what to do or who to trust."
In Wisconsin, the governor shifted $1 million into health insurance outreach, in part to make up for a lack of federal funds, said Allison Espeseth, managing director at Covering Wisconsin, the state's navigator agency. She said the money will go to radio and TV spots, billboards, bus ads and small grants to community organizations.
"A lot of people who lost jobs and insurance didn't know they could enroll before open enrollment, so we are hoping to see them now," Espeseth said.
Toula Barber, 60, is happy to be among those who got clear and useful help. "I'm not that savvy with computers and figuring all this stuff out," said Barber, who lives in Manchester, New Hampshire. After she lost her job as a waitress in August, Barber's health insurance lapsed at the end of September. A First Choice Services navigator helped her find a plan with coverage that started Oct. 1. She pays $200 a month after subsidies.
Because that plan has a $6,000 deductible, however, Barber said she would look for something better during open enrollment, in consultation with the same navigator.
An analysispublished last summer found evidence of a shortage of enrollment assistance. It also pointed out that people who turned to insurance brokers rather than independent navigators for help sometimes were presented with the option of plans (such as short-term policies or cancer-only policies) that don't meet ACA standards.
"The bottom line was that nearly 5 million people who sought help during the last open enrollment could not find it," said Karen Pollitz, a senior fellow at KFF and one of the authors of the study. "I'm concerned that people will face barriers to finding help this year, too."
Some States Are Pushing Harder
In contrast to the states that use the federal website, healthcare.gov, many of the 15 states that run their own ACA marketplaces are committing more resources to outreach and marketing this year to meet the higher demand.
"We market aggressively," said Peter Lee, executive director of Covered California, that state's marketplace. "We want everyone who needs coverage to get it." Of Covered California's $440 million budget this year, Lee said $140 million will go for marketing and outreach. In addition, California is inserting information about the marketplace and subsidized coverage in all unemployment checks.
Just short of 300,000 Californians have enrolled since the pandemic began, and about half did so because they lost employment-based coverage, said Lee.
At the same time, however, about 1 in 4 Covered California enrollees dropped out this year, higher than the normal turnover as some newly qualified for Medicaid and an unknown number could no longer afford the premiums. Still, enrollment was at an all-time high of 1.5 million as of June.
In New York, state officials and private groups have been helping people enroll in Medicaid, marketplace plans or other state-supported programs.
"We've been super busy since April," said Elizabeth Benjamin, vice president of health initiatives at the Community Service Society of New York, an independent advocacy group for low-income residents. "Our governor prioritized this, so it's going well."
One challenge Benjamin noted are the fears that a case currently before the Supreme Court might overturn the law. "Our clients keep asking whether the ACA will still be around next year," she said. "We reassure them it will."
Madeline McGrath, 27, sought insurance help from the service society in May after her coverage through the Peace Corps expired. The corps laid off all its overseas staff in March. Madeline was in Moldova. She returned home to Chazy, New York. She qualified for Medicaid, and just in the nick of time: A few weeks earlier, she had been diagnosed with Crohn's disease, a chronic digestive disorder.
Nursing homes are still taking days to get back COVID-19 test results as many shun the Trump administration's central strategy to limit the spread of the virus among old and sick Americans.
In late summer, federal officials began distributing to nursing homes millions of point-of-care antigen tests, which can be given on-site and report the presence or absence of the virus within minutes. By January, the Department of Health and Human Services is slated to send roughly 23 million rapid tests.
But as of Oct. 25, 38% of the nation's roughly 15,000 nursing homes have yet to use a point-of-care test, a KHN analysis of nursing home records shows.
The numbers suggest a basic disagreement among the Trump administration, state health officials and nursing home administrators over the best way to test this population and how to strike the right balance between speed and accuracy. Many nursing homes still primarily send samples out to laboratories, using a type of test that's considered more reliable but can take days to deliver results.
As a result, in 29% of the approximately 13,000 facilities that provided their testing speed to the government, results for residents took an average of three days or more, the analysis found. Just 17% of nursing homes reported their average turnaround time was less than a day, and the remainder tended to get results in one or two days. Wait times for test results of staff members were similar.
Those lags could have devastating consequences, because even one undetected infection can quietly but rapidly trigger a broad outbreak. It's especially concerning as winter sets in and the pandemic notches daily records of infections.
In the meantime, the coronavirus continues its march through institutions. Nursing homes have reported more than 262,000 infections and 59,000 deaths since the government began collecting the information in May. Even without estimating how many residents died from COVID-19 before then, reported nursing home deaths amount to more than a quarter of all COVID-19 fatalities in the U.S. so far.
During the week ending Oct. 25, the most recent period for which data is available, a third of skilled nursing facilities reported a new suspected or confirmed coronavirus infection of a resident or staff member.
Many state public health authorities and nursing homes have ongoing reservations about the rapid tests. They are considered less accurate than the more expensive ones sent out to laboratories, which are known as polymerase chain reaction, or PCR, tests and identify the virus's genetic material but often take days to complete. And their manufacturers say the rapid tests are designed for people with symptoms — not for screening a general population.
In early November, the Food and Drug Administration warnedof false-positive results — in which someone is told incorrectly they are infected — associated with one type of rapid COVID test, and urged providers to follow Centers for Disease Control and Prevention recommendations for using them in nursing homes. False negativesare also a concern because people who don't know they are infected can unwittingly spread the virus.
HHS bought millions of rapid tests to distribute to nursing homes as the federal government imposed new mandates for the facilities to test staffers at least once a month. Routine staff testing increases to as often as twice a week for homes in areas with the highest infection rates. The Centers for Medicare & Medicaid Services, which is part of HHS, does not recommend testing asymptomatic residents unless a new outbreak occurs or a resident routinely goes outside the facility.
Leaders in multiple states, including Nevada, Vermont and Illinois, have moved to ban antigen tests in nursing homes or limit their use.
"I thought the hard part was getting the testing to the different facilities," said David Grabowski, a health care policy professor at Harvard Medical School. Instead, he said, "the major barriers to the use of rapid testing seem to be a lack of guidance on when and how to use the tests, coupled with concerns about their accuracy."
Dr. Michael Wasserman, immediate past president of the California Association of Long Term Care Medicine, said the national effort has been chaotic and inadequate.
The federal government "just hands stuff off to nursing homes and then says, 'Hey, it's yours; go use it,'" he said. "And then when things fall apart, 'We're not to blame.'"
Nursing homes that don't trust the rapid tests are having to shoulder the higher cost of lab tests. It costs Stuart Almer, president and CEO of Gurwin Jewish Nursing & Rehabilitation Center on New York's Long Island, $125,000 a week to conduct lab tests on up to 1,500 residents and staff members.
"We embrace the testing," Almer said. "But how are we supposed to continue operating and paying for this?"
Goodwin House in Virginia, which includes skilled nursing and assisted living facilities, had performed more than 9,500 tests for COVID-19 as of late October, said Joshua Bagley, an administrator. Only 100 of them were antigen tests. "The majority of our focus is still toward the PCR testing," Bagley said.
The concerns of state health officials were perhaps most evident in Nevada, where in early October the state banned antigen testing in nursing homes. HHS said the order was illegal, and it was revoked within days.
"There is no such thing as a perfect test," Adm. Brett Giroir, a senior HHS official who leads the Trump administration's COVID testing efforts, said on a call with reporters Nov. 9. For example, Giroir said, a risk of PCR tests is that they could provide a positive diagnosis when a person is no longer "actually infectious."
Although there have been widespread accuracy concerns over antigen tests, certain tests the administration is distributing nationwide have comparable accuracy to lab-based tests, he said.
Other state responses have not been as aggressive as Nevada's but nonetheless demonstrated unease over how best to use the devices, if at all.
Vermont recommends the use of antigen tests after a known COVID exposure but says they should not be used to diagnose asymptomatic people.
Ohio was initially reluctant to deploy them after Republican Gov. Mike DeWine's false-positive result from an antigen device, although the tests have since been adopted, said Peter Van Runkle, executive director of the Ohio Health Care Association, which represents some skilled nursing facilities in the state.
Some nursing homes say relying on antigen tests has made a monumental difference. In Hutchinson, Kansas, Wesley Towers Retirement Community has used both types of tests, but it was Abbott's BinaxNOW antigen test that detected its first two asymptomatic people with COVID-19, said Gretchen Sapp, Wesley Towers' vice president of health services.
"We have more confidence that our staff are indeed COVID-free or that they are out and not exposing residents. And that is incredibly helpful," Sapp said. "The biggest challenge is I need more tests."
A total of 1,150 homes told the federal government they did not have enough supplies for point-of-care tests for all workers, the KHN analysis found. Nursing homes can go through millions of tests quickly when testing monthly or more often, depending on the level of COVID-19 in the area.
White House spokesperson Michael Bars said the administration is working "hand-in-hand with our state and local partners" and "doing more than ever to protect the health and safety of high-risk age groups most susceptible to the virus."
Janet Snipes, executive director of Holly Heights Care Center in Denver, said antigen tests have been useful to screen staff members despite a few false-positive results. One test was used on a clergy member a resident had summoned.
"We wouldn't have been able to allow him in, but we were able to do the antigen testing," she said. "With the vulnerable residents we serve, we're hoping for more antigen testing, more testing period, more testing of any type."