A federal court's decision could mean that hospitals will need to revise their policies barring workers from talking to the news media and posting on social media.
This article was published on Friday, July 9, 2021 in Kaiser Health News.
Karen Jo Young wrote a letter to her local newspaper criticizing executives at the hospital where she worked as an activities coordinator, arguing that their actions led to staffing shortages and other patient safety problems.
Hours after her letter was published in September 2017, officials at Maine Coast Memorial Hospital in Ellsworth, Maine, fired her, citing a policy that no employee may give information to the news media without the direct involvement of the media office.
But a federal appellate court recently said Young's firing violated the law and ordered that she be reinstated. The court's decision could mean that hospitals and other employers will need to revise their policies barring workers from talking to the news media and posting on social media.
Those media policies have been a bitter source of conflict at hospitals over the past year, as physicians, nurses and other health care workers around the country have been fired or disciplined for publicly speaking or posting about what they saw as dangerously inadequate COVID-19 safety precautions. These fights also reflect growing tension between health care workers, including physicians, and the increasingly large, profit-oriented companies that employ them.
On May 26, the 1st U.S. Circuit Court of Appeals unanimously upheld a National Labor Relations Board decision issued last year that the hospital, now known as Northern Light Maine Coast Hospital, violated federal labor law by firing Young for engaging in protected "concerted activity." The NLRB defines it as guaranteeing the right to act with co-workers to address work-related issues, such as circulating petitions for better hours or speaking up about safety issues. It also affirmed the board's finding that the hospital's media policy barring contact between employees and the media was illegal.
"It's great news because I know all hospitals prefer we don't speak with the media," said Cokie Giles, president of the Maine State Nurses Association, a union. "We are careful about what we say and how we say it because we don't want to bring the hammer down on us."
The 1st Circuit opinion is noteworthy because it's one of only a few such employee speech rulings under the National Labor Relations Act ever issued by a federal appellate court, and the first in nearly 20 years, said Frank LoMonte, a University of Florida law professor who heads the Brechner Center for Freedom of Information.
The 1st Circuit and NLRB rulings should force hospitals to "pull out their handbook and make sure it doesn't gag employees from speaking," he said. "If you are fired for violating a 'don't talk to the media' policy, you should be able to get your job back."
The American Hospital Association and the Federation of American Hospitals declined to comment for this article.
While the 1st Circuit's opinion is binding only in four Northeastern states plus Puerto Rico, the NLRB decision carries the force of law nationwide. The case applies to both unionized and non-unionized employees, legal experts say.
Hospitals and health care organizations often have policies requiring employees to clear any public comments about the workplace with the organization's media office. Many also have policies restricting what employees can say on Facebook and other social media.
Hospitals say requiring employees to go through their media office prevents the spread of inaccurate information that could damage the public's confidence. In Young's case, the hospital argued that her letter contained false and disparaging statements. But the 1st Circuit panel agreed with the NLRB that her letter was "not abusive" and that its only false statement was not her fault.
Health care organizations have undisputed legal authority to prohibit employees from disclosing confidential patient information or proprietary business information, legal experts say.
But the 1st Circuit panel made clear that an employer cannot bar an employee from engaging in "concerted actions" — such as outreach to the news media — "in furtherance of a group concern." That's true even if the employee acted on her own, as Young did in writing her letter. The key in her case was that she "acted in support of what had already been established as a group concern," the court said.
"I think employers with a blanket ban on talking to the media need to relook at their policies," said Eric Meyer, a partner at FisherBroyles in Philadelphia who often represents companies on employment law matters. "If you go to the media and say, 'There are unsafe working conditions impacting me and my colleagues,' that's protected concerted activity."
Chad Hansen, Young's attorney in a separate federal lawsuit alleging discrimination based on a disability against the hospital, said she has not yet been reinstated to her job. Young would not comment.
The hospital's parent company, Northern Light Health, said only that its news media policy — which was amended after Young's firing — meets the NLRB and 1st Circuit requirements and will not be further changed. The new policy created an exception allowing employees to speak to the news media related to concerted activities protected by federal law.
Speech rights under the National Labor Relations Act are particularly important for employees of private companies. Although the Constitution protects people who work for public hospitals and other government employers with its guarantee of unrestricted speech, employees at private companies do not have a First Amendment right to speak publicly about workplace issues.
"I hope this case keeps alive the right of health care workers to speak out about something that's dangerous," said Dr. Ming Lin, an emergency physician who lost his job last year at PeaceHealth St. Joseph Medical Center in Bellingham, Washington, after publicly criticizing the hospital's pandemic preparedness.
Lin, who was employed by TeamHealth, which provides emergency physician services at the hospital, lost his assignment at PeaceHealth in March 2020 soon after saying on social media and in interviews with news reporters that PeaceHealth was not taking urgent enough steps to protect staff members from COVID. He had worked at the hospital for 17 years.
In an April 2020 YouTube interview, PeaceHealth's chief operating officer, Richard DeCarlo, said Lin was removed from the hospital's ER schedule because he "continued to post misinformation, which was resulting in people being afraid and being scared to come to the hospital." DeCarlo also alleged that Lin, who was out of town for part of the time he was posting, refused to communicate with his supervisors in Bellingham about the situation. PeaceHealth declined to comment for this article.
PeaceHealth's social media policy at that time stated that the company does not prohibit employees from engaging in federally protected concerted activity and that they "are free to communicate their opinions." TeamHealth's social media policy, dated July 15, 2020, states the company reserves the right to take disciplinary action in response to behavior that adversely affects the company.
Lin, who's now working for the Indian Health Service in South Dakota, has sued PeaceHealth, TeamHealth and DeCarlo in state court in Washington claiming wrongful termination in violation of public policy, breach of contract and defamation.
Dr. Jennifer Bryan, board chair of the Mississippi State Medical Association, who publicly defended two Mississippi physicians fired for posting about the inadequacy of their hospitals' COVID safety policies, said she faced pressure from her hospital for speaking to the news media without approval.
The medical association pushed its members to talk to the media about the science of COVID, while employers insisted doctors' messages had to be approved by the media office. That reflected a conflict, she said, between medical professionals primarily concerned about public health and executives of for-profit systems who were seeking to shield their corporate image.
Bryan predicted the court ruling and NLRB decision will be helpful. "Physicians have to be able to stand up and speak out for what they believe affects the safety and well-being of patients," she said. "Otherwise, there are no checks and balances."
I set out to test that statement by comparing prices in two major California hospital systems. I am sorry to report that, at least for now, that status quo — the tangled web that long has cloaked hospital pricing — is alive and well.
I have spent hours toggling among multiple spreadsheets, each containing thousands of numbers, in an effort to compare prices for 20 common outpatient procedures, such as colonoscopies, cataract surgeries, hernia repair and removal of breast lesions.
After three months of glazed eyes and headaches from banging my head against walls of numbers, I am throwing in the towel. It was a fool's errand. My efforts ultimately yielded just one helpful piece of advice: Don't try this at home.
I was most of the way to that realization when a conversation with Shawn Gremminger helped push me over the line.
"You are a healthcare reporter, I'm a healthcare lobbyist, and the fact that we can't do this ourselves is an indictment of where things stand at this point," said Gremminger, health policy director at the Purchaser Business Group on Health, which represents large employers who pay their employees' medical bills directly and have a big stake in price transparency. "The subset of people who can do this is pretty small, and most of them work for hospitals."
I heard similar comments from other veterans of the healthcare industry, even from the former managed-care executive who inspired the story.
He had come to me with a spreadsheet full of price info that appeared to show that a Kaiser Permanente hospital in the East Bay charged significantly higher prices for numerous procedures than a nearby hospital run by archcompetitor Sutter Health.
That was a compelling assertion, since Sutter is widely viewed in California as the poster child for excessive prices. Nearly two years ago, Sutter settled a high-profile antitrust case that accused the hospital system of using its market dominance in Northern California to illegally drive up prices.
I knew from the outset it would be tricky to compare Kaiser and Sutter because, operationally, they are apples and oranges.
Sutter negotiates separate deals with numerous health plans, and its prices can vary by thousands of dollars for the same service, depending on your insurance. Kaiser's hospitals are integrated with its insurance arm, which collects premiums — so, in effect, it is playing with house money. There is just one Kaiser health plan price for each medical service.
Still, the story seemed worth looking into. Those Sutter and Kaiser prices matter, because they are used to calculate how much patients pay out of their own pockets. And helping patients know what they'll owe in advance is one of the goals of the transparency rule.
The federal rule requires hospitals to report prices for all the medical services they provide in huge spreadsheets that can be processed by computers.
It also obliges them to provide prices in a more "consumer-friendly" format for 300 so-called shoppable services, which are procedures that can be scheduled in advance. And it requires that they report the cost of any "ancillary services," such as anesthesia, typically rendered in concert with those procedures. Of the 300 "shoppables," 70 are specified by the government and the rest are chosen by each hospital.
Most of the 20 common medical procedures I attempted to compare were among those 70. But a few, from lists of top outpatient procedures provided by the Healthcare Cost Institute, were not. I decided to use the more comprehensive, less friendly spreadsheets for my comparisons, since they contained all 20 of the procedures I'd chosen.
Each carried a five-digit medical code known as a CPT, a term trademarked by the American Medical Association that stands for "current procedural terminology." The transparency rule requires hospitals to include billing codes, because they supposedly provide a basis for price comparison, or in the rule's jargony language, "an adequate cross-walk between hospitals for their items and services."
Much to my chagrin, I soon discovered they don't provide an adequate crosswalk even within one hospital.
My first inkling of the insuperable complexity came when I noticed that Sutter's Alta Bates Summit Medical Center in Oakland listed the same outpatient procedure with the same CPT code three times, thousands of rows apart, with entirely different prices. CPT 64483 is the designated code for injection of anesthetics or steroids into a spinal nerve root with the use of imaging, which relieves pain in the lower back, legs and feet caused by sciatica or herniated discs. The spreadsheet showed a maximum negotiated price of $1,912 in row 12,718, $3,650.85 in row 19,014 and $5,475.80 in row 19,559 (let your eyes glaze over for just a few seconds, so you know what it feels like). The reason for the triple listing is tied to Medicare billing guidelines, Sutter later told me. I'll spare you the details.
My head really began to hurt when I decided to double-check some of the prices I had pulled from the big spreadsheets against the same items on the shorter shoppables sheets. Kaiser's prices were generally consistent across the two, but for Alta Bates, there were large discrepancies.
The highest negotiated price for removing a breast lesion, for example, was $6,156 on the big sheet and $23,069 on the shorter one. The difference seems largely attributable to the estimated cost of additional services, some rather nonspecific, that Sutter lists on the smaller sheet as accompaniments to the procedure: anesthesia, EKG/ECG, imaging, laboratory, perioperative, pharmacy and supplies.
But why not include them in both spreadsheets? And what do the two dramatically divergent prices actually encompass?
"How many bills they really represent and what they mean is difficult to interpret," said Dr. Merrit Quarum, CEO of Portland, Oregon-based WellRithms, which helps employers negotiate fair prices with hospitals. "It depends on the timing, it depends on the context, which you don't know."
In some cases, Sutter said, its shoppables spreadsheets show charges not only for ancillary services typically rendered on the day of the procedure, but also for related procedures that may precede or follow it by days or weeks.
The listings for Kaiser's ancillary services do not always match Sutter's, which further clouds the comparison. The problematic fact of the matter is that hospitals performing the same procedures bundle their bills differently, use different medications, estimate varying amounts of time in the operating room, and utilize more or less advanced technology. And physician charges are not even included in the posted prices, at least in California.
All of which makes it almost impossible for mere mortals to anticipate the total cost of their medical procedures, let alone compare prices among hospitals. Even if they could, it might be of limited value, since independent imaging centers and surgery centers, which are increasingly common — and generally less expensive — aren't required to report their prices.
The bottom line, I'm afraid, is that despite my efforts I don't have anything particularly insightful to reveal about how Kaiser's prices compare with Sutter's. The prices I examined were as transparent to me as hieroglyphics, and I'm pretty sure that hospital executives — who unsuccessfully sued to stop implementation of the price transparency rule — are not losing any sleep over that fact.
GRAND JUNCTION, Colo. — Dr. Rachel LaCount grasped a metal hoop at a playground and spun in circles with her 7-year-old son, turning the distant mesas of the Colorado National Monument into a red-tinged blur.
LaCount has lived in this western Colorado city of 64,000 nearly her whole life. As a hospital pathologist, she knows better than most that her hometown has become one of the nation's top breeding grounds for the delta variant of COVID-19.
"The delta variant's super scary," LaCount said.
That highly transmissible variant, first detected in India, is now the dominant COVID strain in the United States. Colorado is among the states with the highest proportion of the delta variant, according to the Centers for Disease Control and Prevention.
Mesa County has the most delta variant cases of any county in Colorado, state health officials report, making the area a hot spot within a hot spot. A CDC team and the state's epidemiologist traveled to Grand Junction to investigate how and why cases of the variant were moving so quickly in Mesa County.
At her hospital, LaCount has put in orders for more rapid COVID tests as the caseload has grown. She's seen the intensive care unit start filling up with COVID patients, so that hospital officials are placing two in a room against normal practices.
Despite these alarming signs, many in Mesa County have let down their guard. The rate of eligible residents fully vaccinated has stalled at about 42%. LaCount has noticed that few people wear masks anymore at the grocery store. Thousands of people recently flocked to Mack, 20 miles from Grand Junction, to attend the Country Jam music festival, which could accelerate the variant's spread to the concertgoers' hometowns.
"We're making national news for our COVID variant and the CDC is here investigating, but we have a huge festival where people aren't masking," said LaCount. "Are we going to get herd immunity over here just because everyone's going to get it? I mean, that's probably going to happen at some point, but at what cost?"
LaCount's worries aren't necessarily for herself or her spouse — they are both vaccinated — but for their son, who can't be vaccinated because he is under 12. She is uneasy about sending him to school in the fall for fear of exposure to the variant. She is reluctant to take him to birthday parties this summer knowing there's a good likelihood he'll be teased for wearing a mask.
A few yards away from LaCount and her son on the playground, a man fished in a still pond with his 10-month-old daughter in a backpack. Garrett Whiting, who works in construction, said he believes COVID is still being "blown out of proportion," especially by the news media.
"They got everybody scared really, really fast," said Whiting, slowly reeling in a sparkly blue lure from the water. "There's no reason to stop living your life just because you're scared of something."
Whiting tested positive for COVID about three months earlier. He said he doesn't plan to get vaccinated, nor does his wife. As for the baby on his back, he said he's not sure whether they'll have her vaccinated when regulators approve the shot for young children.
The delta variant is one of six "variants of concern" circulating in the U.S., according to the CDC, because the delta strain spreads more easily, might be more resistant to treatment and might be better at infecting vaccinated people than other variants.
The delta variant has raised alarms around the world. Parts of Australia have locked down again after the variant leapfrogged its way from an American aircrew to a birthday party where it infected all unvaccinated guests, health officials said, and after it also jumped between shoppers in a "scarily fleeting" moment in which two people walked past each other in a mall. Israel reissued an indoor mask requirement after a spate of new cases linked to schoolchildren. A leading health official there said about a third of the 125 people who were infected were vaccinated, and most of the new infections were delta variant.
A rise in delta variant cases delayed the United Kingdom's planned reopening in June. But public health officials have concluded after studying about 14,000 cases of the delta variant in that country that full vaccination with the Pfizer-BioNTech vaccine is 96% effective against hospitalization. Studies around the world have made similar findings. There is also evidence the Moderna and Johnson & Johnson vaccines are effective against the variant.
Los Angeles County recently recommended that residents resume wearing masks indoors regardless of vaccination status, over concern about the delta variant. The World Health Organization is also urging vaccinated people to wear masks, though the CDC hasn't changed its guidelines allowing vaccinated people to gather indoors without masks.
The variant arrived in Mesa County this spring, when it accounted for just 1% of all cases nationwide, said Jeff Kuhr, executive director of Mesa County Public Health.
"We were winding down just like everyone else. We were down to less than five cases a day. I think we had about two people hospitalized at one point," Kuhr said. "We felt as if we were out of the woods."
He even signed off on Country Jam, which bills itself as the state's "biggest country music party."
But in early May, the delta variant appeared in a burst, with five cases among adults working for the school district.
"It started to hit the children, those that were not of the age to be vaccinated," Kuhr said. "That was telling me that, you know, wearing masks in school was not providing the protection with this new variant that it had previously."
The county then started to see breakthrough cases in fully vaccinated elderly residents in long-term care facilities. The hospitals began to fill once more. Nine vaccinated people died, seven of them since the delta variant's arrival, though it's still unclear whether the variant is to blame. All were at least 75 years old, and seven lived in long-term care facilities. Now, Kuhr estimates, "above 90%" of cases in the county are delta variant.
The county is seeing the same trend as the state: The vast majority of people testing positive for COVID, and people being hospitalized with it, are unvaccinated. "It's a superspreader strain if there ever was one," Eric Topol with the Scripps Research Institution told Scientific American. But he said people fully vaccinated with Pfizer or Moderna shots "should not worry at all." There is less information about the protection offered by Johnson & Johnson's vaccine.
Mesa County health officials considered canceling the music festival, but "it was really too late," Kuhr said. After the announcement that the festival was on, about 23,000 people bought tickets.
Officials weighed banning alcohol or trying to get attendees a Johnson & Johnson single-dose vaccine in the weeks leading up to the festival. In the end, they settled on messaging: signs warning people online and at the venue that the area was a COVID hot spot.
According to CDC guidance, outdoor events were low risk. A sporting event at the end of May in Grand Junction that filled a baseball stadium had resulted in only one known case, which made Kuhr optimistic.
"We put messaging on Country Jam's website, and then in their social media pages, saying, you know, 'Mesa County's a hot spot. Be prepared,'" Kuhr said.
A stormy Friday dampened concert attendance at Country Jam. But on the last day of the festival, the sun was out and throngs of cowboy boot-clad concertgoers stepped around prairie dog burrows and kicked up gray-yellow dust on the path to the venue entrance.
Many reveled in being able to attend a summertime event like an outdoor festival, taking it as another sign that the pandemic was waning.
"COVID is over in Colorado," said Ryan Barkley, a college student from Durango who was playing beer pong in an inflatable pool at his campsite outside the gates.
That day, 39 people in the county were hospitalized with COVID, and a CDC investigative team had arrived just four days earlier.
Inside the gates, an open field was filled with stages, concession stands, and vendors selling cowboy hats, coffee mugs and hunting clothes — and crowds of people. Chelsea Sondgeroth and her 5-year-old daughter took in the scene.
"It's just nice to see people's faces again," said Sondgeroth, who lives in Grand Junction and previously had COVID. She described it as one of the mildest illnesses she's ever had, though her senses of taste and smell have not returned to normal. Watermelon tastes rotten to her, beer tasted like Windex for a while, and her daughter said Sondgeroth can't smell certain flowers anymore.
Sondgeroth said she's holding off on getting vaccinated until more research comes out.
Waiting in line at the daiquiri stand, Alicia Nix was one of the few people in sight wearing a mask. "I've gotten people that say, you know, 'That stuff is over. Get over yourself and take that off,'" said Nix, who is vaccinated. "It isn't over."
Amid the music, beer and dancing, a bus turned into a mobile vaccine clinic was empty. A nurse on duty played Jenga with an Army National Guard soldier. Just six people of the thousands attending were vaccinated on the bus.
"You can lead a horse to water, but you can't make them drink," Nix said from behind her blue surgical mask.
While a majority of inmates in most states are fully vaccinated, prison staffers are not, according to data on 36 states and the federal Bureau of Prisons.
This article was published on Thursday, July 8, 2021 in Kaiser Health News.
When the number of COVID-19 cases among inmates in Pennsylvania state prisons last fall topped 1,000 and staff cases hovered in the hundreds, the union representing 11,000 corrections officers began lobbying to get prison staffers to the front of the line for vaccinations.
John Eckenrode, president of the Pennsylvania State Corrections Officers Association, pressed state officials for months to give prison workers the same status as hospital staff members, first responders and teachers.
"This is a health and public safety crisis," Eckenrode said in a January statement. "It's time to prioritize vaccinating staff, so they can do their jobs and also not worry about bringing the virus home to their loved ones."
Yet, after the lifesaving shots became widely available, Pennsylvania prison guards have not rushed out to get them — even though the corrections department has had more than 4,700 staff members test positive over the course of the pandemic and eight die.
By mid-June, 22% of Department of Corrections employees were inoculated, according to voluntary reports collected by the department. At one prison, just 7% of staffers had received shots.
Meanwhile, more than 75% of the 39,000 men and women incarcerated in Pennsylvania's 24 state prisons have had the shots, according to the department.
That disparity is evident across the country. While a majority of inmates in most states are fully vaccinated, prison staffers are not, according to data on 36 states and the federal Bureau of Prisons compiled by the Prison Policy Initiative using information from several prison advocacy and journalism groups.
That report — released in April, when the vaccine was becoming more easily accessible — found 48% of prison staff members nationwide had received at least one dose, although in some states rates were in the teens or lower.
Eckenrode declined to comment to KHN. But he recently told WHYY, the NPR member station in Philadelphia, that he believes many more officers are vaccinated and not reporting their status to prison officials.
He acknowledged reluctance among his members. "I think that no matter what kind of demographic you look at, there's vaccine hesitancy," he said. The vaccines were "approved under experimental conditions, and I believe that it should be an individual choice."
One officer with the New York Department of Corrections and Community Supervision, which reported last month that it had vaccinated 43% of inmates, compared with 30% of staffers, said he waited until late June because he and his wife had survived a bout of COVID and felt they had natural protection from the virus.
Some colleagues have been spooked by internet videos from anti-vaccination groups showing doctors talking about vaccine-related deaths or stoking concerns that the Food and Drug Administration's emergency use authorization for the vaccines — rather than formal approval — means they are less dependable, said the officer, who asked to remain anonymous because corrections staffers are not authorized to speak to reporters. He added that a sense of "I don't want people to think I'm weak" machismo and right-wing politics play into the decision-making.
"There are a lot of conspiracy theorists," the New York guard said.
COVID has taken a high toll inside prisons. Two news organizations, the Marshall Project and The Associated Press, have found nearly 400,000 COVID cases in U.S. prisons and more than 2,700 inmate deaths. Among staff members, more than 114,000 cases and more than 200 deaths have been reported nationwide.
Staff vaccination statistics often do not give the full picture, since states generally don't require corrections staffers to report their status.
In California, which has the nation's second-largest prison system, a reform group is suing over low staff vaccination rates, arguing that unprotected prison workers put vulnerable inmates at risk.
State tallies show that in late June 52% of prison staffers had been fully vaccinated versus 71% of inmates. In its court filing, the Prison Law Office said that, despite efforts by California officials encouraging vaccinations, "infected and unvaccinated staff members continue to pose a significant threat to incarcerated communities."
Health experts say prison staff members also endanger surrounding communities.
Unvaccinated officers are a common cause of infection, because they go back and forth between the prison and the community, said Dr. Anne Spaulding, an associate professor in epidemiology at Emory University and former medical director at the Rhode Island Department of Corrections.
Spaulding also pointed to the "downstream effects" of unvaccinated staffers — especially corrections officers (known as COs), who are in daily close contact with inmates — on the inmates' mental health.
"If it passes from CO to CO, what does that mean with staff shortages? More lockdowns, less programming," she said. "It's going to affect the mental health of those incarcerated, who already have restricted lives."
Kirstin Cornnell, social services director with the Pennsylvania Prison Society, which advocates for reforms, said lockdowns resulting from sick staff members could lead to suspension of family visitation, disrupting connections critical to inmates' mental health.
"We have really serious concerns about how low the rate of staff vaccination is," said Cornnell. "This increases tension in an already stressful situation."
Pennsylvania Corrections Secretary John Wetzel and officials in other states say that, while they are not considering making the shots mandatory, they are pressing employees to get vaccinated.
"We continue to educate our staff and encourage them to get vaccinated for their own protection, but also for those around them," said Wetzel. "Everyone knows that prisons are breeding grounds for infectious diseases like COVID-19, largely because inmates live so close together."
While union officials in several states did not respond to queries, prison officials said their employees have the same concerns as the general public: religious or other objections, false conspiracy theories about the vaccines, worries about a new shot that was developed quickly.
"They want to see how it plays out with others who are vaccinated," said John Bull, a spokesperson for the Department of Public Safety in North Carolina — where 6,607 department employees, or roughly half the staff at 55 facilities, have been vaccinated through prison clinics. "They didn't want to be guinea pigs."
Incentives, such as gift cards, cash lotteries and paid time off, have boosted staff rates in some states, officials said. But Chris Gautz, a spokesperson for the Michigan corrections department, said his state will not provide incentives, despite having only about 15% of staffers vaccinated. He said his agency decided disease prevention was a better motivator.
"The benefit of not dying is not dying," he said. "A $5 gift card to Frosty Boy is not going to put someone over the edge."
The Prison Law Office and other groups are advocating for mandatory prison staff vaccinations, but the potential face-off with powerful prison worker unions has thwarted that idea in some states.
California Gov. Gavin Newsom said at a May news conference that he had no plans to make vaccinations mandatory and would instead urge the corrections officers union to persuade its members to get the shots.
Health experts point to other public institutions, such as schools and colleges, that require vaccination.
"States have the ability to mandate vaccination when it puts someone at risk," said Joseph Amon, an epidemiologist and director of the Office of Global Health at Drexel University in Philadelphia. "This is a case that makes sense. There could be limited exemption, but there should be an expectation that all staff be vaccinated."
When a parent takes an infant to the Children's Health Center in San Francisco for a routine checkup, a pediatrician will check the baby's vitals and ask how the child is doing at home.
Then Janelle Bercun, a licensed clinical social worker, who is also in the room, will look at Mom or Dad and pipe up: What is this like for you? Your frustrations? Joys? Challenges? And she stays to work with the parent long after the pediatrician has left.
The facility's team-based treatment is a pilot project, funded by philanthropies. Yet the approach, which California may soon incorporate on a large scale, could hold the key to fostering a healthy home environment where children thrive, child development experts say. Incorporating therapy for the parents, they say, can lower a child's risk of future mental disorders stemming from family trauma and adversity.
Pediatricians' offices generally don't offer formal counseling or guidance to a child's guardian because they can't bill insurance for these services. That could soon change for the roughly 5.4 million children on Medi-Cal, California's Medicaid program for low-income residents, and their parents.
The 2021-22 state budget, which Gov. Gavin Newsom is expected to sign by Monday, dedicates $800 million, half of it in federal funds, to this new behavioral health benefit over four years. Experts say it would make California the first state to pay for "dyadic care," treating parents and children simultaneously.
"A baby is not showing up by themselves to the pediatrician's office. The caregiver is coming in with their own strengths and stressors," said Dr. Kathryn Margolis, a pediatric psychologist who launched the initiative at the Children's Health Center at Zuckerberg San Francisco General Hospital.
"Without a healthy caregiver, we can't have a healthy baby," Margolis added. "It is the most obvious thing in the world. It is unbelievable it has taken this long to pay for this service."
The new program is among a suite of behavioral health initiatives included in the nearly $263 billion state budget negotiated between Democratic lawmakers and Newsom, who has made mental health services a signature issue.
The state will spend the next year drafting guidelines for the services that could be covered and working with insurance providers on new billing codes for the new benefit. Beginning July 1, 2022, caregivers who enter a clinic or pediatrician's office with a child up to age 21 for routine well visits will be matched with a social worker or behavioral health specialist. They may be screened for depression, treated for tobacco and alcohol use, or offered family therapy, said Jim Kooler, assistant deputy director of behavioral health at the California Department of Healthcare Services. New mothers will get postpartum care; parents could also get help obtaining food vouchers, housing or other help.
"It's a pretty amazing array of services that will be available," Kooler said. "It's things we wouldn't necessarily think about right away, but the health of the young person is impacted."
States including New York and Colorado fund programs that offer holistic care to parents and children together. But California will be the first to offer the service as part of Medicaid pediatric care, said Jennifer Tracey, senior director of growth and sustainability for Zero to Three. The nonprofit organization runs HealthySteps, a program that supports babies and toddlers with integrated care in 24 states, Washington, D.C., and Puerto Rico. Getting the benefit funded in the nation's most populous state was a "groundbreaking" win for children's advocacy groups, Tracey said.
"We haven't seen any other state make this kind of investment," she said. "I hope we'll see other states following California."
Newsom and lawmakers this year had a $76 billion budget surplus and $27 billion in federal aid to fund an array of new programs, but they won't come cheap. New outlays include up to $1.3 billion a year to expand healthcare to undocumented immigrants age 50 and older; $12 billion for homeless programs over the next two years; $4.4 billion in behavioral mental health for people up to age 25 over five years; and $300 million to bolster the state's public health system beginning next July.
Critics say the spending commits Californians to programs that could be hard to fund in the future. And while offering a new Medi-Cal benefit might be worthwhile, California lawmakers would be better off fixing flaws in the government insurance program, said Susan Shelley, vice president of communications for the Howard Jarvis Taxpayers Association.
For example, the state pays physicians who participate in Medi-Cal among the lowest rates in the nation, she said. And a January 2020 report by the California State Auditor found that just under 48% of children enrolled in Medi-Cal went to the doctor for a preventive visit in 2016-17.
"It's unwise to commit taxpayers to this," Shelley said. "All these little kids are going to grow up and have one huge tax bill."
Offering caregivers preventive behavioral treatment has proven to save money by avoiding bigger health problems down the road, according to legislative budget documents. An analysis by HealthySteps of its sites in New York, Colorado, Arizona and Kentucky showed average annual savings to Medicaid of 204% for patients enrolled in their program. The group reports that children were eight times more likely to receive developmental screenings and twice as likely to go to well visits when their parents participated in the HealthySteps program.
"It's a realization that it's not just about providing services today, but it's about thinking about the services that will help defer costs down the road by doing the right things today," Kooler said.
Making a visit to the pediatrician's office more welcoming to parents, and getting mothers screened for depression and other behavioral issues, could improve California's dismal rate of child developmental screenings, said Sarah Crow, managing director of First 5 Center for Children's Policy.
"California, if it really wants to prioritize children's health, then we really need to pull out all the stops and start thinking of new, culturally relevant ways to serve our families," Crow said.
At the clinic in San Francisco, Bercun, the social worker, visits with caregivers for as long as they need, usually about half an hour but sometimes up to an hour. She counsels a mom about a job loss, shows a dad how to soothe his crying infant and guides another mom to lovingly say no to a toddler on the verge of a tantrum. She has helped caregivers develop safety plans if there is violence in the home and has connected them to community resources.
And then there's the pandemic: She talks families through the isolation so many have felt.
"It's working through these moments and feeling less alone and building confidence," Bercun said. "It's about holding space to explore feelings. My hope is that one day all families could benefit."
July Fourth was not the celebration President Joe Biden had hoped for, as far as protecting more Americans with a coronavirus vaccine. The nation fell just short of the White House's goal to give at least a first dose to 70% of adults by Independence Day. By that day, 67% of adult Americans had gotten either the first shot of the Moderna or Pfizer-BioNTech vaccine, or the one-shot Johnson & Johnson vaccine. If children ages 12-17, who are now eligible for the Pfizer product, are included, the national percentage of those who have gotten at least one shot is 64%.
Drilling down from national rates, the picture varies widely at the regional level, and from state to state. For example, Massachusetts and most states in the Northeast reached or exceeded 70% (for adults, age 18 and older) in June. Tennessee and most Southern states have vaccination rates between 50% and 60%, and administration rates are slowing down.
Local variations in demand for the vaccines and in-state strategies for marketing and distributing the shots help explain the range.
In Massachusetts, for example, residents overwhelmed phone lines and appointment websites as soon as vaccines became available. The state began opening mass vaccination sites in January to meet demand. At Gillette Stadium in Foxborough, the home field of the New England Patriots, Jumbotron screens flashed updates and speakers blasted instructions to people arriving for a shot. When demand peaked in March, as many as 8,000 residents a day snaked through lines to a waiting syringe. Registered nurse Francesca Trombino delivered jab after jab at Fenway Park and then at the Hynes Convention Center in Boston for five months.
"I still hold a lot of interactions very dear to my heart," she said, reflecting on those months in late June. "I had so many people cry, just out of pure shock, just being able to feel free."
Heading into the long Fourth of July weekend, more than 82% of Massachusetts adults had received at least one shot. That number doesn't surprise many public health experts because residents generally have embraced vaccination recommendations in the past, and Massachusetts regularly registers some of the highest rates for pediatric and influenza inoculations in the country. In Tennessee, where only 52% of adults are at least partially vaccinated against COVID, nurses sit waiting. In some of the state's rural counties, only 30% of residents have been vaccinated.
"Our first couple weeks we had people booked, then after that we had people start no-showing," said Kirstie Allen, who coordinates COVID vaccinations at the federally subsidized clinic in Linden, Tennessee. "We had a waiting list, the people on the waiting list didn't want to come. It's gradually just gotten worse."
Allen is down to offering the vaccine just one day a week, and she aims to sign up at least 10 patients to avoid wasting doses in the multi-use Moderna vial.
Allen has witnessed plenty of vague skepticism in her town of 1,200 people. And she can sympathize. Despite administering the shots, the mother and licensed practical nurse has not yet been vaccinated and said she's waiting for more research results to be released, and to see how everyone does over time.
"I'm one of those people who are unsure at the moment about getting it," she said, adding she wouldn't get her kids vaccinated yet either.
This wait-and-see attitude is especially common among white, rural conservatives in the South, according to many surveys in recent months. After an initial surge of interest, demand for vaccinations waned, and states like Tennessee held mass vaccination events only in the most densely populated cities.
Having Reached the 70% Goal, Massachusetts Adopts Targeted Strategy
In Massachusetts, with fewer than 20% of adults still unvaccinated, the state is closing its high-volume vaccine clinics and focusing on specific demographic groups and communities with low vaccination rates.
"As these [big] sites come to their mission complete, we need to keep pushing harder into the neighborhoods," said Rodrigo Martinez, "into those locations that really need it."
Martinez is with CIC Health, a company that moved from managing mass vaccination sites to running small outdoor clinics at supermarkets where shoppers who got a shot received a $25 gift card. That hyperlocal approach is part of a growing effort in Massachusetts to bring vaccines to residents, especially those in low-income and minority communities where the virus spread quickly and vaccination rates remain low.
Massachusetts has targeted 20 such cities including Brockton, south of Boston. It's a diverse city of essential workers, a group that has been hit hard during the pandemic. First-dose vaccination rates are especially low for Latinos, at 39%, and Blacks, 41% (for all ages, not just adults).
The hyperlocal approach was on display in Brockton on a Sunday in late June, when the city, with assistance from the state, hosted a mobile vaccine clinic at a popular park. A big, yellow touring bus, retrofitted to hold vaccination stations, idled near tents offering free food, music, legal advice for immigrants and health insurance enrollment assistance.
This particular neighborhood in Brockton features residents who speak Portuguese, Spanish, English and Haitian Creole.
"Bienvenue! Welcome!" shouted Isabel Lopez, a state-funded vaccine ambassador, as she moved from one cluster of families to another, urging them to go grab a free hamburger, hot dog — and a vaccine.
"We are here, bringing the communities together, to make this a fun day and also a creative way to get people vaccinated," Lopez said.
Near the soccer field, Lopez scored a big win. She persuaded five hesitant members of one household to go to the bus and at least talk with a nurse there. A half-hour later, all five had received their first shots. Lenin Gomez said afterward that he had had doubts about the vaccine but was persuaded when the nurse stressed the need to protect the children living in Gomez's home.
"If I'm not fully protected, who will take care of the little ones?" Gomez said. "That's what opened my mind to getting vaccinated."
When Gomez gets his second dose in a few weeks, he can enter himself in a statewide lottery that will give away five $1 million prizes for anyone who's vaccinated. Massachusetts Gov. Charlie Baker said he hopes these jackpots will entice hesitant residents to roll up their sleeves.
Hefty Financial Incentives Are Less Common in the South
In the states that need most to boost vaccination rates, there's little interest in creative financial incentives. Tennessee has no plans. In Alabama, the NAACP funded a recent drawing for $1,000 prizes aimed at millennials and Gen Zers.
Overall, the daily vaccination rate across the South has slowed, worrying health officials who are watching the explosive growth and spread of the delta variant in several parts of the U.S. But some Southern residents continue to come around to the idea. In Lobelville, Tennessee, 57-year-old Laurel Grant was initially hesitant to get the shot because of possible side effects.
"But everybody I know has done real good, just maybe a little fever or a little tiredness," she said.
So Grant got her own shot in June, at a local pharmacy. It helped that the Pilot Flying J truck stop where she works offered a $75 bonus to employees who got fully vaccinated.
"There's a few down there at work who are like, 'I'm not going to get it,'" Grant said, "I'm like, 'Yes, you are. You gotta go, like it or not.'"
Converts like Grant are being seen as the best kind of evangelist for this next phase of vaccinating latecomers. Tennessee's health department has started taping video testimonials to release online. But the marketing efforts are beginning to annoy some Republican state lawmakers convinced the state is trying too hard. They're especially concerned about kids.
A recent hearing in the Tennessee state legislature included threats of disbanding Tennessee's health department. State Rep. Iris Rudder, along with other GOP lawmakers, brandished printouts of social media ads produced by state health officials. They featured smiling kids with adhesive bandages on their shoulders.
"It's not your business to target children. It's your business to inform the parent that their child is eligible for the vaccination," she told health department officials at the hearing in June. "So I would encourage you, before our next meeting, to get things like this off your website."
This criticism was mostly directed at the state's health commissioner, Dr. Lisa Piercey, who responded at the hearing by saying the state is not "whispering to kids" or trying to get them vaccinated behind the backs of their parents. She said she's not going to back off when it comes to vaccination outreach.
Piercey also said she doesn't think the risk level in Tennessee is as dire as the low vaccination rates suggest. Tennessee had a huge surge of COVID cases during the winter. That means at least 850,000 people — based on positive test results — are walking around with some level of natural immunity. Piercey said those residents are partially compensating for low vaccination rates.
"Yes, I want everybody who wants a vaccine to get it," she said. "But what I really want at the end of the day is for this pandemic to go away. I want to minimize cases and eliminate hospitalizations and deaths, and we're pretty close to getting there."
The outlook is less rosy in neighboring Arkansas. The state escaped the worst of the winter outbreaks. Now it is trying to stop flare-ups of illness caused by the more contagious delta variant. Gov. Asa Hutchinson told CBS's "Face the Nation" that if nothing else will inspire Southerners to get vaccinated, "reality will."
Data released Thursday night by Johnson & Johnson showed that the vaccine remains highly protective against the delta variant and immunity may be long-lasting.
This article was published on Friday, July 2, 2021 in Kaiser Health News.
In the past two weeks, many medical experts started to question whether the Johnson & Johnson vaccine, which is administered in a single dose, would be as effective as the two-dose Pfizer-BioNTech or Moderna vaccine in protecting against the new, highly transmissible delta variant that is poised to become the dominant strain in the U.S.
The reason for their doubts were studies showing that the J&J vaccine was less effective at preventing disease than the other two vaccines and also less protective against variants. In recent days, several scientists and even members of the public who originally got J&J decided to get a “booster dose” of an mRNA vaccine, Pfizer-BioNTech or Moderna, to bolster their immune systems.
But data released Thursday night by Johnson & Johnson showed that the vaccine remains highly protective against the delta variant and immunity may be long-lasting.
“Those who got J&J should be less worried than they may have been before about delta,” said Dr. David Diemert, a professor of medicine at George Washington University who was not involved in J&J’s research. “It is reassuring.”
The Food and Drug Administration granted the J&J vaccine emergency use authorization in February on the heels of the Pfizer-BioNTech and Moderna vaccines. After a 10-day pause in April, triggered when the vaccine was found to be associated with rare but severe blood clots, distribution resumed. About 12 million Americans have received it so far.
Experts say the delta variant, first identified in India, is 40% to60% more transmissible than other variants, meaning that unvaccinated people can more easily catch covid-19 and that those who have been vaccinated face a higher risk of breakthrough infections. The delta variant has also been associated with greater disease severity than other variants. In the U.S., it now accounts for about 25% of covid cases.
The Johnson & Johnson data released Thursday offered the first window into how well the J&J shot holds up against the delta variant.
“We believe that our vaccine offers durable protection against COVID-19 and elicits neutralizing activity against the Delta variant,” Dr. Paul Stoffels, chief scientific officer at Johnson & Johnson, said in a press release.
The data comes from two small-sample preprint studies, which have not yet been peer reviewed and were both conducted in laboratories.
One of the new studies showed that the J&J vaccine continued to produce a high number of antibodies in the presence of the delta variant. And the number was actually higher than what recent data had shown for antibody levels against the beta variant (first identified in South Africa).
The second study showed that the J&J vaccine’s immune response lasted at least eight months and that some types of immune cells increased over time. This immune response was found to provide protection even against the delta variant and other variants of concern.
This builds onto research from J&J’s clinical trial before its vaccine received authorization from the FDA. In that study, the vaccine was found to be 72% effective at preventing severe and moderate disease in the U.S. Part of the trial was also conducted in South Africa and Brazil, where variants were circulating as the vaccine was being tested. Those results were slightly lower than in the U.S. trials — 57% in South Africa and 66% in Latin American nations — but, overall, those percentages confirm a high degree of protection.
Still, those percentages were lower than what Pfizer-BioNTech and Moderna had reported in their trials — 95% and 94% effectiveness, respectively, at preventing symptomatic disease. Recent data suggests the twovaccines also protect against the delta variant.
That means that, while there is now some evidence that J&J is protective against the delta variant, its overall efficacy is still lower than that of Pfizer-BioNTech or Moderna, said John Moore, a professor of microbiology and immunology at the Weill Cornell Medical College in New York.
“I don’t think anything has changed about that,” said Moore. He had previously told KHN he thought J&J should be a two-dose vaccine, since it provides less protection than Pfizer and Moderna.
He also pointed out that, if you look closely at one of the new J&J studies, a single person did elect to get an mRNA dose after receiving J&J, which strongly boosted that person’s antibody response.
“That is just a one-off result,” said Moore. “But it is consistent with emerging data.”
Indeed, datafrom studies in the United Kingdom shows that following a single dose of the Oxford-AstraZeneca shot with a Pfizer-BioNTech shot offered an immunity boost. (The Oxford-AstraZeneca vaccine, authorized for use in the U.K. but not the U.S., operates through a similar mechanism as J&J, although two doses are required.)
Experts, though, also maintain that all the covid vaccines authorized for emergency use in the U.S. are very effective, especially compared with other types of vaccines. Flu vaccines have been found to have an average of 33% to 61% effectiveness, depending on the strain they protect against.
Still, Moore said those who got J&J should not pursue booster shots on their own but instead wait for guidance from the Centers for Disease Control and Prevention and FDA.
“If and when FDA and CDC approve a change in policy, then it looks to me entirely appropriate to consider using the mRNAs as a boost for J&J,” said Moore.
In a statement, the FDA said that J&J remains a single-dose shot and that no data is available yet on its interchangeability with other covid vaccines. The CDC said the agency is continuing “to monitor and evaluate COVID-19 vaccine effectiveness.”
Diemert said the data from J&J’s studies supports his view that at this time a booster shot isn’t necessary for those who got J&J.
“Now that we have data that is encouraging that the vaccine might be protective against delta and that the duration of protection is a thing, those two together are encouraging that a booster might not be needed,” said Diemert.
Dr. Robert Wachter, chair of the Department of Medicine at the University of California-San Francisco, said he doesn’t think an mRNA booster is necessary either — but he would still caution those who got J&J to be a bit more careful than those who received Pfizer-BioNTech or Moderna.
“The main difference would be definitely masking indoors (unless certain that everybody was vaccinated), whereas for mRNA vax recipient, I see that as more elective,” Wachter wrote in an email.
As for those who got J&J and have already gotten an mRNA booster shot? For some, the new findings come as a relief.
“These results are great news. I don’t find them surprising, but they are some of the data that was missing when I decided to take an mRNA booster,” said Jason Gallagher, a clinical pharmacy specialist in infectious diseases at Temple University Hospital in Philadelphia.
He got a dose of the Pfizer-BioNTech vaccine after receiving the J&J vaccine because he was concerned about a U.K. study that indicated one dose of the Oxford-AstraZeneca or Pfizer-BioNTech vaccine was much less effective against the delta variant than two doses.
Gallagher said he might not have gotten a booster if the J&J results had been available a month ago, but he doesn’t regret his decision.
“This is an immunologic study suggesting that the vaccine will work against the delta variant, not a clinical study describing whether it did. I’m looking forward to learning more about that,” said Gallagher.
For those who are still considering getting an mRNA booster, it’s important to know that vaccine sites may ask whether you have already been vaccinated against covid. These sites have been instructed to administer vaccines according to CDC and FDA guidelines and have not been authorized to give additional shots to those who have already received a complete vaccine regimen.
Experts also emphasized that the best way to protect against the highly transmissible delta variant is to achieve a high vaccination rate across the U.S. When more people are vaccinated, the amount of circulating virus is reduced, which means everyone is better protected, including those who got the J&J shot.
Almost 67% of U.S. adults have received at least one vaccine dose, but only 47% of the total population is fully vaccinated. Rates of vaccination also vary widely by state. In other words, location has a lot to do with risk. Several Southeastern and Midwestern states, for instance, have less than 55% of their population vaccinated, meaning the delta variant could more easily sweep through those areas.
“All of the evidence on our currently authorized vaccines in the U.S. suggests they remain highly effective against preventing severe disease even against the variants,” said Dr. William Moss, executive director of the International Vaccine Access Center at Johns Hopkins University in Baltimore.
Healthcare — and how much it costs — is scary. But you're not alone with this stuff, and knowledge is power. "An Arm and a Leg" is a podcast about these issues, and its second season is co-produced by KHN.
Veteran health journalist Marshall Allen has been exposing healthcare grifters for years. Now, he's written a book about how to fight them. Host Dan Weissmann spoke with Allen about some of the best tips from "Never Pay the First Bill: And Other Ways to Fight the Healthcare System and Win."
Allen used the skills he learned while doing healthcare deep dives for ProPublica to write the book, which he describes as a field guide to navigating the health system.
"This is not stuff you're going to hear at your company's employee enrollment meeting," Allen said.
Among the tips were some "magic words" you can use if you ever end up in the emergency room. They are worth memorizing or writing down.
In the ER, you'll be asked to sign a form that says you will pay for whatever your insurance does not cover. If you can, X out that section and write in this:
I consent to appropriate treatment and (including applicable insurance payments) to be responsible for reasonable charges up to two times the Medicare rate.
If you could invest $56 billion each year in improving healthcare for older adults, how would you spend it? On a hugely expensive medication with questionable efficacy — or something else?
This isn't an abstract question. Aduhelm, a new Alzheimer's drug approved by the Food and Drug Administration last month, could be prescribed to 1 million to 2 million patients a year, even if conservative criteria were used, according to Biogen and Eisai, the companies behind the drug.
The total annual price tag would come to $56 billion if the average list price, $56,000, is applied to the lower end of the companies' estimate.
That's a huge sum by any measure — more than the annual budget for the National Institutes of Health (almost $43 billion this year). Yet there's considerable uncertainty about Aduhelm's clinical benefits, fueling controversy over its approval. The FDA has acknowledged it's not clear whether the medication will actually slow the progression of Alzheimer's disease or by how much.
"This drug raises all kinds of questions about how we think about health and our priorities," said Dr. Kenneth Covinsky, a geriatrician and professor of medicine at the University of California-San Francisco.
Since most Alzheimer's patients are older and on Medicare, the medication would become a significant financial burden on the federal government and beneficiaries. Several experts warn that outlays for aducanumab, marketed as Aduhelm, could drive up premiums for Medicare Part B and Medicare supplemental policies and raise out-of-pocket expenses.
A likely additional cost: lost opportunities to invest in other improvements in care for older adults. If Medicare and Medicaid must absorb drug spending of this magnitude, other priorities are less likely to receive attention.
I asked a dozen experts — geriatricians, economists, health policy specialists — how they would spend an extra $56 billion a year. Their answers highlight significant gaps in care for older adults. Here's some of what they suggested.
Make Medicare more affordable. High out-of-pocket expenses are a growing burden on older adults and discourage many from seeking care, and Dr. David Himmelstein, a distinguished professor of urban public health at Hunter College in New York City, said extra funding could be directed at reducing those costs. "I'd cut Medicare copayments and deductibles. I think that would go a long way toward improving access to care and health outcomes," he said.Bottom of Form
On average, older adults on Medicare spent $5,801 out-of-pocket for healthcare in 2017 — 36% of the average annual Social Security benefit of $16,104, according to a report last year from AARP. By 2030, out-of-pocket health expenses could consume 50% of average Social Security benefits, KFF predicted in 2018.
Pay for vision, hearing and dental care. Millions of older adults can't afford hearing, vision and dental care — services that traditional Medicare doesn't cover. As a result, their quality of life is often negatively affected and they're at increased risk for cognitive decline, social isolation, falls, infections and depression.
"I'd use the money to help pay for these additional benefits, which have proved very popular with Medicare Advantage members," said Mark Pauly, a professor of healthcare management at the University of Pennsylvania's Wharton School of Business. (Private Medicare Advantage plans, which cover about 24 million people, usually offer some kind of hearing, vision and dental benefits.)
Over 10 years (2020 to 2029), the cost of adding comprehensive hearing, vision and dental benefits to Medicare would be $358 billion, according to the Congressional Budget Office.
Support family caregivers. Nearly 42 million people provide assistance — help with shopping, cooking, paying bills and physical care — generally to older relatives trying to age in place at home. Yet these unpaid caregivers receive little practical support.
Dr. Sharon Inouye, a geriatrician and professor of medicine at Harvard Medical School, suggests investing in paid services in the home to lessen the burden on unpaid caregivers, especially those tending to people with dementia. She would fund more respite care programs that give family caregivers short-term breaks, as well as adult day centers where older adults can socialize and engage in activities. Also, she recommends devoting substantial resources to expanding caregiver training and support and paying caregivers stipends to lessen the financial impact of caregiving. For the most part, Medicare doesn't cover those services.
"Providing these supports could make a huge difference in people's lives," Inouye said.
Strengthen long-term care. Shortages of direct care workers — aides who care for older adults at home and in assisted living facilities, nursing homes, residential facilities and other settings — are a growing problem, made more acute by the coronavirus pandemic. PHI, a research organization that studies the direct care workforce, has estimated that millions of direct care jobs will need to be filled as baby boomers age.
"We could greatly improve the long-term care workforce by paying these workers better and training them better," said Dr. Joanne Lynn, a geriatrician and policy analyst at Altarum, a research and consulting organization.
Help people age in place. Most older adults want to age in place, but many need assistance over time, surveys show. Will they be able to climb the stairs? Cook for themselves? Do the laundry? Take a shower?
Simple solutions can help, including relatively inexpensive home renovations (installing handrails on staircases, grab bars in bathrooms and better lighting, for example) and assistive devices such as raised toilet seats, shower stools or scooters. But Medicare doesn't pay for renovations or certain helpful devices.
Covinsky of UCSF would make a program known as CAPABLE (Community Aging In Place — Advancing Better Living for Elders) a Medicare benefit, available to all 61 million members. That program combines at-home visits from an occupational therapist and a registered nurse, usually conducted over 10 weeks, with up to $1,300 in services from a handyman.
Evidence shows it has a significant positive impact, helping seniors perform daily activities and stay out of nursing homes. The total cost: $3,000 per person. "For less than one infusion of aducanumab, you can greatly improve someone's quality of life and well-being," Covinsky said.
Find out what older adults need. Sarah Szanton, director of the Center for Innovative Care in Aging at the Johns Hopkins School of Nursing, developed CAPABLE. She would use $56 billion to assess every older adult annually to "figure out what they need to be able to live comfortably and independently. From that, I would generate a list of tailored interventions" — specific action items that might include CAPABLE or other programs, she told me.
Initiatives that could use extra funding might focus on managing depression, preventing falls or structuring activities for people with dementia, Szanton said.
Focus on prevention. A growing body of evidence suggests that dementia could be prevented — perhaps up to 40% of the time — if people didn't drink excessive amounts of alcohol, controlled blood pressure and obesity, managed depression, used hearing aids, stopped smoking, and regularly engaged in exercise, social interactions and cognitively stimulating activities, among other strategies.
"If I had $56 billion to spend, I'd focus on prevention," said Laura Gitlin, a dementia expert and dean of Drexel University's College of Nursing and Health Professions.
"There is more evidence for these strategies than there is for Aduhelm at the moment," said Dr. David Reuben, chief of UCLA's geriatrics department and director of its Alzheimer's and dementia care program.
Invest in social determinants of health. The health of older adults is shaped by the environments in which they live, their interactions with other people and how easy it is to fulfill basic needs.
Recognizing this, Dr. Anthony Joseph Viera, a professor of family medicine and community health at Duke University School of Medicine, said he would invest in "transportation for the elderly. Safe housing. Food. Programs that reduce social isolation. Those would end up helping a lot more people."
DUTTON, Mont. — Vern Greyn was standing in the raised bucket of a tractor, trimming dead branches off a tree, when he lost his balance. He fell 12 feet and struck his head on the concrete patio outside his house in this small farming town on the central Montana plains.
Greyn, then 58, couldn't move. His wife called 911. A volunteer emergency medical technician showed up: his own daughter-in-law, Leigh. But there was a problem. Greyn was too large for her to move by herself, so she had to call in help from the ambulance crew in Power, the next town over.
"I laid here for a half-hour or better," Greyn said, recounting what happened two years ago from the same patio. When help finally arrived, they loaded him into the ambulance and rushed him to the nearest hospital, where they found he had a concussion.
In rural America, it's increasingly difficult for ambulance services to respond to emergencies like Greyn's. One factor is that emergency medical services are struggling to find young volunteers to replace retiring EMTs. Another is a growing financial crisis among rural volunteer EMS agencies: A third of them are at risk because they can't cover their operating costs.
"More and more volunteer services are finding this to be untenable," said Brock Slabach, chief operations officer of the National Rural Health Association.
Rural ambulance services rely heavily on volunteers. About 53% of rural EMS agencies are staffed by volunteers, compared with 14% in urban areas, according to an NRHA report. More than 70% of those rural agencies report difficulty finding volunteers.
In Montana, a state Department of Public Health and Human Services report says, about 20% of EMS agencies frequently have trouble responding to 911 calls for lack of available volunteers, and 34% occasionally can't respond to a call.
When that happens, other EMS agencies must respond, sometimes having to drive long distances when a delay of minutes can be the difference between life and death. Sometimes an emergency call will go unanswered, leaving people to drive themselves or ask neighbors to drive them to the nearest hospital.
According to state data, 60% of Montana's volunteer EMTs are 40 or older, and fewer young people are stepping in to replace the older people who volunteer to save the lives of their relatives, friends and neighbors.
Finding enough volunteers to fill out a rural ambulance crew is not a new problem. In Dutton, where Greyn fell out of the tractor bucket, EMS Crew Chief Colleen Campbell says getting people to volunteer and keeping them on the roster has been an issue for most of the 17 years she's volunteered with the Dutton ambulance crew.
Currently the Dutton crew has four volunteers, including Campbell. In its early days, the Dutton ambulance service was locally run and survived off limited health insurance reimbursements and donations. At its lowest point, she said, her crew consisted of two people: her and her best friend.
That made responding to calls, doing the administrative work and organizing the training needed to maintain certifications more than they could handle. In 2011, the Dutton ambulance service was absorbed by Teton County.
That eased some of Campbell's problems, but her biggest challenge remains finding people willing to go through the roughly 155 hours of training and take the written and practical tests in this town of fewer than 300 people.
"It's just a big responsibility that people aren't willing to jump into, I guess," Campbell said.
In addition to personnel shortages, about a third of rural EMS agencies in the U.S. are in immediate operational jeopardy because they can't cover their costs, according to the NRHA.
Slabach said that largely stems from insufficient Medicaid and Medicare reimbursements. Those reimbursements cover, on average, about a third of the actual costs to maintain equipment, stock medications and pay for insurance and other fixed expenses.
Many rural ambulance services rely on patients' private insurance to fill the gap. Private insurance pays considerably more than Medicaid, but because of low call volumes, rural EMS agencies can't always cover their bills, Slabach said.
"So, it's not possible in many cases without significant subsidies to operate an emergency service in a large area with small populations," he said.
Slabach and others say sagging reimbursement and volunteerism means rural parts of the U.S. can no longer rely solely on volunteers but must find ways to convert to a paid staff.
Jim DeTienne, who recently retired as the Montana health department's EMS and Trauma Systems chief, acknowledged that sparsely populated counties would still need volunteers, but he said having at least one paid EMT on the roster could be a huge benefit.
DeTienne said he believes EMS needs to be declared an essential service like police or fire departments. Then counties could tax their residents to pay for ambulance services and provide a dedicated revenue stream.
Only 11 states have deemed EMS an essential service, Slabach said.
The Montana health department report on EMS services suggested other ways to move away from full-volunteer services, such as having EMS agencies merge with taxpayer-funded fire departments or having hospitals take over the programs.
In the southwestern Montana town of Ennis, Madison Valley Medical Center absorbed the dwindling volunteer EMS service earlier this year.
EMS Manager Nick Efta, a former volunteer, said the transition stabilized the service, which had been struggling to answer every 911 call. He said the service recently had nine calls in 24 hours. That included three transfers of patients to larger hospitals miles away.
"Given that day and how the calls played out, I think under a volunteer model it would be difficult to make all those calls," Efta said.
Rich Rasmussen, president and CEO of the Montana Hospital Association, said an Ennis-style takeover might not be financially viable for many of the smaller critical access hospitals that serve rural areas. Many small hospitals that take over emergency services do so at a loss, he said.
"Really, what we need is a federal policy change, which would allow critical access hospitals to be reimbursed for the cost of delivering that EMS service," he said.
Under current Medicare policy, federally designated critical access hospitals can get fully reimbursed for EMS only if there's no other ambulance service within 35 miles, Rasmussen said. Eliminating that mileage requirement would give the hospitals an incentive to take on EMS, Rasmussen said.
"It's a long haul to do this, but it would dramatically improve EMS access all across this country," he said.
A Centers for Medicare & Medicaid Services pilot program is testing the elimination of mileage minimums for emergency services with select critical access hospitals.
The rural EMS crunch puts a greater burden on the closest urban ambulance services. Don Whalen, who manages a private EMS service in Missoula, the state's second-largest city, said his crews regularly respond to outlying communities 70 miles away and sometimes across the Idaho line because local volunteer agencies often can't answer emergency calls.
"We know if we're not going, nobody is coming for the patient, because a lot of times we're the last resort," he said.
Missoula EMS is responsible for calls in the city and Missoula County. Whalen said Missoula EMS has agreements with a couple of volunteer EMS agencies in smaller communities to provide an ambulance when volunteers have difficulty leaving work to respond to calls.
Those agreements, on top of responding to other towns where 911 calls are going unanswered, are taking resources from Missoula, he said.
Communities need to find ways to stabilize or convert their volunteer programs, or private services like his will need financial support to keep responding in other communities, Whalen said.
But lawmakers' appetite for finding ways to fund EMS is limited. During Montana's legislative session earlier this year, DeTienne pushed for a bill that would have studied the benefit of declaring EMS an essential service, among other possible improvements. The bill quickly died.
Back in Dutton, the EMS crew chief is thinking about her future after 17 years as a volunteer. Campbell said she wants to spend more time with her grandchildren, who live out of town. If she retires, there's no guarantee somebody will replace her. She's torn about what to do.
"My license is good until March of 2022, and we'll just see," Campbell said.