Around three dozen of America's elite health systems are searching with a missionary zeal for patients and insurers able to pay high prices that will preserve their financial successes.
This article was published on Tuesday, June 22, 2021 in Kaiser Health News.
Across the street from the Buckingham Palace Garden and an ocean away from its Ohio headquarters, Cleveland Clinic is making a nearly $1 billion bet that Europeans will embrace a hospital run by one of America's marquee health systems.
Cleveland Clinic London, scheduled to open for outpatient visits later this year and for overnight stays in 2022, will primarily offer elective surgeries and other profitable treatments for the heart, brain, joints and digestive system. The London strategy attempts to attract a well-off, privately insured population: American expatriates, Europeans drawn by the clinic's reputation, and Britons impatient with the waits at their country's National Health Service facilities. The hospital won't offer less financially rewarding business lines, like emergency services.
"There are very few people out there in the world who would not choose to have Cleveland Clinic as their healthcare provider," said chief executive Dr. Tomislav Mihaljevic.
Facing the prospect of stagnant or declining revenues at home, around three dozen of America's elite hospitals and health systems are searching with a missionary zeal for patients and insurers able to pay high prices that will preserve their financial successes.
For years, a handful of hospitals have partnered with foreign companies or offered consulting services in places like Dubai, where Western-style healthcare was rare and money plentiful. Now a few, like the clinic, are taking on a bigger risk — and a potentially larger financial reward.
These foreign forays prompt questions about why American nonprofit health systems, which pay little or no taxes in their hometowns, are indulging in such nakedly commercial ventures overseas. The majority of U.S. hospitals are exempt from taxes because they provide charity care and other benefits to their communities. Nonprofit hospitals routinely tout these contributions, though studies have found they often amount to less than the tax breaks.
Despite their tax designation, nonprofit hospitals are as aggressive as commercial hospitals in seeking to dominate their healthcare markets and extract prices as high as possible from private insurers. Though they do not pay dividends, some nonprofits amass large surpluses most years even as more and more patients are covered by Medicare and Medicaid, the U.S. government's insurance programs for the elderly, disabled and poor, which pay less than commercial insurance. Cleveland Clinic, one of the wealthiest, ran an 11% margin in the first three months of this year and paid Mihaljevic $3.3 million in 2019, the most recent salary disclosed.
The advantages of international expansion for their local communities are tenuous. Venturing overseas does not provide Americans with the direct or trickle-down benefits that investing locally does, such as construction work and healthcare jobs. Even when hospitals abroad add to the bottom line, the profits funneled home are minimal, according to the few financial documents and tax returns that disclose details of the operations.
"It's a distraction from the local mission at a minimum," said Paul Levy, a former chief executive at Boston's Beth Israel Deaconess Medical Centerand now a consultant. "People get into them at the beginning, thinking this is easy money. The investment bankers get involved because they get the financing, and the senior faculty get on board and say, 'This is great; it means I can go to Italy for two years' — and there's not a real business plan."
There are financial hazards. For instance, Cleveland Clinic has warned bondholders that its performance could suffer if its London project does not launch as planned. There are also risks to a system's reputation if a foreign venture goes awry.
Finance experts temper expectations that operations of overseas hospitals will have a major bearing on a system's balance sheet. "Even though they do well, they're small hospitals — they're never part of the overall picture," said Olga Beck, a senior director at Fitch Ratings. "It does help [the U.S. operations] because it gives a global name and presence in other markets."
Hospital executives say their foreign ventures provide an additional source of revenue, thus adding stability, and benefit the care of their hometown patients.
"As we go to different areas around the world, we learn and we continuously improve for all our patients," said Dr. Brian Donley, CEO of Cleveland Clinic London. He said the clinic has learned from U.K. practices more efficient ways to sterilize surgical instruments and perform X-rays.
For decades, wealthy foreigners — who are willing to pay the list prices for specialized surgeries and cancer care that domestic insurers bargain down — have been appealing targets for U.S. hospitals. Hospitals like MedStar Health's Georgetown University Hospital in Washington, D.C., solicit and assist foreign patients with special offices staffed by people with job titles such as "international services coordinator" and "international services finance administrator."
Between July 2019 and June 2020, U.S. hospitals treated more than 53,000 foreign patients, charging them more than $2.8 billion, according to a survey of members by the Chicago-based U.S. Cooperative for International Patient Programs. In addition, instead of just importing patients, 37 of 51 health systems in the survey said they offer international advisory or consulting services abroad.
"'Send us your patients' is pretty much a dying approach," said Steven Thompson, a consultant who has spearheaded international programs for Baltimore's Johns Hopkins Medicine and Boston's Brigham and Women's Hospital. "People see it on both sides for what it is: a one-way relationship."
One of the oldest foreign ventures is the organ transplant program the Pittsburgh-based nonprofit system UPMC has run in Palermo, Italy, since 1997, when Sicily's government and Italian insurers realized it would be cheaper to perform those procedures there than continue to send patients to the U.S. Since then, UPMC's Palermo facility has performed more than 2,300 transplants.
In this initial expansion, the U.S. hospital was providing a highly specialized type of surgery — one that UPMC is renowned for — that was not available locally. But UPMC, one of the most entrepreneurial U.S. health systems, didn't stop there. In Ireland, UPMC owns a cancer center and provides care for concussions through sports medicine clinics. Since 2018, the system has acquired hospitals in Waterford, Clane and Kilkenny. They are staffed mostly by independent Irish physicians, but UPMC regularly sends over its leading U.S. specialists to lend expertise, according to Wendy Zellner, a UPMC spokesperson.
UPMC has company in Ireland: in 2019, Bon Secours Mercy Health, a Roman Catholic system with hospitals in Eastern states, merged with a five-hospital Catholic system there.
Over the past two decades, UPMC did advisory and consulting work in 15 countries but ultimately decided to narrow its involvement to four: Italy, Ireland, China and Kazakhstan, where UPMC is helping a university develop a medical teaching hospital. Charles Bogosta, president of UPMC International, said UPMC wanted to focus its efforts where it was confident it could improve the quality of care, bolster UPMC's reputation and earn profit margins greater than its U.S. hospitals do.
UPMC officials said the economics are favorable abroad because labor is cheaper and the mix of patients is heavily tilted toward those with commercial insurance, which pays better than government programs.
"What we've been doing overseas has been really helpful in addressing what everyone in the U.S. is trying to do, which is come up with diversified revenue sources," Bogosta said.
Even so, that extra revenue remains a small part of UPMC's earnings. The health system's foreign hospital business generated gross revenues of $96 million, or 1% of UPMC's $9.3 billion total hospital revenues in 2019, according to a KHN analysis of a UPMC financial disclosure. Since that figure is before accounting for the costs of running the hospitals, taxes and other expenses, the actual profits the foreign hospitals might send back to Pittsburgh are much smaller. In Ireland, where corporations are required to disclose audited financial statements, UPMC Investments Ltd., an umbrella group that owns the Waterford hospital operation and property, reported net profits of about a half-million dollars in 2019 on more than $47 million in gross revenues.
In an email, Zellner said the Ireland statements "do not give you the totality of the picture in Ireland or International, where our results are far better than these documents would suggest." UPMC declined to provide more detailed financial data.
Like other systems, UPMC has expanding ambitions in China. In 2019 it signed an agreement with the multinational corporation Wanda Group to help manage several "world-class" hospitals, starting with one opening in Chengdu next year.
But foreign ventures can misfire. "These partnerships can turn into nightmares, as Hopkins has learned," Thompson wrote in a 2012 article for the Harvard Business Review that described his observations as the founder and first CEO of Johns Hopkins Medicine International, a for-profit venture jointly owned by Johns Hopkins Medicine and Johns Hopkins University.
Anadolu Medical Center, which Hopkins helped establish in Istanbul in 2005, was "plagued by quality problems," including overbooked operating rooms and physicians who refused to follow evidence-based procedures and quality protocols, he wrote. Thompson attributed the problem to the Turkish mandate that the hospital be run by a Turkish citizen and wrote that the problems did not dissipate until Hopkins was allowed to install its own manager in the second-highest position and dissolve the top position to get around the citizenship requirement "while remaining in technical compliance with the law."
While "the project is now thriving," he warned that "lending the Hopkins name to a hospital that delivers unimpressive care could significantly damage our 135-year-old brand — and that's a real danger in developing areas, especially in a project's early days."
Hopkins has remained skittish about outright ownership or even management responsibilities. Instead, it has affiliations with hospitals and health systems in 13 countries, including Vietnam, China, Turkey, Lebanon, Brazil and Saudi Arabia. Hopkins does not run any of the hospitals but helps develop hospital master plans and clinical programs, trains doctors, and advises on patient safety and infection control.
Even so, in 2014 it created a joint venture with the oil and gas company Saudi Aramco to provide healthcare to 255,000 employees and their dependents and retirees. Hopkins, which owns a fifth of the venture, said all foreign net revenue is returned to the system's parent organizations to fund research, expansion of care and scholarships. But its public records report meager income from its foreign subsidiary, just $7 million in 2018 — a tenth of a percent of the health system's $7 billion revenues.
Charles Wiener, the current president of Johns Hopkins Medicine International, focused on other benefits. "If we can put in robust quality and safety at one of our affiliates, their patients do better," he said. "If we can export our education and training models, we believe that allows our people to benefit from learning from other cultures, and some of their people come here to train."
Cleveland Clinic London is unusual in that U.S. health systems rarely build a hospital abroad from scratch without a local partner. The clinic chose that more cautious approach with Cleveland Clinic Abu Dhabi, a 364-bed hospital owned by the Mubadala Investment Co. that the clinic manages. It also has a consulting practice that is helping a Singapore healthcare company build a hospital in Shanghai.
Foreign enterprises appeal to the clinic because it has limited growth opportunities in Ohio, where the population is growing slowly and aging, meaning more patients are leaving high-paying commercial insurers for lower-paying Medicare. The clinic has expanded in Florida, acquiring five hospitals to take advantage of population increases and wealthier patients there.
The London project will have 184 beds and eight operating rooms. Donley said it will be staffed primarily by U.K. physicians, including ones who also work for the National Health Service.
"The clinic has a long track record of being able to execute on its strategies," said Lisa Martin, an analyst at the bond rating agency Moody's Investors Service. "The London project is obviously the biggest venture and the biggest financial risk that they've made abroad."
Millions of people will flock to Montana’s Glacier National Park this summer after last year’s pandemic-caused tourism skid, and they will once more be able sightsee and camp nearby on the recently reopened Blackfeet Indian Reservation.
Those closures fed worries that a major economic driver for residents on the reservation would be crippled. But the tribe’s priority was protecting its elders and stemming the spread of the coronavirus. It worked: The closures and the tribe’s strictly enforced stay-at-home orders and mask mandate led to a low daily case rate held up as an example by federal health officials. Now, boasting one of the highest vaccination rates in the nation, the reservation is back open for business.
On a recent day at the Two Sisters Café, a stone’s throw from Glacier National Park’s eastern boundary, workers stacked dishes and stocked freezers in preparation for a busy season as demand soars for the wide-open spaces national parks can offer during the lingering pandemic.
Susan Higgins, co-owner of the cafe, said she’s seen more traffic whiz past her door than she’s seen at this time of year in nearly three decades. Some passersby stopped and poked their heads through the front door of the restaurant known for fresh huckleberry pies, only to leave disappointed because the restaurant didn’t open for the season until mid-June.
The situation is nothing like last year, when Higgins and sister Beth worried they would rack up massive debt just to survive. With the help of government loans and other grants, they were able to cover their bills and maintain their savings to expand the business.
“When everything happened, we were initially, of course, just concerned about just making it to this year,” Susan Higgins said.
“With such a vulnerable population, I would have hated to see what would have happened last year if we had been open, especially with the issue of getting people to mask up,” Higgins said.
Last year, the number of Glacier visitors plunged to 1.7 million after a record 3 million people visited in 2019. Those who did come stayed and spent their money in non-Blackfeet communities on the western side of the Continental Divide.
The measures the tribe took slowed but didn’t stop the spread of covid. Daily cases surged in September, after the Northwest Montana Fair and Rodeo in August and Labor Day weekend, leading to a strictly enforced stay-at-home order, the tribe’s third, issued Sept. 28.
Daily cases then dropped from a peak of 6.4 per 1,000 per day on Oct. 5 to 0.19 on Nov. 7, a 33-fold drop that the Centers for Disease Control and Prevention held up as an example that such restrictions work.
Out of roughly 10,000 reservation residents, fewer than 50 Blackfeet tribal members have died of covid to date. Kimberly Boy, Blackfeet department of revenue director and a member of the incident command team that leads the tribe’s pandemic response, said she is certain their actions saved lives.
“It was the toughest job I’ve had so far in my life,” Boy said. “We had moved aggressively and extremely restrictive[ly] only due to the fact that our primary goal was to save as many lives as we can.”
The efforts bought time until the covid vaccines became available. Then, the tribe mounted a serious campaign that has resulted in about 85% of the total population — over 90% of adults — being fully vaccinated, according to tribal officials. The national average is about 44%, according to the CDC.
The Blackfeet’s vaccination campaign then stretched into Canada when tribal officials set up a clinic at the border for their counterparts in the Blackfoot Confederacy. The Blackfoot Confederacy, of which the Montana Blackfeet nation is a part, includes affiliated First Nations tribes who live on the Canadian side of the border.
The idea for the makeshift clinic was conceived after U.S. and Canadian officials denied requests to ship vaccines over the border, Blackfoot Confederacy Health Director Bonnie Healy said.
“We were joking, and I said that we’ll just have the Canadians from the confederacy stand on one side of the border and you guys vaccinate us over the fence and we’ll get it done,” Healy said.
Healy said that’s exactly happened in a sense, and the clinic was aptly named the “medicine line vaccine clinic,” referencing what the Blackfeet and Blackfoot call the U.S.-Canadian border that separates the different bands of the tribe.
Mark Pollock, a member of the Blackfeet Tribal Business Council, and others said the strong vaccination rate on the reservation in Montana is giving the tribe the confidence to open to tourists this summer.
Pollock hopes the season will go smoothly and covid can be eliminated among tribal members or cases remain very low. However, if cases rise, he said, the tribe could reduce the current 75% capacity limit on dine-in restaurants and bars, as well as reintroduce restrictive measures like curfews and limits on gatherings.
“Whatever it takes to get that number back down, get a handle on it,” Pollock said.
Jackie Conway owns the Heart of Glacier Campground near Glacier’s east gate with her husband, Steve, a tribal member. Conway said even with all 40 of her RV and camping sites booked for the season, she still can’t make up for last year’s 100% loss. Government relief helped the business survive over the past year.
She’s happy there will be a tourism season this summer but knows in the back of her mind that tribal leaders could shut things down anytime.
“The tribe gets spooked pretty easy. So, you just don’t know,” she said.
Angelika Harden-Norman owns the Lodgepole Gallery & Tipi Village just outside Browning, the reservation’s largest city. Standing in the gallery full of artwork by her late husband, Darrell Norman, and other Blackfeet tribal members, she said it’s up to business owners to keep guests safe and make sure this pandemic tourist season goes smoothly.
She used grant money to move her art gallery from the center of her home to another room with better ventilation. She’s also renovated the bathrooms of the two cabins for overnight guests so they are no longer shared.
“I will do my best to take the responsibility … by asking people to wear a mask when they come indoors to check in, to have hand sanitizers,” she explained.
At Two Sisters Café, Susan Higgins stood inside an unfinished drive-thru coffee stand just outside the restaurant. Higgins said she and her sister had thought about building a coffee stand in the past, but it was the uncertainty of how this season would go that pushed them to do it.
Higgins added she is requiring her workers to be vaccinated and hopes that will allow her to avoid shutting down her business this summer. So, for now, the coffee stand will serve as an addition to her business, but it’s also a Plan B should there be another shutdown.
“Primarily it is to assure ourselves of a continued cash flow should we get shut down again,” she explained.
When two St. Louis Blues hockey players were sidelined because of COVID-19 just days before this year's NHL playoffs, the team said young defenseman Jake Walman had been vaccinated against the deadly illness. But it was mum about the vaccination status of a more well-known player: star forward David Perron.
It wasn't until 10 days later — and after the Colorado Avalanche buried the team, without Perron touching the ice in any of the series' four games — that he begrudgingly acknowledged he had been vaccinated.
"I don't want to talk about that anymore," Perron, the team's leading scorer, said at a press conference.
While fans often know intricate details about athletes' knee joints and concussions, COVID vaccinations are another story. Reticence is common among professional athletes. Vaccination status is also a point of secrecy among some Republican lawmakers, other public figures and even many regular people.
Public health leaders say that people in the limelight do not have an obligation to announce or answer media questions about their vaccination status, but many add that they hoped more well-known names would become role models for getting the vaccines.
Instead, they say, the politicization of the shots, misinformation and flawed public messaging from the federal government have made the vaccines controversial and something some public figures are reluctant to endorse, which then ripples across society.
President Joe Biden is trying to get at least 70% of the nation vaccinated by July 4. So far, according to the Centers for Disease Control and Prevention, 53% of Americans have received at least one dose.
"I continue to be hopeful that celebrities will share their vaccination status and use their platform to encourage people to get vaccinated," said Thomas LaVeist, a sociologist and the dean of the School of Public Health and Tropical Medicine at Tulane University. "But I haven't seen a lot of celebrities really embrace that role."
LaVeist and others in public health hoped someone would step up as Elvis Presley did in 1956 to help increase the low rate of polio vaccinations. He received his shot on "The Ed Sullivan Show."
But that occurred years after the polio vaccine was developed, whereas the COVID vaccines became available less than a year after the onset of the pandemic.
"We still have not done a good enough job of explaining to people how and why it is that we were able to have a vaccine developed so quickly, and a lot of people have questions about whether corners were cut," said LaVeist, who criticized the Trump administration's decision to call its vaccine development program Operation Warp Speed.
Former President Donald Trump also hurt vaccination efforts among Republicans when he received his vaccine privately rather than in a public setting like Biden and other former presidents, said Gregory Zimet, a behavioral scientist who studies vaccination at Indiana University School of Medicine.
When CNN conducted a survey of congressional lawmakers in May, 95 of the 212 Republican House members said they had received the vaccines and 112 Republican offices did not respond at all. (All congressional Democrats said they had received the vaccines.)
"For some individuals, particularly if their social circle is very anti-vaccine or skeptical of the vaccine, it can feel very uncomfortable to come out and say, 'I got vaccinated,'" Zimet said.
Sports stars, who are often asked about their health, could change public perceptions of the vaccines, said Nancy Berlinger, a bioethicist at the Hastings Center, a research institute in Garrison, New York.
"In the worst days of HIV-AIDS, the fact that Magic Johnson was willing to talk about being HIV-positive changed public conversation in this country," Berlinger said. "Not everyone is able to step into that role."
Basketball king LeBron James, when asked if he planned to get a COVID vaccine, told reporters in March, "That's a conversation that my family and I will have. Pretty much keep that to a private thing."
Jennifer Reich, a sociologist at the University of Colorado-Denver who has studied vaccine hesitancy, thinks that James and other NBA stars could be reluctant to promote the vaccines because of the way athletes have been castigated in recent years for taking stands on hot-button issues.
But James has expressed support for the Black Lives Matter movement and called for the prosecution of police officers who shot and killed Breonna Taylor, a Black medical worker, in her Kentucky apartment.
"It's not like he is someone who has been a shrinking violet and has not stepped into the public arena to make very strong statements about inequities and problems in our society," Zimet said. "So, it's a little hypocritical that he would now say, 'This is a private issue.'"
Not everyone in public health is convinced, though, that what James, Perron and other celebrities say is crucial to vaccination efforts.
Sandra Crouse Quinn, a professor of family science at University of Maryland, studied the role of communication in vaccine acceptance during events such as the 2009 H1N1 pandemic. She found that while public figures' disclosures can make a difference, they are not as important as endorsements from "people we care about and people who care about us," she said.
"If Beyoncé came out with a vaccine video, would people watch it? Yes," Quinn said. "Is it entertainment? Yes. Does it move somebody? Not necessarily, because her life is so dramatically different" than that of an ordinary person.
But Timothy Caulfield, a law professor at the University of Alberta and the author of a book on vaccine myths, believes celebrities can make a big difference, pointing to actor Jenny McCarthy's role in the anti-vaccine movement.
"The role that pop culture can play in normalization is a constructive role," Caulfield said. "We are getting close to that hesitancy hurdle in jurisdictions where you are getting 60-65% of people vaccinated, so this messaging may seem trivial, but it matters when you are talking about trying to get another 2% or 3% of the population vaccinated."
During the time when Perron was quiet during the playoff series, sportswriters and fans speculated about his vaccination status. At the press conference where he revealed his vaccination after being questioned about it, Perron said, "I don't know why it's a big deal." He pointed out that he and two other players had gotten COVID despite being vaccinated.
"It's unfortunate and shows that it's not perfect," he said, adding that, among his teammates, "I can tell you that we support each individual to make their own decision."
Even if Perron had declined a vaccine or not revealed his status, some fans would likely not have held it against him.
Thomas Welch, who hosts a hockey podcast, "Locked On Blues," quickly decided to get vaccinated because his father and brother have Crohn's disease, which means they could face a greater risk from the coronavirus. But Welch said he understands that for some people the vaccines might not make sense for various reasons.
"As much as we love talking about these players and breaking down the analytics of the sport, at the end of the day, each of these players are people," said Welch, who lives in Jefferson County, outside St. Louis. "We lose sight of that a lot."
New guidelines issued in February by the Biden administration require migrants seeking asylum to register online or via phone from their home countries.
This article was published on Monday, June 21, 2021 in Kaiser Health News.
TIJUANA, Mexico — El Chaparral Plaza once teemed with tourists, street vendors and idling taxis. But the plaza, just outside the San Ysidro port of entry on the Mexican side of the border, now serves as a sprawling refugee camp where migrants from Mexico, Central America and Haiti wait in limbo while they seek asylum in the U.S.
Dr. Hannah Janeway, an emergency medicine physician who works in a Los Angeles hospital but volunteers at the border, estimates at least 2,000 people are jammed into tents and repurposed tarps here, living without running water and electricity.
Survival is the pressing concern, not COVID.
"The encampment just keeps growing day by day," Janeway said.
A record number of migrants are making the often long and perilous journey to the border. U.S. Customs and Border Protection apprehended 180,034 people at the southern border in May, a 78% increase since February. By comparison, border agents apprehended about 144,000 people in May 2019.
New guidelines issued in February by the Biden administration require migrants seeking asylum to register online or via phone from their home countries, get tested for the coronavirus in Mexico and then come to a U.S. port of entry on a specific day for their asylum interviews. The goal is to reduce the number of people making the dangerous trek and alleviate the waiting in border towns like Tijuana — but people continue to show up without going through the process.Bottom of Form
"As I was driving here, I just saw two buses drop off a group of migrants," Janeway said. "Where are they going to go?"
Because migrant shelters were already at capacity before this year's influx of migrants, many end up at the El Chaparral camp, where food and medical care are scarce and there is little access to sanitation facilities — other than hand-washing stations and portable toilets.
Janeway, who co-directs the Refugee Health Alliance, a nonprofit organization that provides medical care to migrants at the U.S.-Mexico border in Tijuana, visits the camp two to three times a month to tend to patients and spread the word about the nearby clinic she opened in 2018, located a few blocks from the plaza.
The clinic, Resistencia en Salud, provides free care and depends on donations and a mostly volunteer staff to keep the doors open.
"I believe that the people that I'm serving deserve to have healthcare and a reduction to their suffering," Janeway said.
The clinic is small and basic, with two exam rooms. Staffers coordinate with Mexico's public health system to handle patients who need more specialized care, such as surgery or chemotherapy.
On a recent Thursday, Janeway made her way along the edge of the camp — lined with tents, tarps fashioned into makeshift shelters and mounds of trash — to check on the water tank supply her organization provides. She said the Mexican government is not providing much in the way of healthcare or essential provisions, like water.
The office of Baja California's secretary of health (Secretaría de Salud de Baja California) did not respond to multiple requests for comment.
"It's the government's responsibility, but I don't want to play a game of chicken with them about water," she said. "It's critical. There are all these kids here with [gastrointestinal] illnesses."
At the clinic, Janeway and her staff "see it all," she said: heart problems, back pain, cancer, assault injuries. In addition to medical treatment, Resistencia en Salud provides mental health services and support to the LGBTQ community.
By the time doors opened at 10:30 a.m., a line of people were waiting to sign up. Some were turned away because the clinic hit capacity. Octavio Alfaro and his 12-year-old son, whose knees had been hurting, were among the hopefuls.
The 53-year-old from Villanueva, Cortés, in Honduras, had been waiting for asylum for 2½ years.
"My story is cruel," he said.
Alfaro left Honduras with his three children, fleeing gang violence. "In Honduras, you cannot risk starting a business because if you don't pay what the gangs charge you, they will put you in the ground," he said. "They wanted to take my son and were ready to kidnap my daughter to do what they do to young girls."
Stories like his are common in the encampment, he said. "That's why we come. For a better life for these kids."
Alfaro met Janeway at the El Chaparral encampment in late May. She quickly wrote an advocacy letter in support of his 14-year-old daughter Brenda's asylum claim. Brenda has a cardiac murmur that requires immediate surgery in the U.S. "She needs to be seen by a specialist," Janeway said. "She can't get that type of care here."
Janeway said many patients like Alfaro and his family are just trying to survive in Tijuana's encampments and overcrowded shelters, where they fear being assaulted or robbed. Navigating the pandemic is secondary.
The clinic has seen only a handful of COVID patients, Janeway said, and, as far as she knows, no one is vaccinating migrants.
Nurse Luz Elena Esquivel said she tries to educate patients about maintaining distance and wearing masks, "but sometimes it seems impossible," she said. "It's not their priority. Their priority is crossing."
On this day, a dozen clinic staff members saw 55 people in about six hours. They moved in synchrony from patient to patient, attempting to treat as many as possible, including a 3-year-old child from Honduras who was so small he appeared 6 months old, a Mexican transgender woman in need of hormone therapy and a Haitian man complaining of chest pain. In the middle of it all, they rushed to treat a man who collapsed in the waiting area.
The latest wave of migrants has put a strain on the clinic, which needs more money, more volunteers and another doctor. "The working conditions aren't that good. And the salaries we can offer aren't either," Janeway said. "But the people who are here are here because they are very dedicated to helping this population. It's a mission."
Dr. Christian Armenta, a family physician at the clinic, was born and raised in Tijuana. He started working at the clinic in the midst of the pandemic. "It was very scary in the beginning, but I adapted quickly," he said. "As a doctor and a Tijuanense, I have to generate some sort of impact to better my city."
About 95% of the patients are migrants, he said. The rest are people from Tijuana who live on the streets or in shelters. "The environment in which they are living creates the perfect storm to generate health problems," he said.
Alfaro, a construction worker by trade, was robbed more than once. "I've been mistreated here," he said. "My tools have been stolen twice."
Even so, Alfaro said he feels like a child of Tijuana. "The people I have met here are like my family."
In the middle of her shift, Janeway stepped out of the clinic to deliver some good news to Alfaro.
"I just talked to the lawyers and they told me that you have a date to cross on June 8," she said.
"Glory to God," Alfaro said. "I'm so happy. If I've learned one thing here, it's to have patience."
The 5-year-old had nodded off while waiting for her 10-year-old brother to be treated for scabies at the clinic in the Long Beach Convention & Entertainment Center, which she currently calls home. Nurse Chai-Chih Huang asked if she wanted to be taken back to her dormitory to sleep.
"She looked so sad and didn't say anything," Huang recalled. The girl's brother explained that they had been separated for a week during their journey. His sister cried every day without him, he said. Now, she wanted to stick close at all times.
"This has been pretty hard," Huang told KHN later. She knew few details of the siblings' story, but many of the children at the center had trekked across hundreds of miles of dangerous lands guided by a smuggler.
The siblings, not named for privacy reasons, are among the hundreds of children, mostly from Central America, attempting to cross the U.S. border alone from Mexico each day. After brief detention by the Border Patrol, they are sent to shelters run by the Department of Health and Human Services while officials seek to unite them with relatives or other sponsors in the United States.
Long Beach offered housing at its convention center as part of a Biden administration effort to move children more quickly from the forbidding border housing where they are held initially. Those harsh settings, where at least five children died in 2018 and 2019, provoked a backlash against the Trump administration's immigration policies.
The Long Beach location is one of more than a dozen temporary homes the federal government has set up for a massive influx of children. On June 14, it housed 115 children — a mix of girls up to age 17 and boys up to 12, out of consideration for their privacy and safety, an HHS official said — and had connected 755 others with relatives or sponsors since the first children arrived on April 22. Federal officials, citing the safety and privacy of the children, have not allowed KHN or other news media to enter the facility currently.
The children arrive at the Long Beach facility by bus, scared and timid but "very well behaved," said Huang, director of pediatric nursing at Mattel Children's Hospital of UCLA Health, who is doing temporary duty at the shelter. "They warm up to the staff here and when they get to know you and start talking to you, it melts your heart."
DRC Emergency Services, a government contractor that typically performs jobs like debris removal after hurricanes, subcontracted with UCLA Health, UCI Health, Children's Hospital of Orange County and other providers to care for the children.
"We can imagine they have been through a lot," said Jennie Sierra, nursing director in the neonatal intensive care unit at the Orange County hospital. "They're very grateful, and they're an amazing, resilient group."
"Most of my nurses here come from immigrant families, and we consider it an honor and privilege to serve in this capacity," she said.
Before this year's surge of migrants at the U.S. border, HHS ran about 200 such facilities in 22 states and has announced plans to double capacity by adding about 18,500 emergency beds this year. It has signed $400 million in contracts to provide services for unaccompanied children. The federal government is paying about $35 million to house and care for the children at the Long Beach convention center through Aug. 2.
"Border Patrol stations were never designed to be places for minors to be held for any period of time," said Border Patrol spokesperson Matthew Dyman. The cells were intended for "single adult males to be quickly turned around — and not for families or children."
The Border Patrol can legally hold the children 72 hours before putting them in the custody of HHS' Office of Refugee Resettlement, which looks for relatives or sponsors in the U.S. pending immigration hearings.
On a recent day, June 14, HHS was caring for 15,365 children at facilities around the country and discharged 412 into communities. HHS Secretary Xavier Becerra said in May that the agency had reduced time spent in the emergency shelters to an average of 29 days, down from 40 days in late January.
Within two days of their arrival at Long Beach, the children get a health assessment at a pediatric clinic set up by UCLA Health.
Many come with chronic headaches and stomachaches. Some have rough or broken skin, swollen and infected feet, or rashes caused by filth and clothes rubbing against skin on long marches. Some have colds — or COVID; as of Monday, two cases were recorded among children at the convention center. The children stay in isolation and receive appropriate care.
While mental health therapy is limited, visibly sad or anxious children can get counseling and children can take part in weekly group discussions overseen by clinicians, said David Kosub, a federal spokesperson for the Long Beach site. Referrals are provided in the communities to which they are moving, he said.
Caring for the kids "has been very moving and meaningful, even life-changing," said Dr. Charles Golden, a pediatrician and executive medical director of Children's Hospital of Orange County's primary care network.
The doctors and nurses feel loved by their charges, he said. One day, Golden saw a group of children sitting in a circle, playing games. "They came over and gave me a big hug."
UCLA staffers painted murals for the children, who have access to classrooms, indoor and outdoor play spaces and TVs, soccer nets, hula hoops and ample board games.
They have books, and music from their homelands: punta, marimba, merengue, cumbia and bachata, said UCLA Health child life specialist Tracy Reyes Serrano. Performers have played for the children, too, she said.
"When the kids hear songs they recognize, it lifts their spirits; they're quick to get up and dance and sing, and we're happy to join them," she said.
The Long Beach Community Foundation launched a Migrant Children Support Fund that has raised $200,000, said foundation president and CEO Marcelle Epley. The money has gone to educational programs and toys, as well as gift cards that HHS can distribute once the children are settled with families. Long Beach residents have donated books, toys and personalized notes in Spanish.
Sierra recalled a girl who said she wanted to learn English and become a pediatrician.
"I told her, 'This is a great country with great opportunities. You're going to be an amazing doctor,'" Sierra said.
U.S. Rep. Nanette Diaz Barragán (D-Calif.), who represents North Long Beach and the Port of Los Angeles, visited the center May 6 and met children who "seemed to be in a state of hope, smiling and anxious to talk," including a young boy from Honduras.
"He was very happy until I asked about his home country and he looked like he wanted to cry," she said. "Someone in our group said, 'It's beautiful there,' and he said 'No, it's bad,' and talked about gangs and violence. He was willing to disagree with an adult."
The children's histories are mostly a mystery to their temporary caretakers, said Jennifer Sablan Panopio, a nurse manager in UCI Health's neonatal intensive care unit who has been the health system's lead nurse in Long Beach. "We can at least help give them a positive experience here, a good start."
In April, a COVID-19 commission task force for top medical journal The Lancet, composed of international health, education and air quality experts, called various air-cleaning technologies "often unproven" with a potential to create "harmful secondary pollutants."
This article was published on Friday, June 18, 2021 in Kaiser Health News.
When the coronavirus pandemic hit, Scott Dulle scoured the internet for ways to safely get kids back into St. Thomas More School, a private pre-K-8 school in Kansas City, Missouri, where he works as the director of building and grounds.
When Dulle found air-purifying ionization technology that marketing materials said would inactivate over 99% of the virus that causes covid-19 in minutes, he had to have it. Parishioners who support the parochial school, some of whom were out of work, raised roughly $22,000 to buy the devices.
Once the units were added to the school’s air system last summer, Dulle was confident he had made the right decision.
“I knew in my heart, I knew on paper, that we were probably one of the most protected schools in Kansas City,” Dulle said.
More than 100 public and private schools in Missouri are installing air-cleaning technology to try to ease the covid fears of staff members and parents, KHN and St. Louis Public Radio found through a review of school board notes, school websites and news reports. From Dulle’s Kansas City school to the Clayton district west of St. Louis to the Jefferson City School District in central Missouri, the review found schools across the state are collectively spending over $3.5 million on devices that claim to reduce the covid virus.
But in April, a covid-19 commission task force for top medical journal The Lancet, composed of international health, education and air quality experts, called various air-cleaning technologies — ionization, plasma and dry hydrogen peroxide — “often unproven” with a potential to create “harmful secondary pollutants.”
School officials need to be cautious when considering installing the devices, said Yang Wang, an assistant professor in environmental engineering who studies aerosols and air quality at the Missouri University of Science and Technology. He and other air quality experts worry that some versions of the cleaners may emit byproducts such as ozone that can make people sick.
“It’s some schools influencing other schools, and they’ve heard about this thing, and they think this is quite fancy, and maybe they will make the children’s parents feel safer,” he said. “We shouldn’t easily just devote all of our resources onto this device before we know clearly what’s happening.”
At a federal regulatory level, air-purifying devices that use ionization or UV light count as devices that kill pests such as bacteria and viruses, but they do not face the same scrutiny as more traditional pesticides, said Patrick Jones, president of the Association of American Pesticide Control Officials and four lawyers who specialize in pesticide law.
Pratim Biswas, who spent years leading the Energy, Environmental and Chemical Engineering Department at Washington University in St. Louis, said not enough peer-reviewed evidence shows the devices are effective at preventing covid spread — or better than using a multilayered approach that includes low-cost solutions such as opening a window. He added that much of the testing conducted so far has occurred in laboratories, not in a classroom environment.
“People try to sell some of these devices, but there’s no shortcut,” said Biswas, now the University of Miami’s incoming dean of engineering.
Instead, Biswas, Wang and others typically recommend schools install high-quality air filters such as HEPA or more advanced MERV 13 filters, and increase the amount of outdoor air inside a room.
Even so, over 2,000 schools across 44 states have installed ion-blasting or other air-purifying technology, a KHN investigation found in May. To pay the bill, many schools have tapped into a flood of taxpayer money — roughly $193 billion in federal funds sent to schools to pay for anything from salaries to personal protective equipment.
In Kansas City, St. Thomas More School received about $11,000 in taxpayer funds to reimburse the school for half the cost of the devices it installed, Dulle said. St. Louis University High School, a private Catholic school, also used federal funds to pay for ionization technology, according to the school website and its student newspaper. St. Louis University High School did not respond to multiple attempts for comment.
In the St. Louis suburbs, Rockwood School District is spending more than $685,000 to install ionizing units across its campus. “The federal funding that has been made available absolutely was a game changer,” said Chris Freund, Rockwood’s director of facilities. “That’s really what kind of tipped the scales.”
For some larger districts, the costs add up. The public Jefferson City School District has budgeted $1.1 million, not from federal pandemic funding, to install ionization units in its schools, according to district spokesperson Ryan Burns. That could buy more than 3,600 Samsung Chromebook laptops for students.
The “iWave” devices that Kansas City’s Dulle purchased rely on technology from Global Plasma Solutions. The air-purifying company’s marketing materials for its various products explain how they are designed to work: They emit charged ions into the air. Those ions “seek out” particles, like dust or pollen, and make them cluster together. Those clusters are more easily trapped inside a filter in a building’s HVAC system. The North Carolina-based company also says on its website that the ions inactivate pathogens.
The company, which has made products also being installed in Jefferson City Public Schools, St. Louis University High School and other schools in Missouri, is facing a federal lawsuit filed by a consumer who bought one of its devices, alleging the company “continues to defraud consumers by concealing material information regarding the true performance” of its products.
Company spokesperson Kevin Boyle pointed to the company’s motion to dismiss the suit. In those court documents, Global Plasma Solutions said of the lawsuit: “It is devoid of any concrete, specific allegations plausibly alleging that GPS made even a single false or deceptive statement about its products.”
Boyle said peer-reviewed research on the company’s products doesn’t exist yet for the virus that causes covid-19, but his confidence in the technology stems from the company’s testing, stories from customers and the general peer-reviewed research on the benefits of ionization.
“This technology is safe and effective,” he said, noting he was glad it was in his children’s schools. “This is not a silver bullet. This is part of a multilayered solution. And when this technology is used, it absolutely delivers incremental benefits.”
He said the ionizers from Global Plasma Solutions do not emit “harmful volumes of ozone.”
One school district in California turned off its devices when it learned of the lawsuit. Although Dulle’s Kansas City school is aware of the Global Plasma Solutions lawsuit, he said, school officials decided “we’re going to wait and see where this is going.” He said that doctors’ offices and other trusted institutions had bought the technology. And when the school bought the devices last summer, he said, school officials were “every day learning something new about the virus and how to kill it.”
In north St. Louis County, Pattonville School District has installed Global Plasma Solutions technology made possible by federal relief funds, spending over $330,000.
Ron Orr, chief financial officer for the district, noted the appeal of buying devices that fight more than the virus that causes covid-19, as makers of air-purifying devices often tout their ability to curb the spread of viruses that cause colds, flu and other illnesses. He is such a fan, he bought a unit to help with dirt and dander in his home — where he lives with his wife, son and three dogs.
Orr isn’t completely sold on the claims of the devices when it comes to keeping kids safe from covid: “What I will say, it makes our environment safer and healthier, because we’re filtering out more from the air than we otherwise would be.”
He said the price also was hard to beat compared with replacing the district’s entire HVAC systems with a higher filtration option.
“Is there any way that we can get to that standard, without having to replace $40 million in heating and cooling equipment, which just physically wasn’t something that was going to be possible?” Orr asked. “And so that’s what kind of led us down this road.”
Healthcare organizations have faced a workforce conundrum familiar to all manner of providers during the pandemic: how to persuade essential workers to get vaccinated — and in a way that didn’t drive them away.
This article was published on Friday, June 18, 2021 in Kaiser Health News.
Christopher Richmond keeps a running tab on how many workers at the ManorCare skilled nursing facility he manages in western Pennsylvania have rolled up their sleeves for a covid-19 vaccine.
Although residents were eager for the shots this year, he’s counted only about 3 in 4 workers vaccinated at any one time. The excuses, among its staff of roughly 100, had a familiar ring: Because covid vaccines were authorized only for emergency use, some staffers worried about safety. Convenience mattered. In winter, shots were administered at work through a federal rollout. By spring, though, workers had to sign up online through a state program — a time-sucking task.
ManorCare urges every worker to be immunized against covid but turnover has vexed that effort. Managers at ProMedica, a nonprofit health system that operates ManorCare and senior care facilities in 26 states, faced a workforce conundrum familiar to all manner of providers during the pandemic: how to persuade essential workers to get vaccinated — and in a way that didn’t drive them away. Raises and bonuses, costing millions of dollars, did not move the needle to 100%.
Animus toward the vaccine created turmoil for some providers. Dr. Eric Berger, a pediatrician in Philadelphia who opened his practice more than a dozen years ago, enforced mandatory shots in May and saw six of his 47 staff members walk out. Berger said he worked for months to educate resistant workers. In April, he learned that several, women in their 20s and 30s, had attended a private karaoke party. Within days, four staffers were infected with covid.
Berger, who had seen in-office costs for protective equipment soar, then set a deadline for shots. He looks back with steely resolve over the last-minute “I quit” texts he received — and the hassle of finding a new receptionist and billing and medical assistants.
“Fortunately, we had some wonderful people who put in extra time,” he said. “It’s been stressful, but I think we did the right thing.”
Brittany Kissling, 33 and a mother of four, was one of the hesitant workers at Berger’s practice who decided — largely for financial reasons — to get vaccinated. The clinic manager couldn’t afford to lose her job. But she said she was nervous and that most of the workers who left recoiled at being told vaccinations were not negotiable. “I was a no-show my first time,” Kissling said about her first vaccine appointment. “I was scared. There were a lot of unknowns.”
But Kissling said Berger’s practice has spent “thousands and thousands and thousands of dollars” on masks and even paid workers for five days a week when they worked only two during the pandemic’s worst months. She said she understood how and why the karaoke episode prompted a mandate. “I get it from the business side,” said Kissling, about the requirement. “I do think it’s fair. I do think it is tough.”
Berger saw no other choice. “Vaccines are fundamental to our practices. That’s what we do,” he said. “Some got it in their heads that it could cause infertility; some had other reasons. It’s frustrating … [and] I don’t think it was political. If anything, most of these people are apolitical.”
At ManorCare, managers decided money could make a difference. Bonuses — up to $200 per employee — were added as an incentive, which in Pennsylvania alone cost ProMedica $3 million, said Luke Pile, vice president and general manager for ProMedica Senior Care skilled nursing centers.
Richmond, at ManorCare, said the resident council has been pivotal in keeping the focus on the risks of covid to the elderly — and no one there needs a reminder about the stress of the past year. According to Medicare records, the facility had 107 cases of covid among staffers and residents — and 14 deaths among residents beginning in March 2020.
“I constantly wear a mask. Not out of fear, but I don’t want to spread it by being asymptomatic,” Richmond said. “I tell people here: Whatever is happening in the community, that is what is happening in the community. But we are a health care institution and caring for the elderly. We need to be constantly vigilant.”
Richmond and other administrators admit it can be a struggle to understand why some health workers are unmoved by the science.
“Everything has been so polarized this past year. I don’t know that there is a single reason that individuals don’t get the vaccine,” Pile said. “In trying to educate people, personally and professionally, we talk about the history and science. Unfortunately, individual opinions don’t always align with that.”
Mandating vaccines is a step that ProMedica has yet to take, even as more businesses, universities and health care providers do so. A few long-term care operators, such as Atria Senior Living, operating in the United and Canada, and Juniper Communities, announced mandates. Some have been met with lawsuits from workers aligned with conservative groups. In May, more than 100 staffers at Houston Methodist Hospital filed suit to dispute and derail the hospital system’s compulsory vaccination. A judge dismissed the challenge this month on the grounds that the hospital’s requirement did not violate state or federal law or public policy.
Last week, the U.S. Labor Department issued a temporary emergency standard for health care workers, saying they face “grave danger” in the workplace when “less than 100 percent of the workforce is fully vaccinated.”
In Pennsylvania, whose population ranks among the oldest according to 2019 census data, statistical snapshots published in April underscored the need for vigilance. Two state agencies overseeing skilled nursing care and personal care homes reported that only half of their workers were vaccinated. Covid was notably devastating to long-term care facilities nationwide in 2020; some of Pennsylvania’s deadliest outbreaks were reported by local media in places shown later to have low staff vaccination rates.
A survey by the Delphi Group, begun in March 2020 with over 700,000 Facebook respondents ages 18 to 64, recently was analyzed by researchers from Carnegie Mellon and the University of Pittsburgh, who found that health care workers were largely leading the vaccine uptake. But there were notable differences over the winter among people working, side by side, in health care settings.
Pharmacists, physicians and registered nurses were the least hesitant to get vaccinated. Home health care aides, EMTs and nursing assistants showed the highest hesitancy among front-line health workers. Overall hesitancy across professions decreased from January to March 2021, as much as 5 percentage points, as vaccinations expanded, according to the analysis by the university researchers.
University of Pittsburgh researcher Wendy King said people indicated they were receptive to the vaccine if they were familiar with its science. Educators, overall, displayed the least hesitancy; workers in construction, mining and oil/gas extraction showed the greatest. Half of those who were hesitant cited possible side effects — a fear that could be eased by education, King said. A third among the hesitant gave other reasons: They didn’t believe they needed the vaccine. They didn’t trust the government. Or they didn’t trust the covid-19 vaccines.
“We expected hesitancy to vary by group, but how much they varied was surprising,” King said. “These were not people who were anti-vaccine, but they were worried about the effect of the vaccine.”
Still, King said the percentage who didn’t trust the government was alarming. “If somebody doesn’t understand the vaccine, that’s one thing. If you don’t trust that government, that is a much more difficult issue to address.”
That may change as two prominent vaccine makers approach full approval by the Food and Drug Administration. Pfizer and BioNTech applied for approval in May; Moderna applied in early June. A recent KFF poll found nearly a third of unvaccinated adults said they would be more likely to get a vaccine once it was fully approved by the FDA.
At ProMedica, Pile described a multipronged approach in such states as Florida and Pennsylvania, home to large elderly populations. On-site counseling in groups, with familiar doctors and staff, helped persuade some who were reluctant, he said. Short videos on why and how the vaccine worked were readied. ProMedica senior medical staff flew to Florida to advise as the National Guard arrived at its facility in Pinellas County, the health system’s first to receive the vaccine.
Falon Blessing, a nurse, manages other practitioners at ManorCare Health Services Center throughout the Tampa region. She recounted how employees had wondered aloud how such newly created vaccines could be safe.
“I think people at first just wanted to know: I’m not going to grow a tail in five years,” she said. “But then there was a momentum. It wasn’t so much ‘Are you going to get vaccinated?’ but rather ‘Of course, I’m going to get vaccinated.’”
During three vaccinations sessions ended in January, though, the facility reached about the same rate as Pennsylvania overall — about 76% of its workers were vaccinated. That rate has fallen to 62% this month because of attrition. An education effort continues, a ProMedica spokesperson said.
“My takeaway was it mattered to have one-on-one discussions,” Pile said. “If you talk to 10 people, why they wouldn’t get the vaccine, you’d get 10 different reasons.”
“And there were political opinions — what they heard on Facebook — and then they’d say: I want to see how it goes,” he said.
The questions and qualms about vaccines came at the end of a deeply distressing pandemic year for health care workers, and facilities are now finding fewer applicants for essential care.
By spring, ProMedica had 1,500 job postings in Pennsylvania alone, compared with a typical 400 openings. Pile said ProMedica raised wages in dozens of locations, though he declined to provide wage ranges or rates. It spent $4.5 million in Pennsylvania from March through last week — and still supplemented its workforce across the U.S. by hiring through staffing agencies.
“In 2020, we spent over $32 million on staffing agencies,” he said. Through this spring, ProMedica was on course to spend $66 million on staffing agencies for 2021, said Pile, who has worked in the care sector for 18 years.
“I have less employees than ever before,” he said. “I have never seen anything like it.”
The Pennsylvania Health Care Association, an advocacy group, surveyed members in April to better understand vaccine reluctance. Zachary Shamberg, the group’s president, said it found that defining “hesitancy is not that simple.”
Shamberg said PHCA focused on why people had yet to be immunized and the characteristics of the workforce were telling: About 92% of all its workers are women; 65% are between ages 16 and 44. Among them, some worried early on about possible infertility from the new vaccine, he said, and some wanted to wait for the single-shot Johnson & Johnson vaccine. Others were sick with covid and were advised, once recovered, not to get a vaccine for 90 days.
Shamberg was also critical of the state data. Those surveys, taken in March and released in April, reflected a time when the vaccine was new to many people.
Pennsylvania, a battleground state in recent presidential elections, remains politically charged, and Shamberg noted that politics likely plays a role among holdouts. In recent months, PHCA enlisted churches and doctors’ consortiums to change minds. Keeping residents and workers safe should be a priority in a state that, in a few years, will face a “silver tsunami” of residents in their 80s, Shamberg said.
In recent weeks, there has been clear momentum among the general population for shots in Pennsylvania. The state now ranks among the top 10 states in the nation to administer first doses of vaccines, according to data from the Centers for Disease Control and Prevention.
“Pennsylvania is a big and diverse state,” Shamberg said. “And it’s interesting why some of our staff in western Pennsylvania were hesitant versus workers in the city of Philadelphia.”
“The vast majority of workers in Philadelphia are female and, among them, minority populations that have some inherent distrust based on historical experience. Then you go out west and you have a more conservative viewpoint — and a distrust of government today and a distrust of government vaccine.”
The pandemic-caused recession and a federal requirement that states keep Medicaid beneficiaries enrolled until the national emergency ends swelled the pool of people in the program by more than 9 million over the past year, according to a report released Thursday.
The latest figures show Medicaid enrollment grew from 71.3 million in February 2020, when the pandemic was beginning in the U.S., to 80.5 million in January, according to a KFF analysis of federal data. (KHN is an editorially independent program of KFF.)
That’s up from about 56 million in 2013, just before many states expanded Medicaid under the Affordable Care Act. And it’s double the 40 million enrolled in 2001.
Medicaid, once considered the ugly duckling compared with the politically powerful and popular Medicare program, now covers nearly 1 in 4 Americans. In New Mexico, the ratio is more than 1 in 3.
Together, Medicaid and Medicare cover 43% of Americans.
More than three dozen states since 2014 have used billions in ACA funding to expand coverage beyond traditional Medicaid populations to cover adults with incomes below 138% of the federal poverty level, or about $17,800. At the end of 2020, 14.8 million newly eligible adults were enrolled in Medicaid because of the ACA.
States that have seen at least an 80% increase in Medicaid enrollment since 2013 are Kentucky (157%), Nevada (129%), Alaska (94%), Colorado (92%), Montana (88%), Oregon (85%) and New Mexico (80%).
Although Medicaid has often been criticized for having too few physicians who accept its low reimbursement rates, state officials say they have weathered the surge with few complaints from enrollees about accessing health services. One key reason is the dramatic downturn in people seeking medical care during the pandemic because they were mitigating their risks of contracting covid. Also, doctors were able to fit in more patients efficiently through telehealth appointments after federal rules expanded reimbursement for those services.
“We have no access issues,” said Karen Kimsey, Virginia’s Medicaid director. Since March 2020, Virginia Medicaid has added 308,000 members, a 20% increase, state officials said. With the exception of a shortage of some licensed mental health providers, state officials said they have enough providers to handle the increased demand.
Typically, a surge in Medicaid enrollment can cripple state budgets, but a covid relief package passed by Congress last year boosted the federal share of its funding for traditional Medicaid by 6.2 percentage points. Before the pandemic, Washington paid on average about 56% of Medicaid costs, with poorer states getting a larger share of federal funding.
However, the funding hike required states to not remove anyone from the program during the public health emergency unless they die or move out of state.
The increase in federal contributions does not apply to enrollees covered by the ACA Medicaid expansion. The federal government already pays for at least 90% of their expenses.
Among the big winners from the enlarged Medicaid rolls are private health plans, which most states use to cover their enrollees. Health plans such as those run by managed-care titans UnitedHealthcare, Molina Healthcare and Centene Corp. receive a payment from states each month based on enrollment. That means these insurers can profit if they control costs, but they lose money if expenses to treat enrollees are too high.
“We are seeing plans’ revenues go up and utilization of health services decline, which is a recipe for increased profits,” said Massey Whorley, a Medicaid expert with the consulting firm Avalere.
Because of the way they are paid, health insurers benefited financially during the pandemic compared with other major health industry sectors, such as hospitals, physicians and nursing homes forced to stretch budgets for extra staffing and protective gear for workers while their revenues shrank due to waning demand.
Most health experts expect the Biden administration to maintain the nation’s health emergency status until at least the end of the year. Administration officials have said they will give states at least 60 days’ notice before ending the emergency so states can prepare to determine who is still eligible for Medicaid and help those who leave the program transition to other coverage.
“What we are seeing now is the high-water mark for Medicaid enrollment,” Massey said.
Helping to drive Medicaid enrollment this year was the Biden administration’s decision to reopen the ACA insurance marketplace from March until Aug. 15. About 331,000 people who applied as part of that special enrollment were eligible for Medicaid or the Children’s Health Insurance Program.
Anthony Fiori, an analyst with the consulting firm Manatt Health, said some states likely have adjusted payments to health plans when annual contracts were negotiated to account for a drop in health care use. He noted many states have limits on how much health plans can make in profits.
Matt Salo, executive director of the National Association of Medicaid Directors, said some states are considering lowering the rates they pay insurers per person.
As more people get fully vaccinated, Salo said, states expect an uptick in enrollees seeking care that they have put off during the pandemic, which will increase costs. “There will be a lot of pent-up demand that might explode in the near future,” he said.
Several health plans have told Wall Street investors that the pandemic has been good for their financial health.
Molina CEO Joseph Zubretsky said in April that the company’s Medicaid enrollment at the end of March was 3.9 million members, an increase of 260,000 since December. Since the pandemic started, the company estimates, it has added more than 700,000 Medicaid members with no plateau in sight.
“For every month the national covid emergency gets extended, it would produce about $150 million of revenue to our annual total,” he said.
Zubretsky predicted many will remain on Medicaid longer.
“The low-wage service economy, the sandwich shops, the restaurants, the dry cleaner shops aren't coming back real fast, and I still think there will be a significant amount of that membership that will be on Medicaid for an extended period of time,” he said.
KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.
Kyndra Nevin recalls with dread having to ask a Montana judge to sign an order documenting that she'd had gender-confirmation surgery so she could change the gender on her birth certificate to female.
Nevin, a Bozeman resident and now 55, said the process she went through about a decade ago was humiliating and she continually worried the judge would deny her request.
"I had to out myself just to get that court order, to basically every court staff member that I came in contact with," she said. "Until it was all said and done, I was never sure if it was going to be OK."
Montana health officials revised the rules governing birth certificate changes in 2017 so that other transgender people wouldn't have to go through such an ordeal. Obtaining a judge's order was an option, but people could simply fill out a form affirming that they had undergone a gender transition — and the rule did not explicitly define a transition as surgical. Gender-confirmation surgery is not necessary for people to undergo a gender transition.
But this spring, less than four years after those rules were implemented, the Republican-led Montana Legislature passed a bill signed by Republican Gov. Greg Gianforte that once again requires a court order to change a birth certificate.
The state Department of Public Health and Human Services has proposed rules for the new law that say the court order must confirm "that the sex of an individual born in Montana has been changed by surgical procedure."
The new law and rules would affect dozens of people each year. The state health department fielded an average of 55 requests per year over the past three years to change the gender designation on their birth certificates, according to department spokesperson Jon Ebelt. In Montana, there are two designations for gender: male and female.
Fourteen other states require residents to provide proof of surgery to change the gender marker on their birth certificates, said Logan Casey, a senior policy researcher for the Movement Advancement Project, a research and advocacy organization.
"These kinds of laws are intrusive, overly burdensome and even dangerous for transgender people," Casey said.
Anna Peterson, a psychotherapist from Missoula who primarily works with transgender people, said the requirement to not only get the surgery — which many transgender people do not get for various reasons — and then present proof of that surgery to a judge can prevent people from changing their birth certificates.
Having that identity-affirming document is very important, said Peterson, who is transgender. But going through such a public process is not only humiliating, as Nevin experienced, it can also expose them to perpetrators of hate crimes, as Casey noted.
Kyndra Nevin remembers the humiliation in asking a Montana judge to sign a gender-confirmation surgery document so she could change her birth certificate gender to female. Nevin now advocates for transgender rights and participated in a 2018 study on the wellness of rural transgender people. (Kyndra Nevin)
"It can be really dangerous. Not to mention it can be psychologically harmful; it outs us and potentially puts us at risk," Peterson said.
Supporters of the new law said the change is meant to ensure accurate statistical data. They also said the state health department did not have the authority to make such a drastic change in 2017 without legislative approval.
Sen. Carl Glimm (R-Kila) sponsored Senate Bill 280, the legislation that became the new law. He said health department officials waited until after the legislature had convened in 2017 to begin the rule-making process to avoid input from the legislature on a major policy shift.
Glimm said his goal was to reverse that policy change and put the power of making such changes back in the hands of state lawmakers. The facts on a birth certificate are all important for statistical data and therefore a person must have a "very good reason" for changing them, he said.
Nevin, who now advocates for transgender rights and participated in a 2018 study on the wellness of rural transgender people, said she followed the bill through the legislative process and never heard a legitimate justification for changing the rules back.
"I would sure like to know what their reasoning was because everything I heard in the legislative hearings didn't really amount to a good reason — other than that they were just upset that it happened," Nevin said.
Lucien Wiggins, 12, arrived at Tufts Children's Hospital by ambulance June 7 with chest pains, dizziness and high levels of a protein in his blood that indicated inflammation of his heart. The symptoms had begun a day earlier, the morning after his second vaccination with the Pfizer-BioNTech mRNA shot.
For Dr. Sara Ross, chief of pediatric critical care at the Boston hospital, the event confirmed a doubt she'd been nursing: Was the country pushing its luck by vaccinating children against COVID at a time when the disease was relatively mild in the young — and skepticism of vaccines was frighteningly high?
"I have practiced pediatric ICU for almost 15 years and I have never taken care of a single patient with a vaccine-related complication until now," Ross told KHN. "Our standard for safety seems to be different for all the other vaccines we expose children to."
To be sure, cases of myocarditis like Lucien's have been rare, and the reported side effects, though sometimes serious, generally resolve with pain relievers and, sometimes, infusions of antibodies. And a COVID infection itself is far more likely than a vaccine to cause myocarditis, including in younger people.
Lucien went home, on the mend, after two days on intravenous ibuprofen in intensive care. Most of the 800 or so cases of heart problems among all ages reported to a federal vaccine safety database through May 31 followed a similar course. Yet the pattern of these cases — most occurred in young males after the second Pfizer or Moderna shot — suggested that the ailment was caused by the vaccine, rather than being coincidental.
On Friday, the Centers for Disease Control and Prevention's vaccine advisory committee is set to meet to discuss the possible link and whether it merits changing its recommendations for vaccinating teenagers with the Pfizer vaccine, which the Food and Drug Administration last month authorized for children 12 and older. A similar authorization for the Moderna vaccine is pending, and both companies are conducting clinical trials that will test their vaccines on children as young as 6 months old.
At a meeting last week of an FDA advisory committee, vaccine experts suggested that the agency require the pharmaceutical companies to hold larger and longer clinical trials for the younger age groups. A few said FDA should hold off on authorizing vaccination of younger children for up to a year or two.
Interestingly, Lucien and his mother, Beth Clarke, of Rochester, New Hampshire, disagreed. Her son's reaction was "odd," she said, but "I'd rather him get a side effect [that doctors] can help with than get COVID and possibly die. And he feels that way, which is more important. He thinks all his friends should get it."
Data regarding COVID's impact on the young is somewhat messy, but at least 300 COVID-related deaths and thousands of hospitalizations have been reported in children under 18, which makes COVID's toll as large or larger than any childhood disease for which a vaccine is currently available. The American Academy of Pediatrics wants children to receive the vaccine, assuming tests show it is safe.
But healthy people under 18 have generally not suffered major COVID effects, and the number of serious cases among the young has tumbled as more adults become vaccinated. Unlike other pathogens, such as influenza, children are generally not infecting older, vulnerable adults. Under these circumstances, said Dr. Cody Meissner — who as chief of pediatric infectious diseases at Tufts consulted on Lucien's case — the benefits of COVID vaccination at this point may not outweigh the risks for children.
"We all want a pediatric vaccine, but I'm concerned about the safety issue," Meissner told fellow advisory commission members last week. An Israeli study found a five- to 25-fold increase in the heart ailment among males ages 16-24 who were vaccinated with the Pfizer shot. Most recovered within a few weeks. Two deaths occurred in vaccinated men that don't appear to have been linked to the vaccine.
Young people could experience long-term effects from the suspected vaccine side effect such as scarring, irregular heartbeat or even early heart failure, Meissner said, so it makes sense to wait until the gravity of the problem becomes clearer.
"Could the disease come back this fall? Sure. But the likelihood I think is pretty low. And our first mandate is do no harm," he said.
Ross said the biggest pandemic threats to children that her ICU has witnessed are drug overdoses and mental illness brought on by the shutdown of normal life.
"Young children are not the vectors of disease, nor are they driving the spread of the epidemic," Ross said. While eventually everyone should be vaccinated against COVID, use of the vaccines should not be expanded to children without extensive safety data, she said.
The government could authorize childhood vaccination against COVID without recommending it immediately, noted Dr. Eric Rubin, an advisory committee member who is editor-in-chief of the New England Journal of Medicine. "In September, when kids are back in school, people are indoors, and the vaccination rates are very low in certain parts of the country, who knows what things are going to look like? We may want this vaccine."
Moderna and Pfizer this summer began testing their vaccines in younger kids. A Pfizer spokesperson said the company expects to give about 2,250 children ages 6 months-11 years vaccine as part of its trial; Moderna said it would vaccinate about 3,500 children in the 2-11 age range.
Some members of the FDA advisory committee proposed that up to 10,000 kids be included in each trial. But Marion Gruber, leader of the FDA's vaccine regulatory office, pointed out that even trials that large wouldn't necessarily detect a side effect as rare as myocarditis seems to be.
At some point, federal regulators and the public must decide how much risk they are willing to accept from vaccines versus the risk of a COVID virus that continues to spread and mutate around the world, said Dr. Paul Offit, director of the Vaccine Education Center at Children's Hospital of Philadelphia.
"We're going to need a highly vaccinated population for years or perhaps decades," Offit said at the meeting. "It seems hard to imagine that we won't have to vaccinate children going forward."
Ross argued that it makes more sense to selectively vaccinate children who are most at-risk for serious COVID disease, such as those who are obese or have diabetes. Yet even to raise questions about the vaccination program can be a freighted decision, she said. While authorities have a duty to speak frankly about the safety of vaccines, there is also a responsibility not to frighten the public in a way that discourages them from seeking protection.
A 10-day pause in the Johnson & Johnson vaccination campaign in April, while authorities investigated a link to an occasionally fatal blood-clotting disorder, led to a major decline in public confidence in that vaccine, although as of late May authorities had detected only 28 cases among 8.7 million U.S. recipients of the vaccine. Because of the declining appetite for the Johnson & Johnson vaccine, millions of doses are in danger of passing their use-by date in refrigerators around the country.
Focusing too much attention on potential harms from the Pfizer and Moderna vaccines for children could have a tragic result, said Dr. Saad Omer, director of the Yale Institute for Global Health and an expert on vaccine hesitancy. "Very soon we could be in a situation where we really need to vaccinate this population, but it will be too late because you've already given the message that we should not be doing it," he said.
Eventually, perhaps next year, K-12 mandates might be called for, said Dr. Sean O'Leary, a professor of pediatric infectious diseases at the University of Colorado. "There's so much misinformation and propaganda spreading that people are reticent to go there, to further poke the hornet's nest," he said. But once there is robust safety data for children, "when you think about it, there's no logical or ethical reason why you wouldn't."