The Little Shell Tribe of Chippewa Indians of Montana is building its health services largely from scratch roughly a year after becoming the United States' 574th federally recognized Indigenous tribe.
This article was published on Friday, February 19, 2021 in Kaiser Health News.
By Katheryn Houghton Linda Watson draped a sweater with the words "Little Shell Chippewa Tribe" over her as she received the newly recognized tribal nation's first dose of covid-19 vaccine.
"I wanted to show my pride in being a Little Shell member," Watson, 72, said. "The Little Shell are doing very good things for the people."
Watson has diabetes and a heart condition. The shot brought some peace of mind during a time when that isn't fully possible. One of her sons is among those who have died of covid.
The Little Shell Tribe of Chippewa Indians of Montana is building its health services largely from scratch roughly a year after becoming the United States' 574th federally recognized Indigenous tribe. Because of the pandemic, it's doing it on hyperdrive.
The long-sought recognition came just months before the pandemic took hold, arriving in time to guarantee the right to crucial healthcare and a tribal supply of protective covid vaccines. Federal pandemic relief dollars are speeding up the Little Shell Tribe's ability to build its own clinic.
Without the CARES Act funds, Indian Health Service and Little Shell officials said it would have likely taken years using only IHS resources to establish a clinic. The IHS already has a list of new and replacement healthcare facility projects nationwide estimated to cost more than $14.5 billion, yet it reported in 2019 it receives roughly $240 million each year to get that work done. At that pace, it would take 60 years to get through its current needs.
Now, in Great Falls, roughly 2 miles from where Watson got her shot, a brick building under renovation bears a banner announcing the Little Shell Tribal Health Clinic: "Coming 2021." The former animal hospital site that the tribe purchased will provide medical, dental, vision and behavioral care, alongside traditional medicine, a pharmacy and a lab. The goal is to open the clinic by late summer.
When Watson drives by the future clinic's site on her way to work as the tribal nation's enrollment officer, she said, she feels proud.
"To have a Little Shell name on it, to see the results of what our ancestors had worked so hard for," Watson said. "It's their descendants that are now experiencing it."
The Little Shell have advocated for their place as a sovereign nation for more than 150 years. Although Montana formally recognized the tribe in 2000, not having federal recognition until December 2019 kept it from accessing many vital services and programs.
And without a recognized homeland, the tribe's more than 5,700 members had scattered across Northern Plains states and Canada. The vast majority live in Montana.
Because of the federal recognition, Little Shell tribal enrollment has surged and its Ojibwe language course has a lengthening waitlist.
But this newfound strength is tempered by the deep challenges of the pandemic. The coronavirus has stalled in-person celebrations and planning in the tribe's first year of federal recognition.
Worst yet, covid has disproportionately infected and killed Indigenous people nationwide, exposing long-standing health inequities caused by a history of colonization and underinvestment in Indian Country. In Montana, Native Americans make up roughly 7% of the population yet account for 11% of the state's covid cases and 17% of related deaths.
The Little Shell tribal healthcare system is so new, it doesn't have electronic health records set up and hasn't tracked the statistics.
In October, the tribal nation hired its first health director, who had to create a covid vaccination plan while juggling other immediate needs, such as helping establish a transportation service for members to get to doctor appointments. Setting up infrastructure for a sovereign nation without a reservation presents challenges. The tribe's service area encompasses four counties — Blaine, Cascade, Glacier and Hill — that together would span an area larger than Maryland. Only two of those counties share a border, so the distances are even greater.
Little Shell members now have access to any IHS facility nationwide, but, until their clinic is ready, some services such as dental and vision care are far-flung even for those close to the nation's Great Falls headquarters.
"Without our clinic, members would have to drive 118 miles one way to get some basic services — and try doing that in January and February in Montana," Tribal Chairman Gerald Gray said.
In the meantime, the tribe is partnering with the Cascade City-County Health Department to administer about 100 vaccine doses each week, according to the tribal health department. The effort has attracted tribal members from out of state.
Many questions remain as to how the new clinic will operate. Gray said the tribe has been told IHS will operate the clinic for at least three years before the tribal nation has the chance to completely run its services. Bryce Redgrave, the Billings-area IHS director, said in a statement the agency is discussing the possibilities but "no plan has been finalized at this time."
"The model is about treating the whole person and prioritizing Indigenous interventions," said Little Shell tribal council member Kim McKeehan.
What that looks like for the Little Shell is still being decided, said Molly Wendland, the Little Shell tribal health director. She said one idea is to grow plants for traditional medicines behind the clinic. The tribe also plans to have a smudge room, she said, in which members can burn sage and ask for healing.
Linda Wilmore, 51, a Little Shell member who lives in Great Falls, said the new clinic would mean she wouldn't put off care such as going to the dentist anymore. Without an option close to home, she said, she has often waited until she's in enough pain to warrant the three-hour round trip to an IHS healthcare facility that offers dental care, where her insurance won't leave her with unwieldy out-of-pocket costs.
She is also excited about having a clinic designed for, and by, the Little Shell Tribe. Growing up, Wilmore remembers her family having to ask permission to use IHS facilities in Montana before state recognition in 2000 guaranteed it.
"You felt like the redheaded stepchild asking, 'We're Little Shell, can we use your clinic?'" Wilmore said.
The Great Falls clinic will also fill gaps in care for other Indigenous people in nearby rural communities and the city itself.
Little Shell members who live far from Great Falls are sorting through how to tap into newly granted services or how to access specialty treatment they can't get at an IHS clinic.
Little Shell member Jonni Kroll, 55, lives in Deer Park, Washington, some 380 miles from the tribe's future clinic. Her closest IHS alternative is a roughly 50-minute drive. Her first call was to book an eye appointment, only to find the clinic doesn't have an optometrist.
"So then I go to the next clinic on my list," Kroll said. "That's a problem across the board with IHS nationwide, and I think that will affect Little Shell people trying to figure out: How do we utilize this when we are scattered?"
Little Shell people are spread out largely because they weren't recognized, she noted, and now they're having to play catch-up to understand how to access the services that recognition ensures. She said members, some of whom have never met, are connecting by phone or online to work through those questions together.
"The Little Shell are so resilient," Kroll said. "We've gotten to the point of federal recognition and so now we find a way to come past that. There are lots of doors that opened, but we have a lot to learn."
About 2.7 million veterans who use the VA health system are classified as "rural" or "highly rural" patients, residing in communities or on land with fewer services and less access to healthcare.
This article was published on Friday, February 19, 2021 in Kaiser Health News.
A Learjet 31 took off before daybreak from Helena Regional Airport in Montana, carrying six Veterans Affairs medical providers and 250 doses of historic cargo cradled in a plug-in cooler designed to minimize breakage.
Even in a state where 80-mph speed limits are normal, ground transportation across long distances is risky for the Moderna mRNA-1273 vaccine, which must be used within 12 hours of thawing.
The group's destination was Havre, Montana, 30 miles from the Canadian border. About 500 military veterans live in and around this small town of roughly 9,800, and millions more reside in similarly rural, hard-to-reach areas across the United States.
About 2.7 million veterans who use the VA health system are classified as "rural" or "highly rural" patients, residing in communities or on land with fewer services and less access to health care than those in densely populated towns and cities. An additional 2 million veterans live in remote areas who do not receive their health care from VA, according to the department. To ensure these rural vets have access to the covid vaccines, the VA is relying on a mix of tools, like charter and commercial aircraft and partnerships with civilian health organizations.
The challenges of vaccinating veterans in rural areas — which the VA considers anything outside an urban population center — and "highly rural" areas — defined as having fewer than 10% of the workforce commuting to an urban hub and with a population no greater than 2,500 — extend beyond geography, as more than 55% of them are 65 or older and at risk for serious cases of covid and just 65% are reachable via the internet.
For the Havre event, VA clinic workers called each patient served by the Merril Lundman VA Outpatient Clinic in a vast region made up of small farming and ranching communities and two Native American reservations. And for those hesitant to get the vaccine, a nurse called them back to answer questions.
"At least 10 additional veterans elected to be vaccinated once we answered their questions," said Judy Hayman, executive director of the Montana VA Health Care System, serving all 147,000 square miles of the state.
The Havre mission was a test flight for similar efforts in other rural locations. Thirteen days later, another aircraft took off for Kalispell, Montana, carrying vaccines for 400 veterans.
In Alaska, another rural state, Anchorage Veterans Affairs Medical Center administrators finalized plans for providers to hop a commercial Alaska Airlines flight on Thursday to Kodiak Island. There, VA workers expected to administer 100 to 150 doses at a vaccine clinic conducted in partnership with the Kodiak Area Native Association.
"Our goal is to vaccinate all veterans who have not been vaccinated in and around the Kodiak community," said Tom Steinbrunner, acting director of the Alaska VA Healthcare System.
VA began its outreach to rural veterans for the vaccine program late last year, as the Food and Drug Administration approached the dates for issuing emergency use authorizations for the Pfizer-BioNTech and Moderna vaccines, according to Dr. Richard Stone, the Veterans Health Administration's acting undersecretary. It made sense to look to aircraft to deliver vaccines. "It just seemed logical that we would reach into rural areas that, [like] up in Montana, we had a contract with, a company that had small propeller-driven aircraft and short runway capability," said Stone, a retired Army Reserve major general.
Veterans have responded, Stone added, with more than 50% of veterans in rural areas making appointments.
As of Wednesday, the VA had tallied 220,992 confirmed cases of covid among veterans and VA employees and 10,065 known deaths, including 128 employees. VA had administered 1,344,210 doses of either the Pfizer or Moderna vaccine, including 329,685 second vaccines, to veterans as of Wednesday. According to the VA, roughly 25% of those veterans live in rural areas, 2.81% live in highly rural areas and 1.13% live on remote islands.
For rural areas, the VA has primarily relied on the Moderna vaccine, which requires cold storage between minus 25 degrees Centigrade (minus 13 degrees Fahrenheit) and minus 15 degrees C (5 degrees F) but not the deep freeze needed to store the Pfizer vaccine (minus 70 degrees C, or minus 94 degrees F). That, according to the VA, makes it more "transportable to rural locations."
The VA anticipates that the one-dose Johnson & Johnson vaccine, if it receives an emergency use authorization from the FDA, will make it even easier to reach remote veterans. The vaccines from Moderna and Pfizer-BioNTech both require two shots, spaced a few weeks apart. "One dose will make it easier for veterans in rural locations, who often have to travel long distances, to get their full vaccination coverage," said VA spokesperson Gina Jackson. The FDA's vaccine advisory committee is set to meet on Feb. 26 to review J&J's application for authorization.
Meanwhile, in places like Alaska, where hundreds of veterans live off the grid, VA officials have had to be creative. Flying out to serve individual veterans would be too costly, so the Anchorage VA Medical Center has partnered with tribal health care organizations to ensure veterans have access to a vaccine. Under these agreements, all veterans, including non-Native veterans, can be seen at tribal facilities.
"That is our primary outreach in much of Alaska because the tribal health system is the only health system in these communities," Steinbrunner said.
In some rural areas, however, the process has proved frustrating. Army veteran John Hoefen, 73, served in Vietnam and has a 100% disability rating from the VA for Parkinson's disease related to Agent Orange exposure. He gets his medical care from a VA location in Canandaigua, New York, 20 miles from his home, but the facility hasn't made clear what phase of the vaccine rollout it's in, Hoefen said.
The hospital's website simply says a staff member will contact veterans when they become eligible — a "don't call us, we'll call you," situation, he said. "I know a lot of veterans like me, 100% disabled and no word," Hoefen said. "I went there for audiology a few weeks ago and my tech hadn't even gotten her vaccine yet."
VA Canandaigua referred questions about the facility's current phase back to its website: "If you're eligible to get a vaccine, your VA health care team will contact you by phone, text message or Secure Message (through MyHealtheVet) to schedule an appointment," it states. A call to the special covid-19 phone number established for the Canandaigua VA, which falls under the department's Finger Lakes Healthcare System, puts the caller into the main menu for hospital services, with no information specifically on vaccine distribution.
For the most part, the VA is using Centers for Disease Control and Prevention guidelines to determine priority groups for vaccines. Having vaccinated the bulk of its health care workers and first responders, as well as residents of VA nursing homes, it has been vaccinating those 75 and older, as well as those with chronic conditions that place them at risk for severe cases of covid. In some locations, like Anchorage and across Montana, clinics are vaccinating those 65 and older and walk-ins when extra doses are available.
According to Lori FitzGerald, chief of pharmacy at the VA hospital in Fort Harrison, Montana, providers have ended up with extra doses that went to hospitalized patients or veterans being seen at the facility. Only one dose has gone to waste in Montana, she said.
To determine eligibility for the vaccine, facilities are using the Veterans Health Administration Support Service Center databases and algorithms to help with the decision-making process. Facilities then notify veterans by mail, email or phone or through VA portals of their eligibility and when they can expect to get a shot, according to the department.
Air Force veteran Theresa Petersen, 83, was thrilled that she and her husband, an 89-year-old U.S. Navy veteran, were able to get vaccinated at the Kalispell event. She said they were notified by their primary care provider of the opportunity and jumped at the chance.
"I would do anything to give as many kudos as I can to the Veterans Affairs medical system," Petersen said. "I'm so enamored with the concept that 'Yes, there are people who live in rural America and they have health issues too.'"
The VA is allowed to provide vaccines only to veterans currently enrolled in VA health care. About 9 million U.S. veterans are not enrolled at the VA, including 2 million rural veterans.
After veterans were turned away from a VA clinic in West Palm Beach, Florida, in January, Rep. Debbie Wasserman Schultz (D-Fla.) wrote to Acting VA Secretary Dat Tran, urging him to include these veterans in their covid vaccination program.
Stone said the agency does not have the authorization to provide services to these veterans. "We have been talking to Capitol Hill about how to reconcile that," he said. "Some of these are very elderly veterans and we don't want to turn anybody away."
For a decade, Jennifer Crow has taken care of her elderly parents, who have multiple sclerosis. After her father had a stroke in December, the family got serious in its conversations with a retirement community — and learned that one service it offered was covid-19 vaccination.
"They mentioned it like it was an amenity, like 'We have a swimming pool and a vaccination program,'" said Crow, a librarian in southern Maryland. "It was definitely appealing to me." Vaccines, she felt, would help ease her concerns about whether a congregate living situation would be safe for her parents, and for her to visit them; she has lupus, an autoimmune condition.
As the coronavirus death toll soars and demand for the covid vaccines dwarfs supply, an army of hospitals, clinics, pharmacies and long-term care facilities has been tasked with getting shots into arms. Some are also using that role to attract new business — the latest reminder that health care, even amid a global pandemic, is a commercial endeavor where some see opportunities to be seized.
"Most private sector companies distributing vaccines are motivated by the public health imperative. At some point, their DNA also kicks in," said Roberta Clarke, associate professor emeritus of marketing at Boston University.
Among senior living facilities — which saw their largest drop in occupancy on record last year — some companies are marketing vaccinations to recruit residents. Sarah Ordover, owner of Assisted Living Locators Los Angeles, a referral agency, said many in her area are offering vaccines "as a sweetener" to prospective residents, sometimes if they agree to move in before a scheduled vaccination clinic.
Oakmont Senior Living, a high-end retirement community chain with 34 locations, primarily in California, has advertised "exclusive access" to the vaccines via social media and email. A call to action on social media reads: "Reserve your apartment home now to schedule your Vaccine Clinic appointment!"
Although the vaccine offer was a selling point for Crow, it wasn't for her parents, who have not been concerned about contracting covid and didn't want to forgo their independence, she said. Ultimately, they moved in with her sister, who could arrange home care services.
This marketing approach might sway others. Oakmont Senior Living, based in Irvine, reported 92 move-ins across its communities last month, a 13% increase from January 2020, noting the vaccine is "just one factor among many" in deciding to become a resident.
But some object to facilities using vaccines as a marketing tool. "I think it's unethical," said Dr. Michael Carome, director of health research at consumer advocacy group Public Citizen. While he believes that facilities should provide vaccines to residents, he fears attaching strings to a vaccine could coerce seniors, who are particularly vulnerable and desperate for vaccines, into signing a lease.
Tony Chicotel, staff attorney at California Advocates for Nursing Home Reform, worries that seniors and their families could make less informed decisions when incentivized to sign by a certain date. "You're thinking, 'I've got to get moved in in the next week or otherwise I don't get this shot. I don't have time to read everything in this 38-page contract,'" he said.
Oakmont Senior Living responded by email: "Potential residents and their families are always provided with the information they need to be confident in a decision to choose Oakmont."
Some people say facilities are simply meeting their demand for covid vaccines. "Who is going to put an elderly person in a place without a vaccine? Congregate living has been a hotbed of the virus," said retired philanthropy consultant Patti Patrizi. She and her son recently chose a retirement community in Los Angeles for her ex-husband for myriad reasons unrelated to the vaccines. However, they accelerated the move by two weeks to coincide with a vaccination clinic.
"It was definitely not a marketing tool to me," said Patrizi. "It was my insistence that he needs it before he can live there."
A few pharmacies have continued these marketing activities while rolling out covid shots. On its covid vaccine information site, CVS Pharmacy encouraged visitors to sign up for its rewards program to earn credits for vaccinations. Supermarket and pharmacy chain Albertsons and its subsidiaries have a button on their covid vaccine information sites saying, "Transfer your prescription."
But the pandemic isn't business as usual, said Alison Taylor, a business ethics professor at New York University. "This is a public health emergency," she said. Companies distributing covid vaccines should ask themselves "How can we get society to herd immunity faster?" rather than "How many customers can I sign up?" she said.
In an email response, CVS said it had removed the reference to its rewards program from its covid vaccination page. Patients will not earn rewards for receiving a covid shot at its pharmacies, the company said, and its focus remains on administering the vaccines.
Albertsons said via email that its covid vaccine information pages are intended to be a one-stop resource, and information about additional services is at the very bottom of these pages.
Boston University's Clarke doesn't see any harm in these marketing activities. "As long as the patient is free to say 'no, thank you,' and doesn't think they'll be penalized by not getting a vaccine, it's not a problem," she said.
At least one health care provider is offering complimentary services to people eligible for covid vaccines. Membership-based primary care provider One Medical — now inoculating people in several states, including California — offers a free 90-day membership to groups, such as people 75 and older, that a local health department has tasked the company with vaccinating, according to an email from a company spokesperson who noted that vaccine supply and eligibility requirements vary by county.
The company said it offers the membership — which entails online vaccine appointment booking, second dose reminders and on-demand telehealth visits for acute questions — because it believes it can and should do so, especially when many are struggling to access care.
While these may very well be the company's motives, a free trial is also a marketing tactic, said Silicon Valley health technology investor Dr. Bob Kocher. Whether it's Costco or One Medical, any company offering a free sample hopes recipients buy the product, he said.
Offering free trial memberships could pay off for providers like One Medical, he said; local health departments can refer many patients, and converting a portion of vaccine recipients into members could offer a cheaper way for providers to get new patients than finding them on their own.
"Normally, there's no free stuff at a provider, and you have to be sick to try health care. This is a pretty unique circumstance," said Kocher, who doesn't see boosting public health and taking advantage of an uncommon marketing opportunity as mutually exclusive here. "Vaccination is a super valuable way to help people," he said. "A free trial is also a great way to market your service."
One Medical insisted the membership trial is not a marketing ploy, noting that the company is not collecting credit card information during registration or auto-enrolling trial participants into paid memberships. But patients will receive an email notifying them before their trial ends, with an invitation to sign up for membership, said the company.
Health equity advocates say more attention needs to be paid to the people who slip under the radar of marketers — yet are at the highest risk of getting and dying from covid, and the least likely to be vaccinated.
Kathryn Stebner, an elder-abuse attorney in San Francisco, noted that the high cost of many assisted living facilities is often prohibitive for the working class and people of color. "African Americans are dying [from covid] at a rate three times as much as white people," she said. "Are they getting these vaccine offers?"
The federal government has penalized 774 hospitals for having the highest rates of patient infections or other potentially avoidable medical complications. Those hospitals, which include some of the nation's marquee medical centers, will lose 1% of their Medicare payments over 12 months.
The penalties, based on patients who stayed in the hospitals anytime between mid-2017 and 2019, before the pandemic, are not related to covid-19. They were levied under a program created by the Affordable Care Act that uses the threat of losing Medicare money to motivate hospitals to protect patients from harm.
On any given day, one in every 31 hospital patients has an infection that was contracted during their stay, according to the Centers for Disease Control and Prevention. Infections and other complications can prolong hospital stays, complicate treatments and, in the worst instances, kill patients.
"Although significant progress has been made in preventing some healthcare-associated infection types, there is much more work to be done," the CDC says.
Now in its seventh year, the Hospital-Acquired Condition Reduction Program has been greeted with disapproval and resignation by hospitals, which argue that penalties are meted out arbitrarily. Under the law, Medicare each year must punish the quarter of general care hospitals with the highest rates of patient safety issues. The government assesses the rates of infections, blood clots, sepsis cases, bedsores, hip fractures and other complications that occur in hospitals and might have been prevented. The total penalty amount is based on how much Medicare pays each hospital during the federal fiscal year — from last October through September.
Hospitals can be punished even if they have improved over past years — and some have. At times, the difference in infection and complication rates between the hospitals that get punished and those that escape punishment is negligible, but the requirement to penalize one-quarter of hospitals is unbending under the law. Akin Demehin, director of policy at the American Hospital Association, said the penalties were "a game of chance" based on "badly flawed" measures.
Some hospitals insist they received penalties because they were more thorough than others in finding and reporting infections and other complications to the federal Centers for Medicare & Medicaid Services and the CDC.
"The all-or-none penalty is unlike any other in Medicare's programs," said Dr. Karl Bilimoria, vice president for quality at Northwestern Medicine, whose flagship Northwestern Memorial Hospital in Chicago was penalized this year. He said Northwestern takes the penalty seriously because of the amount of money at stake, "but, at the same time, we know that we will have some trouble with some of the measures because we do a really good job identifying" complications.
Other renowned hospitals penalized this year include Ronald Reagan UCLA Medical Center and Cedars-Sinai Medical Center in Los Angeles; UCSF Medical Center in San Francisco; Beth Israel Deaconess Medical Center and Tufts Medical Center in Boston; NewYork-Presbyterian Hospital in New York; UPMC Presbyterian Shadyside in Pittsburgh; and Vanderbilt University Medical Center in Nashville, Tennessee.
There were 2,430 hospitals not penalized because their patient complication rates were not among the top quarter. An additional 2,057 hospitals were automatically excluded from the program, either because they solely served children, veterans or psychiatric patients, or because they have special status as a "critical access hospital" for lack of nearby alternatives for people needing inpatient care.
The penalties were not distributed evenly across states, according to a KHN analysis of Medicare data that included all categories of hospitals. Half of Rhode Island's hospitals were penalized, as were 30% of Nevada's.
All of Delaware's hospitals escaped punishment. Medicare excludes all Maryland hospitals from the program because it pays them through a different arrangement than in other states.
Over the course of the program, 1,978 hospitals have been penalized at least once, KHN's analysis found. Of those, 1,360 hospitals have been punished multiple times and 77 hospitals have been penalized in all seven years, including UPMC Presbyterian Shadyside.
The Medicare Payment Advisory Commission, which reports to Congress, said in a 2019 report that "it is important to drive quality improvement by tying infection rates to payment." But the commission criticized the program's use of a "tournament" model comparing hospitals to one another. Instead, it recommended fixed targets that let hospitals know what is expected of them and that don't artificially limit how many hospitals can succeed.
Although federal officials have altered other ACA-created penalty programs in response to hospital complaints and independent critiques — such as one focused on patient readmissions — they have not made substantial changes to this program because the key elements are embedded in the statute and would require a change by Congress.
Boston's Beth Israel Deaconess said in a statement that "we employ a broad range of patient care quality efforts and use reports such as those from the Centers for Medicare & Medicaid Services to identify and address opportunities for improvement."
UCSF Health said its hospital has made "significant improvements" since the period Medicare measured in assessing the penalty.
"UCSF Health believes that many of the measures listed in the report are meaningful to patients, and are also valid standards for health systems to improve upon," the hospital-health system said in a statement to KHN. "Some of the categories, however, are not risk-adjusted, which results in misleading and inaccurate comparisons."
Cedars-Sinai said the penalty program disproportionally punishes academic medical centers due to the "high acuity and complexity" of their patients, details that aren't captured in the Medicare billing data.
"These claims data were not designed for this purpose and are typically not specific enough to reflect the nuances of complex clinical care," the hospital said. "Cedars-Sinai continually tracks and monitors rates of complications and infections, and updates processes to improve the care we deliver to our patients."
Last December, Mirande Gross graduated from Bellarmine University in Louisville, Kentucky, with a bachelor's degree in communications. But Gross has changed her mind and is heading back to school in May for a one-year accelerated nursing degree program. The pandemic that has sickened more than 27 million people in the United States and killed nearly 500,000 helped convince her she wanted to become a nurse.
"I was excited about working during the pandemic," Gross, 22, said. "It didn't scare me away."
Enrollment in baccalaureate nursing programs increased nearly 6% in 2020, to 250,856, according to preliminary results from an annual survey of 900 nursing schools by the American Association of Colleges of Nursing.
"In the pandemic we saw an increased visibility of nurses, and I think that's been inspirational to many people," said Deb Trautman, president and CEO of the association, whose members represent nursing programs at the bachelor's, master's and doctoral levels. "It's a profession where you can make a difference."
Two-year associate nursing degree programs seem to be experiencing a similar bump, though hard numbers are unavailable, said Laura Schmidt, president of the Organization for Associate Degree Nursing.
There's no way to know exactly what is propelling the new applications. But medical schools also saw an 18% boost in applications last year, a jump partly attributed to the pandemic and high profile of key doctors, such as Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, during the crisis.
It's possible that the media stories, social media accounts and front-line medical workers' personal accounts of battling the novel coronavirus have played a role. "Nurse" was the No. 1 term that people queried "how to become" on Google in 2020, according to Google trends data.
For Gross, it was a turn back to an initial career choice. When she started college, nursing was her chosen path. But after fainting twice while shadowing a nurse at the hospital, she switched to a major that didn't involve needles or blood. For the past two years, she's worked as a newborn photographer at a hospital near her Louisville home, and she no longer gets squeamish at the sight of IVs or injuries.
"When I saw on the news nurses being so overworked, I thought, 'Gosh, I wish I could be in there helping,'" said Gross.
Demand for nurses was strong even before the pandemic hit. There are about 3 million registered nurses in the United States, but employment is expected to grow 7% between 2019 and 2029, according to the Bureau of Labor Statistics, faster than the 4% average for all occupations. Many hospital medical staffs are stretched to the breaking point as they deal with a surge of covid-19 patients and at the same time cope with staff shortages as medical personnel have become ill with covid or had to quarantine.
Meeting the demand for nurses is hampered by long-standing capacity issues at nursing schools. According to a report by the American Association of Colleges of Nursing, programs at the bachelor's and graduate degree levels turned away more than 80,000 qualified applicants in 2019. The reasons included not having enough faculty, clinical training sites and supervisors or classroom space, as well as budget constraints, the report found.
"The people who are prepared to teach are at least master's degree level and frequently have doctorate degrees," said Beverly Malone, president and CEO of the National League for Nursing. "They can work at hospitals or community care centers for [significantly] more money."
Malone and others also noted that it can be difficult to ensure access to the clinical training slots that nursing students need. This problem was exacerbated during the pandemic when many hospitals sent nursing students home to avoid their getting sick and to conserve scarce personal protective equipment for staffers treating covid patients.
For some nursing students, the pandemic has opened their eyes to new possibilities for patient care. David Namnath is finishing a two-year associate nursing degree at the College of Marin in Kentfield, California. He learned last spring that his clinical rotation at the local hospital would be canceled because of covid.
Instead, he and other students took on a telenursing project, in which he made regular wellness check-ins and provided health education related to chronic conditions such as diabetes and back pain with eight patients over video and phone.
"It was really helpful for me," said Namnath, 29, who has a bachelor's degree in biochemistry and worked in a lab before starting nursing school. "It's not something you normally learn. I think we became more three-dimensional because of it."
Some people who got nursing degrees in years past but didn't practice also may be taking a fresh look at the profession, said David Benton, CEO of the National Council of State Boards of Nursing. More than 222,000 nurses who were educated in the U.S. took the National Council Licensure Examination last year, a figure that was 5% higher than the year before, he said.
The economic downturn that has shuttered thousands of businesses may have made nursing more attractive, he said.
"We know that, nationally, services like the restaurant industry have shut down," Benton said. "But one thing that hasn't shut down is demand for healthcare."
Nurses who worked in hospitals made $79,400 a year on average in 2019, according to the Bureau of Labor Statistics. But as the covid crisis hit and hospitals scrambled to find staff last year, nurses who were willing to travel to covid hot spots could make many times that amount, in some cases up to $10,000 a week.
There are many paths to becoming a nurse. A growing proportion of nurses get a bachelor of science degree in nursing at four-year colleges. But many still go to community colleges for two-year associate degrees in nursing. These programs are more affordable and may appeal to older students who are parents or going back for a second degree, said Schmidt.
Both types of graduates can take the nurse licensing exam and become registered nurses. But nurses with bachelor's degrees may be better positioned for higher-level jobs or supervisory roles. They may also earn more money. According to the association of nursing colleges' annual survey, 41% of hospitals and other healthcare facilities require new nursing hires to have a bachelor's degree in nursing.
Many nursing schools have "RN to BSN" programs that enable registered nurses with associate degrees to get the additional training they need for their bachelor of nursing degrees. And numerous accelerated programs, like the one Mirande Gross will start in May, allow people to fill in their nursing education gaps in a compressed time frame.
Not every nursing student sees the pandemic as an opportunity, however. Steven Bemben worked as a paramedic in Uvalde County, Texas, west of San Antonio, during the first frightening months of the pandemic last year. Personal protective equipment was hard to come by, and sometimes the calls to transport very sick covid patients came nonstop.
"It was extremely stressful, and people were getting fatigued and burned out," said Bemben, 33, who had been on the job for nine years.
Last October, he quit his paramedic job, and in January he started a two-year bachelor's nursing program at the University of Texas-San Antonio. (He already has an associate degree, although not in nursing.)
When Bemben finishes school, he hopes, the pandemic will be in our collective rearview mirror.
"By the time I graduate, I'm trying to stay optimistic that we'll be past all this stuff," he said.
The state's existing system of programs and services can be confusing for seniors who must navigate a disconnected patchwork of public and private offerings.
This article was published on Thursday, February 18, 2021 in Kaiser Health News.
Even as the pandemic derailed some of Gov. Gavin Newsom's biggest healthcare proposals, such as lowering prescription drug costs, it crystallized another: the pressing need to address California's rapidly aging population.
Already nine months into their work when Newsom issued the nation's first statewide stay-at-home order last March, members of a state task force on aging watched as the coronavirus disproportionately sickened and killed older people, and left many isolated in nursing homes, assisted living facilities and their own homes.
"In many ways, it just accelerated and made more urgent that work," said Kim McCoy Wade, director of California's Department of Aging, who led the task force.
The group's work culminated in the release last month of a 10-year "Master Plan for Aging," a blueprint intended to guide state and local governments, the private sector and charitable organizations to improve housing, healthcare, caregiving, equity and affordability for California's older residents.
The state's existing system of programs and services can be confusing for seniors who must navigate a disconnected patchwork of public and private offerings. If they're able to find a program that fits their needs, it's often too costly for anyone other than low-income Medi-Cal recipients, whose participation is covered by public funding.
McCoy Wade hopes the state's Master Plan website will serve as a destination for Californians looking for programs or support, much as the First 5 website is for caregivers of young children.
But right now, the site mostly lists scores of ideas, such as creating a variety of affordable housing options for Californians, improving public transit, expanding geriatric care, redesigning nursing homes to be smaller and more home-like, improving broadband access and expanding telehealth.
That broad, holistic approach to healthcare is needed to help the state's aging population, said Dr. Sarita Mohanty, president and CEO of The SCAN Foundation, which advocates for older people. (Kaiser Health News, which publishes California Healthline, receives support for its coverage of aging and long-term care issues from The SCAN Foundation.)
The number of Californians age 60 and older is projected to grow to about 11 million by 2030, accounting for one-quarter of the state's population. In 2019, that group made up roughly one-fifth of the state's population, according to U.S. Census data.
"We can't be reactive. We have to be extremely proactive," said Mohanty, an internist. "It's not just about healthcare; it's about health and communities."
But will the plan end up gathering dust on a shelf, as have so many other government reports? McCoy Wade pledged that won't happen, pointing to an online dashboard that tracks the administration's progress implementing the plan's proposals through the state budget, the legislature and in communities.
There is already momentum. The administration has pledged to embark on more than 100 initiatives in the next two years, McCoy Wade said. In his proposed 2021-22 state budget, Newsom has asked for $250 million to buy and rehabilitate assisted living facilities for homeless seniors, and his administration is working with the federal government to determine how Californians can continue to use telehealth medicine after the pandemic.
McCoy Wade talked to California Healthline about why Newsom issued an executive order to create the plan, why it is so important for Californians and some ways to move it forward. The interview has been edited for length and clarity.
Q: Why does California need a Master Plan for Aging?
The executive order was really driven by the demographic change that we're living longer, we're having multiple stages of aging, and aging is diversifying.
Are you living in a single-family home that entire 30, 40, 50 years? Are you working perhaps longer, are you volunteering longer, are you living with three, four or five generations in one house? Are you living alone because your spouse, your friends and your peers may have died? That has been one of the "aha" moments but also one of the challenges: How do you plan for aging when it is so diverse?
Q: The Master Plan offers a blueprint for the next 10 years, but what are some proposals that can be tackled in the next few years?
In this pandemic, we learned a lot. It's important that people can stay in the home they choose but also have services accessible to them. For middle-class people, Medicare doesn't pay for the services people need, so you see the governor proposing a new Office of Medicare Innovation and Integration to help more Californians.
As we age, there are a couple of things that can be really helpful: taking care of housecleaning, taking care of shopping, taking care of cooking. We can retrofit houses to prevent falls. I think there's a real recognition that we have to expand the ability for middle-class folks to afford and have access to services and supports.
Home and health go together at all ages. But as you age, in particular, and for the older adults who are not homeowners, keeping up with rent, keeping up with the house itself, really becomes a risk to health. How do we make sure there are affordable housing options?
You see the governor's budget proposal for $250 million to purchase residential living facilities and dedicate them to older adults who either are at risk of homelessness or are homeless.
Q: What are some of the long-term goals?
The big issue for all of California is affordability. The governor has unveiled strategies around more housing, more housing, more housing and a range of housing in terms of families living together, caregivers living together, and affordable housing options. Older adults could either stay in the main house or move to a smaller unit. It just creates a whole lot of opportunities for those different ages and stages.
Getting healthcare costs and housing costs and care costs — the expense side of the ledger — down is incredibly helpful. But, the income has to somehow keep up to provide basic needs and basic quality of life. The SSI/SSP program is a top priority of our stakeholders, and there is a commitment to try to start walking that back up towards the federal poverty line and to begin to increase it in 2023. There's a widespread recognition it is not keeping up with the cost of living, much less the federal poverty line.
Q: You say many older Californians have a hard time paying for the help and services they need as they age. Is it just too expensive?
"Expensive" feels like not a shocking enough word. In community forums, people cry about spending down their savings and their kids' savings and they're going bankrupt. It's not hundreds of dollars. It's in the five figures a month.
Q: How did the pandemic affect what you included in the plan?
We pivoted to check-in campaigns to call people and check in at home because we knew there were challenges around isolation or gaps in services. That check-in campaign was manual, list by list. So, one of the things we want to look at is how do we create more preregistration, more automated systems. All this calling and lists should not be a one-time thing, and, sadly, in California we need it for wildfires. Now we need it for vaccines. We may need it in an earthquake.
This pandemic had just a devastating impact on Black and Latino and South Pacific Islander communities. The catch line for the Master Plan became that equity is baked in; it's not kind of the last paragraph. So, language access has become much more essential. Our department is doing a plan on diversifying our hiring and all the commission appointments. We just really need to do better.
Marilyn Bartlett might be the closest thing health policy has to a folk hero. A certified public accountant who barely tops 5 feet, Bartlett bears zero resemblance to Paul Bunyan. But she did take an ax to Montana's hospital prices in 2016, stopping the state's employee health plan from bleeding money.
"Marilyn is not a physically imposing person," said Montana Board of Investments Executive Director Dan Villa, who worked closely with Bartlett in state government. "She is a blend of your favorite aunt, an accounting savant and a little bit of July Fourth fireworks."
Bartlett, whose faith in data borders on fervent, hauls binders full of numbers everywhere she goes. "My focus has always been following the dollars," she said. "You've got to roll up your sleeves and get down to the nitty-gritty detail, especially in healthcare."
Bartlett's success in Montana saved the state more than $30 million in three years by pegging hospital prices to a multiple of what Medicare pays. Now, she is an in-demand adviser to states, counties and businesses all trying to control healthcare costs. But as she's hit the road, binders in tow, she's found it difficult to replicate the Montana solution.
A Montana Miracle
Bartlett earned her reputation as administrator of the Montana state employee health plan, a role she assumed in 2014 as the plan hurtled toward insolvency. As Bartlett dug into the data, she discovered hospitals were charging the state as much as five times what they charge Medicare, the federal insurance program — for exactly the same services.
Historically, the state had accepted the seemingly arbitrary prices set by hospitals. Bartlett, staring down a $9 million shortfall, knew that had to change. She wanted the state to start dictating the rates they were willing to pay, but she needed a benchmark first.
She turned to Medicare. Unlike most payers, who bury prices in secret contracts, Medicare makes its payments public. Bartlett borrowed those rates and then more than doubled them — to 234% — knowing that hospitals often complain Medicare pays too little. This new kind of contract, known as reference-based pricing, was among the first attempted at this scale.
Bartlett expected the hospitals to chafe at the offer, but with Montana's plan insuring 30,000 people, more than any other employer in the state, she had the upper hand. Despite what Bartlett described as "very, very tense" negotiations, all the state's hospitals signed on.
Five years later, the state health plan regularly runs in the black. Villa, who was former Gov. Steve Bullock's budget director, said governors dip into the plan's reserves to fill budget gaps. "I now refer to the state health plan as the ATM," he said.
The Player Becomes the Coach
Montana's success became a small sensation, at least in health policy circles. Now, one big question remains — the same one that has deflated the highest hopes of so many healthcare leaders. Can it be replicated?
Many of the country's employers are desperate to find out. Their costs have risen 50% in just the past decade. Employee spending on healthcare is also on the rise, growing two times faster than wages. Leading economics researchers point to high hospital prices as a key culprit.
Since retiring from Montana state government in December 2019, Bartlett said she has spoken at numerous conferences, given hours of free advice, and answered a seemingly endless stream of calls.
One of the first calls came from Trish Riley, executive director of the National Academy for State Health Policy (NASHP). Riley hired Bartlett in 2019 to serve as "a coach, cheerleader and mentor" for officials from dozens of states trying to cut costs, including New Jersey, which passed a bill in 2020 overhauling the state's health coverage for teachers and estimated to save the state $30 million annually.
Bartlett is also advising regional business coalitions stretching from Houston to Maine and seeing early signs of progress.
In Colorado, Bartlett is coaching a group of public employers, including city, county and state health plans, that have come together to negotiate with hospitals. The group recently notched its first win, signing one hospital to a Medicare-benchmarked contract.
In Indiana, Bartlett is advising the Employers' Forum of Indiana, a coalition that recently pressured insurer Anthem to renegotiate its contract with a notoriously expensive health system.
Bartlett is even shaping legislation, including recent failed attempts in the Montana legislature to more broadly control hospital prices and in the U.S. Senate to increase transparency.
'A Hard, Hard Thing to Tackle'
Bartlett has learned over the past five years just how difficult her model is to export. "It's a hard, hard thing to tackle," she said.
Opposition from hospitals is often fierce. In Montana, the deal Bartlett negotiated has actually boosted some hospitals' bottom lines, but the Montana Hospital Association still criticizes it. MHA President Rich Rasmussen faults the contract for focusing on prices and largely neglecting issues of quality and access. "It doesn't connect all the dots," he said. Rasmussen also argued Medicare rates are an "inadequate" starting point for negotiations because they fall short of covering the full cost of care.
That opposition pales in comparison to what Bartlett has seen crisscrossing the country. "What I faced in Montana was nothing like North Carolina faced," she said, her eyes widening as she described the sheer power of the "mega systems" she encountered while advising North Carolina officials.
North Carolina's plan to pay hospitals roughly twice Medicare rates fell short in 2019 after just five hospitals agreed to the deal and several giant health systems refused to budge.
Bartlett understands that, as a result of decades of mergers, more states face hospital landscapes like North Carolina's, with its immense consolidation, than Montana's, with its more than 40 rural hospitals. And the insurance industry nationwide also is highly concentrated, leaving employers with fewer alternatives.
Saying No to Employees
For employers to have any chance at the negotiating table, Bartlett said, they must be willing to make tough calls. In practice, that might mean dropping a hospital that delivered an employee's twins or a surgeon who cured a CEO's cancer. "That's pretty damn hard," she acknowledged.
"Employers don't want to disrupt their employees' care," said Elizabeth Mitchell, CEO of Purchaser Business Group on Health, which represents Fortune 500 companies like Walmart and Microsoft. "It takes a lot of fortitude to carve a marquee-brand hospital out of a network."
A 2020 KFF survey found only 4% of employers had dropped a hospital from a network in order to cut costs. (KHN is an editorially independent program of KFF.)
Bartlett is quick to remind cold-footed employers that continuing to contract with expensive hospitals and doctors has a price, too. "You're going to disrupt members when they get less and less benefits and pay more and more," she said. High healthcare costs also eat up wage increases in the private sector and school funding in the public sector.
Will Covid-19 Be a Catalyst?
Bartlett's work has hit a crossroads during the pandemic. It is harder to criticize hospitals and their business practices as they play such a vital role. Meanwhile, employers and workers are hurting financially.
"Many large employers are facing economic pressures they frankly haven't had for a while. They're laying off tens of thousands of employees," said Mitchell. "There's a new sensitivity to costs."
Bartlett sees an opportunity and is hustling to help employers meet it. She has teamed up with researchers at Rice University on a NASHP project called the Hospital Cost Tool.
"It breaks open this black box and lets you ask where these dollars are going and why," said Riley of NASHP. The tool aims to automate the kind of forensic accounting of hospitals' finances that Bartlett had been doing on a one-off basis.
'You're Not Going to Be Liked'
There's one final test Bartlett has tried to prepare employers for — one for which numbers won't help. It's the personal toll that comes with challenging the status quo.
While working for the state health plan and before her work delivered results, Bartlett lost close friends, was cut out of meetings and even discovered her co-workers had created a Facebook group to criticize her. "You're not going to be liked. You're going to be ridiculed."
She reminds employers they have a moral and fiscal duty.
"The reality is this is hard work, and it became harder than I ever anticipated," said Bartlett. "But employers have been given this money, by the taxpayer, by the member, for these benefits. They are responsible for every penny spent. You can't turn your back on that."
In Montana, the premiums and copays state workers pay have not increased a single cent since Bartlett and colleagues renegotiated with the hospitals. Over that same time, the average premium paid by American families with employer-based insurance rose 13%.
Dan Gorenstein is the creator and host of the Tradeoffs podcast and Leslie Walker is a senior producer on the show. Their Feb. 18 episode profiles employers' efforts to purchase healthcare in new ways.
San Francisco restaurant owners, already simmering over covid-19 restrictions, are ready to boil over because of a city ban on natural gas stoves in new buildings that takes effect in June.
The ban, which also affects other gas appliances, is part of a statewide campaign aimed at reducing climate change-feeding carbon emissions as well as health hazards from indoor gas exposure. A similar ban went into effect in Berkeley in 2020; Oakland and San Jose recently passed similar measures, and other California cities are considering them.
Officials championing the bans say they’re responding to evidence that gas stoves emit dangerous levels of toxic gases such as nitrogen oxide, nitrogen dioxide and formaldehyde, which can cause heart and lung problems, aggravate asthma and contribute to early death, according to federally funded research.
Restaurant owners say it’s an outrageous, unnecessary law that will make expansions and opening in new buildings impossible. It puts salt in the wounds of businesses agonizing over covid restrictions, they add.
“If you get rid of the gas element, I don’t think restaurants can do it unless you’re like a coffee shop with a panini press,” said Matthew Dolan, executive chef and partner of restaurant 25 Lusk in San Francisco. “Whoever cooked up this idea should be reprimanded.”
Many are skeptical that properly vented stoves pose any health problems. Restaurants in California are required to have state-of-the-art ventilation systems that remove byproducts of burning natural gas and circulate fresh air, Dolan said. “The average employee isn’t really in contact with those issues,” he said.
The California Restaurant Association sued Berkeley in 2019 over its ban, arguing that it makes it impossible to prepare flame-seared meats, charred vegetables and wok-prepared dishes, putting steakhouses, ethnic restaurants and others out of business.
“You cannot cook with an electric wok,” said Vice Mayor Chin Ho Liao of San Gabriel, a Los Angeles suburb with 200 restaurants, mostly Asian. “You can cook with them, but it won’t taste good.”
Defenders of the law say it’s a long-delayed recognition of the harm of indoor pollution, which isn’t regulated by the Environmental Protection Agency, and is especially important since 87% of the typical person’s life is spent indoors.
Research shows clearly that gas stoves put out potentially dangerous levels of toxic fumes. Electric stoves also pollute, but at lower levels. While it’s difficult to prove gas stoves diminish health, studies have shown correlations between their use and higher rates of illness.
Buildings account for the second-largest percentage of San Francisco’s carbon footprint, next to transportation, and natural gas accounts for more than 75% of that. Roughly half of California homes use natural gas for cooking, according to the California Energy Commission. But health impacts are potentially a more immediate risk than climate change.
A study by UCLA’s Fielding School of Public Health in June found that in modeled scenarios where a gas stove and oven are used simultaneously for one hour, concentrations of nitrogen dioxide usually exceed the pollution levels dictated by national and California air quality standards. Gas appliances also release carbon monoxide and particulates.
“All of those have been shown to be detrimental to human health,” said Yifang Zhu, lead author of the UCLA study and a professor in the school’s department of environmental health sciences.
San Francisco Supervisor Rafael Mandelman, the sponsor of the city’s ban, said in a written release that building electrification is “a critical step in addressing the serious public health and safety hazards of natural gas, and of course the ever-intensifying climate crisis.” He also cited a report by the Rocky Mountain Institute, a clean energy think tank, which found high levels of harmful emissions in homes and businesses with gas stoves.
In November, California’s air regulation agency adopted a resolution to curtail emissions from gas appliances in buildings and said pollution could exacerbate covid-19. Climate activists are urging the California Energy Commission to include a ban on gas hookups in its next building regulations update, a move that would affect the entire state.
There’s been a similar push in Massachusetts. The nation’s oldest medical society last December became the first to recognize the health impacts of gas cooking — though it also noted that ventilation mitigates such effects.
When caring for children with asthma, health care practitioners should ask, “‘What kind of stove do you have?’” said Dr. T. Stephen Jones, a retired former Centers for Disease Control and Prevention official who co-sponsored a resolution on the matter passed by the Massachusetts Medical Society.
Society members were taken aback by the data on how gas stoves could make children sick.
“This is not really out in the general public. It’s not out among providers,” said Dr. Heather Alker, chair of the society’s environmental and occupational health committee.
Low-income people are at particularly high risk because they tend to live in smaller residences where gases can concentrate; may use kitchen appliances for supplemental heat; and cannot easily maintain or replace older equipment, especially if they rent, according to the UCLA study.
A government-funded 2014 study concluded that residents of 62% of the Southern California homes it measured were routinely exposed to nitrogen dioxide through hoodless appliances at levels that exceed health standards. A 2012 study done at the behest of the DOE found particulate matter from indoor gas burning could hurt lungs and reduce life expectancy.
As outdoor air gets cleaner, policymakers are focusing more on indoor air quality, which was “under the radar previously” and generally not regulated by state or federal governments, Zhu said.
Critics of the bans argue that electricity is more expensive than natural gas and will drive prices up, making it especially hard for low-income residents. And not all cities are on board with the move away from gas.
More than 100 California cities, including San Gabriel, have approved resolutions, with language put forward by the Southern California Gas Co., calling for “balanced energy solutions.”
In addition to the near impossibility of properly stir-frying food with electricity, Liao is worried about making residents rely solely on the state’s overworked electrical grid, which was hit with rolling blackouts last year. He is pushing for the development of clean gas derived from methane captured from rotting food, a process called anaerobic digestion. Riverside has such a project. But the approach needs more funding and development to be scalable, the vice mayor acknowledged.
The gas ban could pose an extra burden on restaurants struggling to survive covid strictures, owners and chefs say.
“This is the last thing in the world we need right now,” said Dolan. “It’s an added burden on an already burdened industry.”
But advocates for the change say people need to look at the issue a new way.
“When you actually stop and think about it as ‘This is a gas-guzzling device that’s in the middle of my house,’ it is sort of like a mind shift,” said Brady Seals, a senior associate at the Rocky Mountain Institute. “I don’t think it’s unrealistic to think that, in a generation or two, we’ll come to a place where our kids can’t ever imagine why we would want to burn a fossil fuel in our kitchen that emits some of the same pollutants that come from tailpipes.”
Even though the CDC has acknowledged the virus can spread through tiny airborne particles, it needs to take "strong immediate" action to update its guidance to reduce the risk.
This article was published on Wednesday, February 17, 2021 in Kaiser Health News.
A prominent group of academics is pressing the Biden administration to move faster and take stronger action to protect high-risk workers from airborne exposure to the coronavirus, urging enforceable standards to help safeguard risky workplaces including healthcare, food processing and prisons.
The researchers say that even though the Centers for Disease Control and Prevention has acknowledged the virus can spread through tiny airborne particles, it needs to take "strong immediate" action to update its guidance to reduce the risk.
"This is the opportunity now," said David Michaels, a professor at George Washington University and former director of the Occupational Safety and Health Administration.
Changes to help drive down the spread of the virus could include broader use of N95 masks in workplaces as well as better ventilation, according to a letter sent Monday to the CDC.
High-profile signers include Rick Bright, who was dismissed from the Trump administration after pushing for more careful attention to science; Michael Osterholm, an adviser to the Biden transition team; and Virginia Tech aerosol scientist Linsey Marr.
Current CDC guidelines reflect the initial supply chain crisis the country faced, which to a large degree has eased, the letter says. They also fail to acknowledge months of research that showed the heightened risks faced by essential workers in several industries.
The letter criticizes current guidelines that say that those outside healthcare should not get N95 masks, and that even within healthcare those masks should be reserved for workers doing "aerosol-generating" procedures like intubations.
Yet, since those guidelines were written, research has shown that deadly outbreaks have occurred in meatpacking plants and prisons, with aerosol spread believed to be at play. And within healthcare, researchers discovered that "front door" staff members like paramedics and those in emergency rooms faced the highest infection risks.
"It really bothers me that healthcare workers and essential workers who need this extra level of protection have gone this long with a crisis standard of care and without appropriate … respiratory protection," Bright said in an interview.
Even more recent research that painstakingly examined a September covid-19 outbreak in a Boston hospital with "mature" infection-control practices showed that health technicians caught the virus from a patient while wearing surgical masks and face shields — common personal protective equipment for health workers caring for covid patients. The finding spurred the authors to suggest broader use of N95s throughout hospitals.
KHN and The Guardian have been writing about hundreds of more than 3,400 healthcare workers who died of covid for the Lost on the Frontline project. Families of many workers have expressed concern about PPE in at least 100 cases, and many others were not aware of what a loved one was wearing. Worker complaints to government officials about protective gear, one story in the series found, preceded a worker's death in dozens of cases.
Jane Thomason, lead industrial hygienist for National Nurses United, who was not involved with the letter, applauded its contents and said it reflected many of the concerns of nurses the past year.
To add to the list of concerns, Thomason said the CDC guidelines fail to reflect research showing that pre-symptomatic and asymptomatic spread of the virus is common.
Current guidance to hospitals that they screen only patients with covid-like symptoms means that many with the virus slip through and are placed under the care of workers with suboptimal PPE. Thomason said solutions would include universal patient testing and providing the N95 as the minimum respiratory protection in a hospital.
"The crisis standards the CDC created essentially serve as a menu for employers to race to the bottom," she said. "I think it's appalling that these are still the same issues a year in."
The CDC did not respond Tuesday evening. CDC Director Dr. Rochelle Walensky has already announced a thorough review of the agency's guidelines, based on "the best available evidence," the letter notes.
Those guidelines will set a standard that workplace safety regulators can enforce, said Lisa Brosseau, a University of Minnesota aerosol scientist who signed the letter. She said CDC acknowledgment of the need to protect workers from inhaling the virus will give OSHA more clout to keep workers safe.
Dr. Donald Milton, a professor of environmental health at the University of Maryland School of Medicine who signed the letter, said now is the time to see how low we can drive virus levels — so we don't have to shut the nation down again if there's another pandemic.
"There needs to be a commitment to figuring it out and doing what needs to be done so we never have to do this again," he said.
Editor's note: KHN wrote about St. James Parish Hospital in April, when it was experiencing its first surge of covid-19 patients. Ten months later, we checked in to see how the hospital and its staff were faring.
The "heroes work here" sign in front of St. James Parish Hospital has been long gone, along with open intensive care unit beds in the state of Louisiana.
Staffers at the rural hospital spent hours each day in January calling larger hospitals in search of the elusive beds for covid-19 patients. They leveraged personal connections and begged nurses elsewhere to take patients they know are beyond their hospital's care level.
But as patients have waited to be transferred out of the hospital, which is about 45 minutes outside New Orleans, doctors such as Landon Roussel are forced to make unthinkable choices. As recently as Jan. 29, he had to decide between two patients: Which one should get the sole available BiPAP machine to push oxygen into their lungs?
That's like a "war situation, which is not a situation that I want to be in — in the United States," he said.
As the nation's attention shifts to the vaccine rollout, rural hospitals such as St. James Parish Hospital have struggled to handle their communities' sick following the holiday surge of covid patients.
"We knew it was coming. We saw it coming," Mary Ellen Pratt, St. James Parish Hospital's CEO, said by phone. "It really has to happen to their family for them to really go, 'OK, wow.'"
And even though the vaccines have arrived and caseloads continue to improve after the holiday surge, only about 30% of staffers have opted to get their shots. Disparities in the broader community persist: In the initial rollout, only 9% of those vaccinated were Black in a parish — the Louisiana equivalent of a county — that is nearly 49% Black.
Staff members are burned out from months of handling never-ending covid crises.
"They had been giving 150%, and they're just getting really tired," Pratt said. "It's just exhausting."
'Sometimes, Your Best Isn't Enough'
In mid-January, the closest intensive care bed the staff could find was some 600 miles away in Brownsville, Texas — so far that a plane would have been necessary to transport a patient. After three days, a closer bed was found at a Veterans Affairs hospital about 45 miles away.
Staffers have tried Mississippi and Alabama with mixed luck. One patient they tried to transfer four hours away couldn't go because the ambulance didn't have enough oxygen to make it that far. A hospital in Florida even called them looking for ICU beds at St. James Parish Hospital, which has never had any.
More than half of U.S. counties are like St. James Parish and have no intensive care beds, full or empty. Rural hospitals in those communities are designed for step-down care: They often serve as a stopping point to stabilize people before they can be sent to larger hospitals with more specialized staff and equipment.
Across the country, rural residents' mortality rate from covid has been consistently higher than that of urban residents since August, according to the Rural Policy Research Institute Center for Rural Health Policy Analysis. That has occurred even though covid incidence has been lower among rural populations than urban ones since the middle of December, said Fred Ullrich, who runs the health policy department at the University of Iowa's College of Public Health and co-authored the study.
But, he said, rural populations are typically older, sicker and poorer than urban populations. And the nation has lost at least 179 rural hospitals over the past 17 years.
"This crisis is just magnifying existing access issues in a rural context," said Alan Morgan, the head of the National Rural Health Association. "If you don't have a local hospital, that impacts the diagnosis, the initial treatment, the complex treatment. It has multiple impacts, all leading to what we're seeing: higher mortality."
And at the hospitals that remain, such as St. James Parish Hospital, the stress level is palpable, because the level of care needed for such sick patients is higher than what staffers normally handle, said Karley Babin, the hospital's acute nurse manager.
"It's just an uncomfortable spot," she said. "You know you're doing everything you can and that patient just needs more."
That's led to many sleepless nights for Pratt.
"Sometimes your best isn't enough if you don't have the right resources," she said.
'We Know All These People'
Radiology technologist Brooke Michel lives seven minutes from the hospital, where she works with her husband and five other relatives. Her grandfather, grandmother and aunt were hospitalized there in December with covid.
Her family brought folding chairs to sit outside her 83-year-old grandfather's hospital window each day, keeping vigil through the glass on Christmas Eve. He died Jan. 3 while family members stood outside, taking turns looking in and praying.
"It gave us a sense of closure," Michel said. "We were all together. We were with him. We would never have gotten that at a bigger hospital."
Seeing multiple family members hospitalized at the same time is tough on the staff, said Scott Dantonio, the hospital's pharmacy director. "We know all these people," he said.
Dozens of hospital staffers also have battled covid, and three have been hospitalized. A nurse's aide died last summer after contracting it. One staffer, who was particularly close to that aide, now has a hard time treating covid patients, said Rhonda Zeringue, chief nursing officer.
"It's a reminder: 'You took my person,'" she said.
'It's Just Exhausting'
St. James Parish Hospital has been running short-staffed, because they haven't been able to hire more nurses or pay traveling nurses — they're just too expensive. Amid the pandemic, traveling nurses can command more than double what the staff nurses make.
So Babin's kids ask often why she works all the time.
Community praise has died down, she said. People aren't thanking them in grocery stores anymore. One upside? Pratt is happy to have finally lost the "covid 19" — the weight she put on from the community bringing food to the hospital back in the spring.
Pratt and Zeringue have offered staff members counseling, massage sessions, coffee and doughnuts. But it's not enough.
Zeringue said the stress has gone through the staff in waves: First they were scared to death of being the front line in the spring. Now she sees burnout and sheer exhaustion.
The vaccines were supposed to offer hope. But when Pratt heard they would be distributed through CVS and Walgreens, she knew immediately the logistics of getting the ultra-cold Pfizer vaccine from its cooler into residents' arms would fall to them. She said the community has no chain pharmacies nearby and the local health department is overloaded.
"We get an email at, like, 4:30 on Friday which says, 'We're going to send you another 350 vaccines on Wednesday and you have to respond in the next 10 minutes,'" Pratt said. "There's not enough planning or time to do it."
Staff members, who are juggling monoclonal antibody infusions and elective surgeries to deal with the backlog from the spring on top of the surge, must also call members of the community to let them know they have the vaccine available. And then the problems begin.
"People don't answer the phone or they're not available," Dantonio said. "Or they can't come at that time or they scheduled somewhere else."
Most of the people coming in following the hospital's advertising online and on Facebook have been white. So Pratt called on the people she had relied on during the rollout of the Affordable Care Act: Black preachers and well-respected Black local leaders such as Democratic state Rep. Kendricks Brass. After word from the pulpit spread and Brass' team staffed a phone line, the vaccine distribution the next week jumped to 30% Black residents from the prior week's 9%.
Even some among the St. James Parish Hospital staff have been reluctant. Many have told Zeringue they're worried about their fertility. Others just don't want to be first. So the hospital's line of defense has many holes.
And the covid patients keep coming.
"This is a nightmare," said Kassie Roussel, the hospital's marketing director. "It's crazy because it's at the same time we marketed the beginning of the end."