Biden's Covid Challenge: 100M Vaccinations in the First 100 Days. It Won't Be Easy.

KFF Health News, January 20, 2021

Biden may run into difficulty meeting that 100 million mark.

This article was published on Wednesday, January 20, 2021 in Kaiser Health News.

By Victoria Knight

t's in the nature of presidential candidates and new presidents to promise big things. Just months after his 1961 inauguration, President John F. Kennedy vowed to send a man to the moon by the end of the decade. That pledge was kept, but many others haven't been, such as candidate Bill Clinton's promise to provide universal health care and presidential hopeful George H.W. Bush's guarantee of no new taxes.

Now, during a once-in-a-century pandemic, incoming President Joe Biden has promised to provide 100 million covid-19 vaccinations in his first 100 days in office.

"This team will help get … at least 100 million covid vaccine shots into the arms of the American people in the first 100 days," Biden said during a Dec. 8 news conference introducing key members of his health team.

When first asked about his pledge, the Biden team said the president-elect meant 50 million people would get their two-dose regimen. The incoming administration has since updated this plan, saying it will release vaccine doses as soon as they're available instead of holding back some of that supply for second doses.

Either way, Biden may run into difficulty meeting that 100 million mark.

"I think it's an attainable goal. I think it's going to be extremely challenging," said Claire Hannan, executive director of the Association of Immunization Managers.

While a pace of 1 million doses a day is "somewhat of an increase over what we're already doing," a much higher rate of vaccinations will be necessary to stem the pandemic, said Larry Levitt, executive vice president for health policy at KFF. (KHN is an editorially independent program of KFF.) "The Biden administration has plans to rationalize vaccine distribution, but increasing the supply quickly" could be a difficult task. 

Under the Trump administration, vaccine deployment has been much slower than Biden's plan. The rollout began more than a month ago, on Dec. 14. Since then, 12 million shots have been given and 31 million doses have been shipped out, according to the Centers for Disease Control and Prevention's vaccine tracker.

This sluggishness has been attributed to a lack of communication between the federal government and state and local health departments, not enough funding for large-scale vaccination efforts, and confusing federal guidance on distribution of the vaccines.

The same problems could plague the Biden administration, said experts.

States still aren't sure how much vaccine they'll get and whether there will be a sufficient supply, said Dr. Marcus Plescia, chief medical officer for the Association of State and Territorial Health Officials, which represents state public health agencies.

"We have been given little information about the amount of vaccine the states will receive in the near future and are of the impression that there may not be 1 million doses available per day in the first 100 days of the Biden administration," said Plescia. "Or at least not in the early stages of the 100 days."

Another challenge has been a lack of funding. Public health departments have had to start vaccination campaigns while also operating testing centers and conducting contact tracing efforts with budgets that have been critically underfunded for years.

"States have to pay for creating the systems, identifying the personnel, training, staffing, tracking people, information campaigns — all the things that go into getting a shot in someone's arm," said Jennifer Kates, director of global health & HIV policy at KFF. "They're having to create an unprecedented mass vaccination program on a shaky foundation."

The latest covid stimulus bill, signed into law in December, allocates almost $9 billion in funding to the CDC for vaccination efforts. About $4.5 billion is supposed to go to states, territories and tribal organizations, and $3 billion of that is slated to arrive soon.

But it's not clear that level of funding can sustain mass vaccination campaigns as more groups become eligible for the vaccine.

Biden released a $1.9 trillion plan last week to address covid and the struggling economy. It includes $160 billion to create national vaccination and testing programs, but also earmarks funds for $1,400 stimulus payments to individuals, state and local government aid, extension of unemployment insurance, and financial assistance for schools to reopen safely.

Though it took Congress almost eight months to pass the last covid relief bill after Republican objections to the cost, Biden seems optimistic he'll get some Republicans on board for his plan. But it's not yet clear that will work.

There's also the question of whether outgoing President Donald Trump's impeachment trial will get in the way of Biden's legislative priorities.

In addition, states have complained about a lack of guidance and confusing instructions on which groups should be given priority status for vaccination, an issue the Biden administration will need to address.

On Dec. 3, the CDC recommended health care personnel, residents of long-term care facilities, those 75 and older, and front-line essential workers should be immunized first. But on Jan. 12, the CDC shifted course and recommended that everyone over age 65 should be immunized. In a speech Biden gave last week detailing his vaccination plan, he said he would stick to the CDC's recommendation to prioritize those over 65.

Outgoing Health and Human Services Secretary Alex Azar also said Jan. 12 that states that moved their vaccine supply fastest would be prioritized in getting more shipments. It's not known yet whether the Biden administration's CDC will stick to this guidance. Critics have said it could make vaccine distribution less equitable.

In general, taking over with a strong vision and clear communication will be key to ramping up vaccine distribution, said Hannan.

"Everyone needs to understand what the goal is and how it's going to work," she said.

A challenge for Biden will be tamping expectations that the vaccine is all that is needed to end the pandemic. Across the country, covid cases are higher than ever, and in many locations officials cannot control the spread.

Public health experts said Biden must amp up efforts to increase testing across the country, as he has suggested he will do by promising to establish a national pandemic testing board.

With so much focus on vaccine distribution, it's important that this part of the equation not be lost. Right now, "it's completely all over the map," said KFF's Kates, adding that the federal government will need a "good sense" of who is and is not being tested in different areas in order to "fix" public health capacity.

Today marks the launch of The Biden Promise Tracker, which monitors the 100 most important campaign promises of President Joseph R. Biden. Biden listed the coronavirus and a variety of other health-related issues among his top priorities. You can see the entire list – including improving the economy, responding to calls for racial justice and combating climate change – here. As part of KHN's partnership with PolitiFact, we will follow the health-related issues and then rate them on whether the promise was achieved: Promise Kept, Promise Broken, Compromise, Stalled, In the Works or Not Yet Rated. We rate the promise not on the president's intentions or effort, but on verifiable outcomes. PolitiFact previously tracked the promises of President Donald Trump and President Barack Obama. 

Victoria Knight: vknight@kff.org, @victoriaregisk

On Trump's Last Full Day, Nation Records 400,000 Covid Deaths

KFF Health News, January 20, 2021

Given its large population, the U.S. death rate from covid remains lower than the rate in many other countries.

This article was published on Tuesday, January 19, 2021 in Kaiser Health News.

By Will Stone

While millions wait for a lifesaving shot, the U.S. death count from covid-19 continues to soar upward with horrifying speed. On Tuesday, the last full day of Donald Trump’s presidency, the death toll reached 400,000 — a once-unthinkable number. More than 100,000 Americans have perished in the pandemic in just the past five weeks.

In the U.S., someone now dies of covid every 26 seconds. And the disease is claiming more American lives each week than any other condition, ahead of heart disease and cancer, according to the Institute for Health Metrics and Evaluation at the University of Washington.

“It didn’t have to be like this, and it shouldn’t still be like this,” said Kristin Urquiza, whose father, Mark, died of covid in June, as the virus was sweeping through Phoenix.

Urquiza described it as “watching a slow-moving hurricane” tear apart her childhood neighborhood, where many people have no choice but to keep going to work and risking their health.

“I talk to dozens of strangers a day who are going through what I did in June, but the magnitude and the haunting similarities between our stories six months later is really hard,” said Urquiza, who addressed the Democratic National Convention in August. She co-founded Marked By COVID, to organize grieving families and supporters. The group calls for a faster government response and a national memorial for pandemic victims.

Given its large population, the U.S. death rate from covid remains lower than the rate in many other countries. But the death toll of 400,000 now exceeds any other country’s count — close to double what Brazil has recorded, and four times the toll in the United Kingdom.

“It’s very hard to wrap your mind around a number that is so large, particularly when we’ve had 10 months of large numbers assaulting our senses and really, really horrific images coming out of our hospitals and our morgues,” said Dr. Kirsten Bibbins-Domingo, chair of epidemiology at the University of California-San Francisco.

Scientists had long expected that wintertime could plunge the country into the deadliest months yet, but even Bibbins-Domingo wasn’t ready for the sheer pace of deaths, or the scale of the accumulated losses. The mortality burden has fallen heavily on her own state of California, which was averaging fewer than 100 deaths a day for long stretches of the pandemic, but has ranged up to more than 500 in recent days.

She said California followed the science with its handling of the pandemic, yet the devastation unfolding in places like Los Angeles reveals just how fragile any community can be.

“It’s important to understand virology. It’s important to understand epidemiology. But ultimately, what we’ve learned is that human behavior and psychology is a major force in this pandemic,” she said.

The U.S. in mid-January has averaged more than 3,300 deaths a day — well above the most devastating days of the early spring surge, when daily average deaths hovered around 2,000.

“At this point, looking at the numbers, for me the question is: Is there any way we can avoid half a million deaths before the end of February?” said Dr. Ashish Jha, dean of the Brown University School of Public Health.

“I think of how much suffering as a nation we seem to be willing to accept that we have this number of people getting infected and dying every day.”

How Did U.S. Go From 300,000 Deaths to 400,000?

The path to 400,000 deaths was painfully familiar, with patterns of sickness and death repeating themselves from earlier in the pandemic.

A shocking number of people in nursing homes and assisted living facilities continue to die each week — more than 6,000 in the first week of January.

Deaths linked to long-term care account for more than a third of all covid deaths in the U.S. since the beginning of the pandemic. In a handful of states, long-term care contributed to half the total deaths.

Certain parts of the country have a disproportionately high death rate. Alabama and Arizona, in particular, have experienced high rates, given their populations. The virus continues to kill Black and Indigenous Americans at much higher rates than whites.

The chance of dying of covid remains much higher in rural America than in the urban centers.

People over 65 make up the overwhelming majority of deaths, but Jha said more young people are dying than earlier in the pandemic, simply because the virus is so widespread.

In this newest and grimmest chapter of the pandemic, the virus has preyed upon a public weary of restrictions and rules, and eager to mix with family and friends over the holiday season.

Like many other health workers, Dr. Panagis Galiatsatos at Johns Hopkins Hospital is now witnessing the tragic consequences in his daily rounds.

“My heart breaks, because we could have prevented this,” said Galiatsatos, an assistant professor of medicine who cares for covid patients in the intensive care unit.

“A lot of what we saw during the holiday travel was the inability to reach our loved ones or family members — not like a public service announcement, but one on one, talking to them [about the exposure risks]. … I really felt like we failed.”

Galiatsatos still recalls a grandmother who was transported six hours from her home to his hospital — because there were no beds anywhere closer. On the phone, he heard her family’s shock at her sudden passing.

“They said, ‘But she was so healthy. She cooked us all Thanksgiving dinner and we had all the family over,’” he said. “They were saying it with sincerity, but that’s probably where she got it.”

Light at the End of a Very Long Tunnel

The enormous loss of life this winter has happened, paradoxically, at a time that many hope marks the start of the final chapter of the pandemic.

A quarter of all covid deaths have happened during the five weeks since the Food and Drug Administration authorized the first vaccine.

“The trickle of vaccine is so tragically scant. What we need is more of a river of it,” said Dr. Howard Markel, who directs the University of Michigan’s Center for the History of Medicine.

Markel, who has written about the 1918-19 flu pandemic, said it’s estimated it killed upward of 700,000 Americans.

Of the covid pandemic, he said, “I hope we’re not talking … 600,000 or more.”

At this point, about 3 in 100 people have been vaccinated, placing America ahead of many other countries but behind the optimistic promises made in the early days of the rollout. Given the current pace of vaccination, experts warn, Americans cannot depend solely on the vaccine to prevent a crushing number of additional deaths in the coming months.

UCSF’s Bibbins-Domingo worries that the relief of knowing a vaccine will eventually be widely available — the light at the end of the tunnel — may actually lull millions more Americans into a false sense of safety.

“This tunnel is actually a very long tunnel, and the next few months, as the last few months have been, are going to be very dark times,” she said.

The emergence of more contagious variants of SARS-CoV-2, the covid virus, complicates the picture and makes it all the more imperative that Americans spend the coming months doubling down on the very same tactics — masks and physical distancing — that have kept many people safe so far.

But Jha, of Brown University, says the country now faces a different task from that of the fall, when “big behavioral changes and large economic costs” were required to prevent deaths.

“Right now what is required is getting people vaccinated with vaccines we already have,” he said. “The fact that’s going super slow still is incredibly frustrating.”

It is this dichotomy — the advent of lifesaving vaccines as hospitals are filled with more dying patients than ever before — that makes this moment in the pandemic so confounding.

“I can’t help but feel this immense somberness,” said Kristin Urquiza. “I know that a vaccine isn’t going to make a difference for the people that are in the hospital right now or who will be in the hospital next week or even next month.”

This story is from a reporting partnership with NPR.

Are Public Health Ads Worth the Price? Not if They're All About Fear

KFF Health News, January 19, 2021

Marketing experts say public health advertising often falls short because it incites people's worst fears rather than providing clear steps viewers can take to save lives.

This article was published on Tuesday, January 19, 2021 in Kaiser Health News.

By Eric Berger

ST. LOUIS — The public service announcement showed a mother finding her teenage son lifeless, juxtaposed with the sound of a ukulele and a woman singing, "That's how, how you OD'd on heroin."

It aired locally during the 2015 Super Bowl but attracted national attention and has been viewed more than 500,000 times on YouTube.

"You want to tap into a nerve, an emotional nerve, and controversy and anger," said Mark Schupp, whose consulting firm created the ad pro bono. "The spot was designed to do that, so we were happy with it."

But like other ads and PSAs seeking to move the needle on public health, it went only so far.

Marketing experts say public health advertising often falls short because it incites people's worst fears rather than providing clear steps viewers can take to save lives. They say lessons from opioid messaging can inform campaigns seeking to influence behavior that could help curb the coronavirus pandemic, such as wearing masks, not gathering in big groups and getting a covid-19 vaccine.

The Super Bowl ad was produced and aired by the St. Louis chapter of the National Council on Alcohol and Drug Abuse using $100,000 from an anonymous donor. Then-director Howard Weissman said a top priority for his group was for Missouri to start a prescription drug monitoring program.

Five years later, Missouri remains the only state without a statewide program. And the number of opioid deaths has steadily increased in that time, state data shows, up from 672 in all of 2015 to 716 deaths in just the first six months of 2020.

The national council, now called PreventEd, is one of many nonprofits and government agencies that invest millions in messaging aimed at curbing the opioid epidemic. People who study such advertisements said it's difficult to measure their impact, but if the metric is the number of overdose deaths, they have not yet succeeded. The country set a record for overdose deaths in 2019 that it was on pace to break in 2020.

"You have to give them a solution, especially in a health context, like with opioids, because similar to with cigarette smoking, if you increase fear and don't give a solution, they are just going to abuse more because that's their coping mechanism," said Punam Anand Keller, a Dartmouth College professor who studies health marketing.

To address public health issues, marketers often use images of diseased lungs to discourage smokers or the bloody aftermath of car crashes to prevent drunken driving. But these can provoke "defensive responses" that may be avoided by giving people ways to take action, said a 2014 International Journal of Psychology review of campaigns that use fear to persuade people.

Missouri's state health and mental health departments, with the help of federal funds, spent at least $800,000 on advertising in 2019 to curb the opioid epidemic through their Time 2 Act and NoMODeaths campaigns, according to data from advertising agencies and partner organizations.

Mac Curran, a 34-year-old social media influencer, described his struggles with opioid addiction in a number of videos for Time 2 Act, one of which was viewed more than 100,000 times on Facebook. In another recent video, Curran used storytelling to highlight the benefits of getting treatment for his addiction. He talked about strangers cheering for him when he returned to a friend's streetwear store after getting out of the recovery program, and discussed how he learned coping skills he could use throughout life.

Jay Winsten, a Harvard University scientist who spearheaded the U.S. designated-driver campaign to combat drunken driving, described Curran's videos as "really excellent because he comes across as genuine and well spoken. People remember stories more than they do someone simply lecturing at them."

Still, Winsten emphasized the importance of including actionable steps and would like to see Missouri and other groups focus on teaching friends of users "how to intervene and what language to use and not to use."

Others, including the libertarian Cato Institute, argue that PSAs on drug use just don't work and point to the history of failed campaigns to discourage teen marijuana use.

Yet agencies keep trying. Missouri's mental health department and the Missouri Institute of Mental Health at the University of Missouri-St. Louis convened focus groups in 2019 with drug users and their families and captured their words on billboards for the NoMODeaths campaign. One said, "Don't give up on treatment. It's worth the work," and gave a number to text for help with heroin, fentanyl or pill misuse.

In addition to giving information, the goal was "to let people who use drugs know that other people care if they live or die," said Rachel Winograd, a psychologist who leads the NoMODeaths group aimed at reducing harm from opioid misuse.

She said she understands the argument that PSAs are a waste of money, given that organizations like hers have limited funds and also try to provide housing for those in recovery and naloxone, used to revive people after overdoses.

But, Winograd said, some of the advertisements appeared to work. The organization saw a big increase after the ads ran in the number of people who visited its website or texted a number for information on treatment or obtaining naloxone.

Although federal funding rose for fiscal years 2021 and 2022, Winograd's team and state officials decided to cut NoMODeaths' advertising budget in half and instead spend the money on direct services like naloxone, treatment and housing.

Now health agencies are consumed by the coronavirus pandemic and are trying to craft messages that cut through politically charged discourse and get the public to adopt safety measures such as wearing masks, staying physically distanced and getting vaccinated.

Convincing people to wear masks has been difficult because messages have been mixed. Missouri's health department has tried to depoliticize mask-wearing and get people to view it as a public health solution, said spokesperson Lisa Cox.

But Missouri Gov. Mike Parson has appeared without a mask at public events and has declined to enact a statewide mask mandate. He also said at a Missouri Cattlemen's Association event in July, "If you want to wear a dang mask, wear a mask."

Cox would not comment on whether Parson's approach undermined the state's public health efforts, but Keller said it did.

Missouri's messaging about vaccines has been much more straightforward and clear. A website provides facts and answers to common questions as it encourages people to "make an informed choice" on whether to get the shots.

Keller praised the "unemotional, not-fear-arousing" approach to the vaccine messaging issued so far.

"It needs the right messengers: well-known individuals who have high credibility within specific population groups that currently are hesitant about taking the vaccine," Winsten said.

This time, Parson has been one of those messengers. When he announced the launch of the vaccine website in November, he said in a news release: "Safety is not being sacrificed, and it's important for Missourians to understand this."

In spite of the politicization of the virus crisis, Winsten, who serves on the board of advisers of the Ad Council's $50 million covid vaccine campaign, has "guarded optimism" that enough people will get vaccinated to curb the pandemic.

And he remains hopeful that PSAs could eventually help reduce the number of people who die from opioids.

"Look at the whole anti-smoking movement. That took over two decades," he said. "These are tough problems. Otherwise, they would be solved already."

'An Arm and a Leg': Host Dan Weissmann Talks Price Transparency on 'Axios Today'

KFF Health News, January 19, 2021

A new federal rule requires hospitals to make public the prices they negotiate with insurers.

This article was published on Tuesday, January 19, 2021 in Kaiser Health News.

By Dan Weissmann

Can't see the audio player? Click here to listen.

About This Podcast

Health care — and how much it costs — is scary. But you're not alone with this stuff, and knowledge is power. "An Arm and a Leg" is a podcast about these issues, and its second season is co-produced by KHN.

Visit armandalegshow.com

As we settle into the new year, we have two small doses of good news.

First, a new federal rule could help cut through one health care issue. Host Dan Weissmann talked about the rule — which requires hospitals to make public the prices they negotiate with insurers — in a short conversation with his former public-radio colleague, Niala Boodhoo, for the daily-news podcast "Axios Today."

You'll find more detail on that rule in this story from reporter Celia Llopis-Jepsen, whose reporting about a $50,000 "air ambulance" ride formed the core of a recent episode about how consumers get squeezed by insurers on one side and providers on the other.

Later in the episode, a listener describes how he used what he learned from "An Arm and a Leg" to head off an insurance nightmare.

Here's a transcript for this episode.

"An Arm and a Leg" is a co-production of Kaiser Health News and Public Road Productions.

To keep in touch with "An Arm and a Leg," subscribe to the newsletter. You can also follow the show on Facebook and Twitter. And if you've got stories to tell about the health care system, the producers would love to hear from you.

To hear all Kaiser Health News podcasts, click here.

And subscribe to "An Arm and a Leg" on iTunes, Pocket Casts, Google Play or Spotify.

Black Americans Are Getting Vaccinated at Lower Rates Than White Americans

KFF Health News, January 17, 2021

The vast majority of the initial round of vaccines has gone to health care workers and staffers on the front lines of the pandemic — a workforce that's typically racially diverse made up of physicians, hospital cafeteria workers, nurses and janitorial staffers.

This article was published on Sunday, January 17, 2021 in Kaiser Health News.

By Hannah Recht and Lauren Weber

Black Americans are receiving covid vaccinations at dramatically lower rates than white Americans in the first weeks of the chaotic rollout, according to a new KHN analysis.

About 3% of Americans have received at least one dose of a coronavirus vaccine so far. But in 16 states that have released data by race, white residents are being vaccinated at significantly higher rates than Black residents, according to the analysis — in many cases two to three times higher.

In the most dramatic case, 1.2% of white Pennsylvanians had been vaccinated as of Jan. 14, compared with 0.3% of Black Pennsylvanians.

The vast majority of the initial round of vaccines has gone to health care workers and staffers on the front lines of the pandemic — a workforce that’s typically racially diverse made up of physicians, hospital cafeteria workers, nurses and janitorial staffers.

If the rollout were reaching people of all races equally, the shares of people vaccinated whose race is known should loosely align with the demographics of health care workers. But in every state, Black Americans were significantly underrepresented among people vaccinated so far.

Access issues and mistrust rooted in structural racism appear to be the major factors leaving Black health care workers behind in the quest to vaccinate the nation. The unbalanced uptake among what might seem like a relatively easy-to-vaccinate workforce doesn’t bode well for the rest of the country’s dispersed population.

Black, Hispanic and Native Americans are dying from covid at nearly three times the rate of white Americans, according to a Centers for Disease Control and Prevention analysis. And non-Hispanic Black and Asian health care workers are more likely to contract covid and to die from it than white workers. (Hispanics can be of any race.)

“My concern now is if we don’t vaccinate the population that’s highest-risk, we’re going to see even more disproportional deaths in Black and brown communities,” said Dr. Fola May, a UCLA physician and health equity researcher. “It breaks my heart.”

Dr. Taison Bell, a University of Virginia Health System physician who serves on its vaccination distribution committee, stressed that the hesitancy among some Blacks about getting vaccinated is not monolithic. Nurses he spoke with were concerned it could damage their fertility, while a Black co-worker asked him about the safety of the Moderna vaccine since it was the company’s first such product on the market. Some floated conspiracy theories, while other Black co-workers just wanted to talk to someone they trust like Bell, who is also Black.

Dose 2 is in! Just some mild arm soreness that will probably be worse tomorrow. I’ll check in tomorrow to give an update. h/t: @gradydoctor for the T-shirt idea#RightToBareArms 💪🏾 💉 #ShotOfHope#BlackMenInMedicine pic.twitter.com/56jAu0V5zy

— Dr. Taison Bell (@TaisonBell) January 5, 2021

But access issues persist, even in hospital systems. Bell was horrified to discover that members of environmental services — the janitorial staff — did not have access to hospital email. The vaccine registration information sent out to the hospital staff was not reaching them.

“That’s what structural racism looks like,” said Dr. Georges Benjamin, executive director of the American Public Health Association. “Those groups were seen and not heard — nobody thought about it.”

UVA Health spokesperson Eric Swenson said some of the janitorial crew were among the first to get vaccines and officials took additional steps to reach those not typically on email. He said more than 50% of the environmental services team has been vaccinated so far.

A Failure of Federal Response

As the public health commissioner of Columbus, Ohio, and a Black physician, Dr. Mysheika Roberts has a test for any new doctor she sees for care: She makes a point of not telling them she’s a physician. Then she sees if she’s talked down to or treated with dignity.

That’s the level of mistrust she says public health officials must overcome to vaccinate Black Americans — one that’s rooted in generations of mistreatment and the legacy of the infamous Tuskegee syphilis study and Henrietta Lacks’ experience.

A high-profile Black religious group, the Nation of Islam, for example, is urging its members via its website not to get vaccinated because of what Minister Louis Farrakhan calls the “treacherous history of experimentation.” The group, classified as a hate group by the Southern Poverty Law Center, is well known for spreading conspiracy theories.

Public health messaging has been slow to stop the spread of misinformation about the vaccine on social media. The choice of name for the vaccine development, “Operation Warp Speed,” didn’t help; it left many feeling this was all done too fast.

Benjamin noted that while the nonprofit Ad Council has raised over $37 million for a marketing blitz to encourage Americans to get vaccinated, a government ad campaign from the Health and Human Services Department never materialized after being decried as too political during an election year.

“We were late to start the planning process,” Benjamin said. “We should have started this in April and May.”

And experts are clear: It shouldn’t merely be ads of famous athletes or celebrities getting the shots.

“We have to dig deep, go the old-fashioned way with flyers, with neighbors talking to neighbors, with pastors talking to their church members,” Roberts said.

Speed vs. Equity

Mississippi state Health Officer Dr. Thomas Dobbs said that the shift announced Tuesday by the Trump administration to reward states that distribute vaccines quickly with more shots makes the rollout a “Darwinian process.”

Dobbs worries Black populations who may need more time for outreach will be left behind. Only 18% of those vaccinated in Mississippi so far are Black, in a state that’s 38% Black.

It might be faster to administer 100 vaccinations in a drive-thru location than in a rural clinic, but that doesn’t ensure equitable access, Dobbs said.

“Those with time, computer systems and transportation are going to get vaccines more than other folks — that’s just the reality of it,” Dobbs said.

In Washington, D.C, a digital divide is already evident, said Dr. Jessica Boyd, the chief medical officer of Unity Health Care, which runs several community health centers. After the city opened vaccine appointments to those 65 and older, slots were gone in a day. And Boyd’s staffers couldn’t get eligible patients into the system that fast. Most of those patients don’t have easy access to the internet or need technical assistance.

“If we’re going to solve the issues of inequity, we need to think differently,” Boyd said.

Dr. Marcus Plescia, chief medical officer at the Association of State and Territorial Health Officials, said the limited supply of vaccine must also be considered.

“We are missing the boat on equity,” he said. “If we don’t step back and address that, it’s going to get worse.”

While Plescia is heartened by President-elect Joe Biden’s vow to administer 100 million doses in 100 days, he worries the Biden administration could fall into the same trap.

And the lack of public data makes it difficult to spot such racial inequities in real time. Fifteen states provided race data publicly, Missouri did so upon request, and eight other states declined or did not respond. Several do not report vaccination numbers separately for Native Americans and other groups, and some are missing race data for many of those vaccinated. The CDC plans to add race and ethnicity data to its public dashboard, but CDC spokesperson Kristen Nordlund said it could not give a timeline for when.

Historical Hesitation

One-third of Black adults in the U.S. said they don’t plan to get vaccinated, citing the newness of the vaccine and fears about safety as the top deterrents, according to a December poll from KFF. (KHN is an editorially independent program of KFF.) Half of them said they were concerned about getting covid from the vaccine itself, which is not possible.

Experts say this kind of misinformation is a growing problem. Inaccurate conspiracy theories that the vaccines contain government tracking chips have gained ground on social media.

Just over half of Black Americans who plan to get the vaccine said they’d wait to see how well it’s working in others before getting it themselves, compared with 36% of white Americans. That hesitation can even be found in the health care workforce.

“We shouldn’t make the assumption that just because someone works in health care that they somehow will have better information or better understanding,” Bell said.

In Colorado, Black workers at Centura Health were 44% less likely to get the vaccine than their white counterparts. Latino workers were 22% less likely. The hospital system of more than 21,000 workers is developing messaging campaigns to reduce the gap.

“To reach the people we really want to reach, we have to do things in a different way, we can’t just offer the vaccine,” said Dr. Ozzie Grenardo, a senior vice president and chief diversity and inclusion officer at Centura. “We have to go deeper and provide more depth to the resources and who is delivering the message.”

That takes time and personal connections. It takes people of all ethnicities within those communities, like Willy Nuyens.

Nuyens, who identifies as Hispanic, has worked for Kaiser Permanente Los Angeles Medical Center for 33 years. Working on the environmental services staff, he’s now cleaning covid patients’ rooms. (KHN is not affiliated with Kaiser Permanente.)

In Los Angeles County, 92% of health care workers and first responders who have died of covid were nonwhite. Nuyens has seen too many of his co-workers lose family to the disease. He jumped at the chance to get the vaccine but was surprised to hear only 20% of his 315-person department was doing the same.

So he went to work persuading his co-workers, reassuring them that the vaccine would protect them and their families, not kill them.

“I take two employees, encourage them and ask them to encourage another two each,” he said.

So far, uptake in his department has more than doubled to 45%. He hopes it will be over 70% soon.

When COVID Deaths Aren't Counted, Families Pay the Price

KFF Health News, January 17, 2021

When Gwendolyn Davis received her husband's death certificate, she was taken aback. The causes of death? Sepsis and renal failure. No mention of covid-19.

This article was published on Friday, January 15, 2021 in Kaiser Health News.

By Melissa Bailey and Eli Cahan

On Sundays, Bishop Bruce Davis preached love. Through his Pentecostal ministry, he organized youth parades and gave computers, bicycles and food to families in need.

During the week, Bruce practiced what he preached, caring for prisoners at a Georgia hospital. On March 27 he began coughing, and on April 1 he was hospitalized. He’d tested positive for covid-19. The virus swept through his household, infecting his wife and daughter and hospitalizing their disabled son. Ten days after landing in the hospital, Bruce died.

But when Gwendolyn Davis received her husband’s death certificate, she was taken aback. The causes of death? Sepsis and renal failure. No mention of covid-19.

“He wouldn’t have had kidney failure if he didn’t have covid,” Gwendolyn said.

After Bruce died, his wife applied to two pandemic relief programs seeking help with $1,500 in missed payments on a truck and an electricity bill. But, she said, she was denied because his death certificate didn’t mention covid-19.

“I think it’s wrong,” Gwendolyn said. “It’s almost like we didn’t count.”

The count has profound implications for families and the country. Omitting covid-19 on death certificates threatens to undercount the toll of the pandemic nationwide. For Davis’ family and others, it can pile financial hardship onto emotional despair, as death benefits and other covid-19 relief programs are withheld. Interviews with families across the U.S. shed light on reasons covid deaths are being undercounted — and the consequences loved ones have endured.

When covid patients die, the “immediate” cause of death is always something else, such as respiratory failure or cardiac arrest. Residents, doctors, medical examiners and coroners make the call on whether covid was an underlying factor, or “contributory cause.” If so, the diagnosis should be included on the death certificate, according to the Centers for Disease Control and Prevention.

Even beyond the pandemic, there is wide variation in how certifiers describe causes of death: “There’s just no such thing as an objective measure of cause of death,” said Lee Anne Flagg, a statistician at the CDC’s National Center for Health Statistics.

Partly because of a lack of training in how to fill them out, “the quality of the death certificates is not good,” said Dr. James Gill, vice president of the National Association of Medical Examiners. And in cases in which people had other chronic conditions, it can be difficult to determine whether covid was a contributing cause of death, he said. That was especially true early on, when reliable testing was not widely available.

Since early in the pandemic, the CDC has encouraged certifiers who suspect covid as a cause of death to list it on the death certificate as “probable” or “likely.”

Still, some clinicians are “reluctant to certify a death as a covid death without a test in hand,” Gill said.

It’s not clear how Bruce Davis’ case slipped under the radar. His death was certified by William Ken Garland, deputy coroner in Baldwin County. Reached by phone, Garland said the causes of death were provided by Dr. Joseph Coppiano, a medical resident who pronounced Davis dead at Augusta University Medical Center, about 90 miles away. No autopsy was done.

“I did certify the record, but that’s about all I did,” Garland said.

Hospital spokesperson Danielle Harris declined to comment on the case, citing patient privacy. She said the hospital follows Georgia Department of Public Health guidelines.

In the absence of certainty, the CDC has encouraged coroners to document the virus. “We’re not worried that we’re overcounting the number of [covid-19] deaths,” Farida Ahmad, epidemiologist and mortality surveillance team leader at NCHS, said in April.

Missed cases are one reason that experts agree covid deaths are being undercounted nationwide. As evidence for that, they point to the vast number of excess deaths — additional deaths compared to what would be expected based on prior-year numbers and demographic trends.

Over the past year, the U.S. had endured up to 431,792 excess deaths as of Jan. 6, with 68% directly attributed to covid, according to the CDC.

These excess deaths “tend to track pretty closely with covid cases, trailing by a couple of weeks,” said Daniel Weinberger, an epidemiologist at Yale School of Public Health who has published on this topic. “This strongly suggests that a large proportion of these uncounted deaths are due to covid but not recorded as such.”

We may never know how many covid deaths went uncounted: Postmortem tests can detect the virus, but it’s “unlikely that this type of testing will be performed at a [sufficient] scale,” Weinberger said. Early in the pandemic, especially in the Northeast, many of those who were treated clinically for covid and then died were not tested for the virus — so they never made it into the statistics.

Testing Troubles Affect Lawsuits, Hospital Bills

Inaccurate death certificates can make it harder to pursue a lawsuit or win a workers’ compensation case when a loved one dies after contracting covid on the job. Gwendolyn Davis did win workers’ compensation death benefits from Bruce’s employer, a state psychiatric facility in Milledgeville, by providing medical records. But problems with covid testing can complicate the process.

Bruce’s supervisor at work, Mark DeLong, also died after contracting covid, but it did not appear on his death certificate with the other causes: cardiopulmonary arrest, respiratory failure and diabetes.

The omission on DeLong’s certificate seemed to stem from a delay in test results: His covid-positive results didn’t arrive until three days after he died, according to his widow, Jan DeLong. She has asked the local coroner to correct the record.

In New Jersey, attorney Paul da Costa represents 75 family members who lost loved ones at veterans homes in Menlo Park and Paramus in April and May. He said he knows of at least five patients whose death certificates did not list covid-19 despite evidence suggesting it killed them.

The root problem, he said, was a “complete dearth of testing.” Patients were transferred to hospitals, or dying in the veterans facilities, without ever being tested, he said.

The gap between excess deaths and confirmed covid deaths has “narrowed over time as testing has increased,” Weinberger said.

Early testing inaccuracy may also have led to undercounting, which creates a different burden: hospital bills. Without a diagnosis, families can be on the hook for thousands of dollars in charges that otherwise would have been covered under the CARES Act.

Correcting the Record

In some cases, families have sought to have death certificates changed to reflect covid. Dorothy Payton, 95, who lived in the ManorCare nursing home in Denver, first showed covid symptoms April 5. Five days later, Payton — known as “Nana Dee” — tested positive for it. And on April 13, her husband, Edward Benjamin, received a call that she had died.

The death certificate offered a litany of causes: vascular dementia, atrial fibrillation, congestive heart failure, gait instability, difficulty swallowing and “failure to thrive.”

But not covid-19. So it “seemed logical to fight for listing her cause of death under her cause of death,” Benjamin said.

After a few calls, her husband was able to get the certificate amended. ManorCare could not be reached for comment.

For Benjamin, it wasn’t about public health statistics or financial considerations. It simply offers a sense of closure.

“I want her life and death remembered the way it was, and I’m glad we set the record straight,” he said. “It’s the first step towards moving on.”

This story is part of “Lost on the Frontline,” an ongoing project from The Guardian and Kaiser Health News that aims to document the lives of health care workers in the U.S. who die from COVID-19, and to investigate why so many are victims of the disease. If you have a colleague or loved one we should include, please share their story.

Biden Terms Vaccine Rollout 'A Dismal Failure' as He Unveils Pandemic Response Plan

KFF Health News, January 16, 2021

On his first day in office, he said, he will instruct the Federal Emergency Management Agency to start setting up mass vaccination centers across the country. 

This article was published on Friday, January 15, 2021 in Kaiser Health News.

By Victoria Knight

In the past 24 hours, President-elect Joe Biden has delivered two speeches focused on the nation’s covid response.

Thursday night, he laid out a $1.9 trillion-dollar plan to address what he’s calling the “twin crises” of the covid-19 pandemic and the economy.

Biden proposed, among other things, that Congress allocate funds for implementing a national vaccination program, reopening schools, sending $1,400 checks to Americans who need them, providing support for small businesses and extending unemployment insurance. He also proposed increasing subsidies for Affordable Care Act insurance coverage, and providing more assistance for housing, nutrition and child care.

The plan is ambitious and will likely face some pushback in Congress. (Read PolitiFact’s analysis here.)

Friday afternoon he offered a more detailed take on his vaccine distribution plan.

On his first day in office, he said, he will instruct the Federal Emergency Management Agency to start setting up mass vaccination centers across the country. Biden promised to have 100 of these sites set up by the end of his first month in office.

He also said his administration will work with pharmacies across the country to distribute vaccine more effectively and employ the Defense Production Act to ensure adequate vaccine supplies. His administration will also launch a public education campaign to address vaccine hesitancy and ensure that marginalized communities will be reached.

Biden maintained during the speech that he intends to reach the goal of “100 million shots the first 100 days in office.” He also said he will stick with the Centers for Disease Control and Prevention’s latest recommendation to distribute covid vaccines to those who are 65 and older, as well as essential workers, to push states to allocate the supply quickly.

During his Thursday speech outlining what he’s dubbed the “American Rescue Plan,” Biden made several claims about the current response to the pandemic and how it’s affecting Americans. We fact-checked and gave context to a couple of the president-elect’s statements.

“The vaccine rollout in the United States has been a dismal failure thus far.”

The vaccine rollout is far short of what officials promised. According to a Centers for Disease Control and Prevention tracker, since mid-December, when vaccines first started being distributed, about 30 million doses have been sent out. But only about 11 million have actually been administered into the arms of Americans. The Department of Health and Human Services had initially issued a goal of administering 20 million doses by the end of December.

A key reason for the slow pace, experts said, is that many state and local health departments lack the funding and resources to execute such a mass vaccination campaign. Communication with the federal government has also been dicey. Many states have complained that they aren’t informed about how much vaccine they will receive and when — making logistical planning difficult. In addition, the outgoing Trump administration recently changed its recommendations for who should qualify, adding an additional layer of confusion.

Still, public health experts say part of the reason the initial rollout was slow was that it occurred during the December holidays, when many locations were understaffed. And since Congress approved a second covid stimulus bill, states will receive about $3 billion in funding, which will help efforts.

“One in 7 households in America — more than 1 in 5 Black and Latino households in America — report they don’t have enough food to eat.”

This is accurate. Estimates vary on the exact number of Americans who live in households that are food insecure, but Biden’s numbers match recent numbers from the U.S. Census Bureau. The numbers translate to about 14% of all households and 20% of Black and Latino households.

The Census Bureau estimates food insecurity throughout the pandemic in a weekly report. According to numbers from December, 14% of all adults in the country reported their households sometimes or often not having enough food in the past seven days. The data from December also shows that 24% of Black households and 21% of Latino households did not have enough to eat.

A Northwestern University study estimates that at one point during the pandemic, nearly 23% of households experienced food insecurity.

“These crises are straining the budgets of states and cities and tribal communities that are forced to consider layoff and service restrictions of the most needed workers.”

This is accurate. State and local governments generally by law are required to balance their operating budgets, resulting in layoffs and reductions in services — though federal aid provided through covid relief helped. Late last year, the Brookings Institution projected state and local revenues would decline by $155 billion in 2020 and $167 billion in 2021. According to a report by the Center on Budget and Policy Priorities, states and localities had furloughed or laid off 1.2 million workers through October 2020. Brookings also noted that, because state and local governments “are at the forefront of the response to the pandemic,” they “will likely need to increase their typical spending to provide crucial public health services and help communities adapt to social distancing guidelines.”

Additionally, news reports starting early last summer detail a high number of health care workers being laid off or losing their jobs during the pandemic. Public health workers have also been furloughed or had their hours cut, despite having to create covid testing sites, initiate contact tracing programs and now create mass vaccination campaigns.

“Over the last year alone, over 600,000 educators have lost their jobs in our cities and towns.”

This is a softened version of a previous claim about laid-off “teachers” that we rated Mostly False. This number likely refers to Bureau of Labor Statistics data that shows the number of local government education jobs declined from March to October by 666,000.

But that number doesn’t refer only to layoffs. Rather, it notes a net decrease in jobs. Reports show that, during the pandemic, some educators have quit, retired or taken a leave of absence.

It’s also not clear what type of educators Biden was referring to, and though the BLS does track layoff data by industry, it lumps state and local education data together, which means public college staff numbers are included. The BLS data shows that from March to October, 39,000 state and local educators were laid off or discharged.

5 Reasons to Wear a Mask Even After You're Vaccinated

KFF Health News, January 16, 2021

Although covid vaccines are highly effective, health experts say there are good reasons to continue to mask up.

This article was published on Friday, January 15, 2021 in Kaiser Health News.

By Liz Szabo

As an emergency physician, Dr. Eugenia South was in the first group of people to receive a covid vaccine. She received her second dose last week  — even before President-elect Joe Biden.

Yet South said she’s in no rush to throw away her face mask.

“I honestly don’t think I’ll ever go without a mask at work again,” said South, faculty director of the Urban Health Lab at the University of Pennsylvania in Philadelphia. “I don’t think I’ll ever feel safe doing that.”

And although covid vaccines are highly effective, South plans to continue wearing her mask outside the hospital as well.

Health experts say there are good reasons to follow her example.

“Masks and social distancing will need to continue into the foreseeable future — until we have some level of herd immunity,” said Dr. Preeti Malani, chief health officer at the University of Michigan. “Masks and distancing are here to stay.”

Malani and other health experts explained five reasons Americans should hold on to their masks:

1. No vaccine is 100% effective.

Large clinical trials found that two doses of the Moderna and Pfizer-BioNTech vaccines prevented 95% of illnesses caused by the coronavirus. While those results are impressive, 1 in 20 people are left unprotected, said Dr. Tom Frieden, a former director of the Centers for Disease Control and Prevention.

Malani notes that vaccines were tested in controlled clinical trials at top medical centers, under optimal conditions.

In the real world, vaccines are usually slightly less effective. Scientists use specific terms to describe the phenomenon. They refer to the protection offered by vaccines in clinical trials as “efficacy,” while the actual immunity seen in a vaccinated population is “effectiveness.”

The effectiveness of covid vaccines could be affected by the way they’re handled, Malani said. The genetic material used in mRNA vaccines — made with messenger RNA from the coronavirus — is so fragile that it has to be carefully stored and transported.

Any variation from the CDC’s strict guidance could influence how well vaccines work, Malani said.

2. Vaccines don’t provide immediate protection.

No vaccine is effective right away, Malani said. It takes about two weeks for the immune system to make the antibodies that block viral infections.

Covid vaccines will take a little longer than other inoculations, such as the flu shot, because both the Moderna and Pfizer products require two doses. The Pfizer shots are given three weeks apart; the  Moderna shots, four weeks apart.

In other words, full protection won’t arrive until five or six weeks after the first shot. So, a person vaccinated on New Year’s Day won’t be fully protected until Valentine’s Day.

3. Covid vaccines may not prevent you from spreading the virus.

Vaccines can provide two levels of protection. The measles vaccine prevents viruses from causing infection, so vaccinated people don’t spread the infection or develop symptoms.

Most other vaccines — including flu shots — prevent people from becoming sick but not from becoming infected or passing the virus to others, said Dr. Paul Offit, who advises the National Institutes of Health and Food and Drug Administration on covid vaccines.

While covid vaccines clearly prevent illness, researchers need more time to figure out whether they prevent transmission, too, said Phoenix-based epidemiologist Saskia Popescu, an assistant professor in the biodefense program at George Mason University’s Schar School of Policy and Government.

“We don’t yet know if the vaccine protects against infection, or only against illness,” said Frieden, now CEO of Resolve to Save Lives, a global public health initiative. “In other words, a vaccinated person might still be able to spread the virus, even if they don’t feel sick.”

Until researchers can answer that question, Frieden said, wearing masks is the safest way for vaccinated people to protect those around them.

4. Masks protect people with compromised immune systems.

People with cancer are at particular risk from covid. Studies show they’re more likely than others to become infected and die from the virus, but may not be protected by vaccines, said Dr. Gary Lyman, a professor at Fred Hutchinson Cancer Research Center.

Cancer patients are vulnerable in multiple ways. People with lung cancer are less able to fight off pneumonia, while those undergoing chemotherapy or radiation treatment have weakened immune systems. Leukemia and lymphoma attack immune cells directly, which makes it harder for patients to fight off the virus.

Doctors don’t know much about how people with cancer will respond to vaccines, because they were excluded from randomized trials, Lyman said. Only a handful of study participants were diagnosed with cancer after enrolling. Among those people, covid vaccines protected only 76%.

Although the vaccines appear safe, “prior studies with other vaccines raise concerns that immunosuppressed patients, including cancer patients, may not mount as great an immune response as healthy patients,” Lyman said. “For now, we should assume that patients with cancer may not experience the 95% efficacy.”

Some people aren’t able to be vaccinated.

While most people with allergies can receive covid vaccines safely, the CDC advises those who have had severe allergic reactions to vaccine ingredients, including polyethylene glycol, to avoid vaccination. The agency also warns people who have had dangerous allergic reactions to a first vaccine dose to skip the second.

Lyman encourages people to continue wearing masks to protect those with cancer and others who won’t be fully protected.

5. Masks protect against any strain of the coronavirus, in spite of genetic mutations.

Global health leaders are extremely concerned about new genetic variants of the coronavirus, which appear to be at least 50% more contagious than the original.

So far, studies suggest vaccines will still work against these new strains.

One thing is clear: Public health measures — such as avoiding crowds, physical distancing and masks — reduce the risk of contracting all strains of the coronavirus, as well as other respiratory diseases, Frieden said. For example, the number of flu cases worldwide has been dramatically lower since countries began asking citizens to stay home and wear masks.

“Masks will remain effective,” Malani said. “But careful and consistent use will be essential.”

The best hope for ending the pandemic isn’t to choose between masks, physical distancing and vaccines, Offit said, but to combine them. “The three approaches work best as a team,” he said.

Geography Is Destiny: Dentists' Access to Covid Shots Depends on Where They Live

KFF Health News, January 15, 2021

Oregon is one of a handful of states that have put dentists lower in priority order than other health professionals who treat patients — even though they have their hands in people's mouths and are exposed to aerosols that spray germs in their faces during procedures.

This article was published on Friday, January 15, 2021 in Kaiser Health News.

By Phil Galewitz

Dr. Monte Junker, an Oregon dentist, is waiting for his turn to get vaccinated for covid even though he considers himself a front-line health worker.

"If they offered it to me today, I would be there," he said.

In December, just before the first vaccines were cleared for emergency use, the Centers for Disease Control and Prevention immunization advisory board recommended that healthcare workers — as well as nursing home residents and staff members — be the first to be inoculated because of their high risks of infection.

But Oregon is one of a handful of states, including Colorado, North Carolina and Texas, that have put dentists lower in priority order than other health professionals who treat patients — even though they have their hands in people's mouths and are exposed to aerosols that spray germs in their faces during procedures.

As a result, dentists in those states must wait while many of their peers got their shots in December.

Dr. Tam Le, president of the Connecticut State Dental Association, was vaccinated in December along with employees at his practice in Cheshire. He said he lobbied the state to include dentists with other front-line hospital and health workers.

"In Connecticut, we are doing really well," he said, noting that the state set up an online registration system for eligible health workers and then contacted them about when and where they could get the vaccine. Le said he and his staff went to a nearby community health center for their shots.

Dentists gained goodwill from state officials last spring by donating gloves and masks to hospitals, Le said. They also offered to help administer the shots since they have experience with that.

States are increasingly diverging from CDC guidance in their vaccination plans, according to an analysis by KFF. "Timelines vary significantly across states, regardless of priority group, resulting in a vaccine rollout labyrinth across the country," the report said. (KHN is an editorially independent program of KFF.)

The American Dental Association said it's aware that the lack of a national immunization strategy has meant that dentists and their staffs are not being treated equally across the country.

The CDC advisory board included dentists when it recommended that front-line health workers get priority.

"Each state government's approach to vaccination will be different based on populations and need, but all dental team members should be prioritized in the first-tier distribution as the vaccines roll out by the different state and county public health departments," said Daniel Klemmedson, the ADA president. An oral surgeon in Arizona, he has been vaccinated.

In Florida, dentists and their staffs are included among front-line workers eligible for vaccines in the first wave, but a lack of supply has hindered some from getting their shots, according to Drew Eason, CEO of the Florida Dental Association. Some county health departments have also incorrectly turned dentists away, he added.

Dr. Cindy Roark, a Boca Raton dentist and chief clinical officer of Sage Dental, which has 15 offices in Florida and Georgia, said she has no idea when she'll get vaccinated. She said Georgia dentists in her company have been vaccinated, while those in Florida must wait. The only exceptions appear to be the relatively few dentists affiliated with hospitals. "We are equally vulnerable," she said.

Still, Roark said she is not upset. "I know I can protect myself," she said, adding that her office staffers wear N95 masks, face shields and gloves to protect themselves and patients. "Most dentists feel completely safe running their practice and preventing transmission."

Junker, regional dental director at Advantage Dental in The Dalles, Oregon, said he understands that intensive care staff members, emergency department workers and the elderly in nursing homes need the vaccine first.

"But we are definitely up there for the copious quantities of aerosol in our faces each day," he said. "The atmosphere is highly concentrated" with virus.

He's upset at the poor planning and coordination between states and the federal government to make dentists a priority.

In cases where hospital staffers are declining the vaccine because they don't trust it, Junker said, hospitals should offer shots to dentists and others who are eager for them.

"I don't think it's fair for them to sit on the vaccine for a month or two. It needs to get used, and if the hospital workers later decide to get vaccinated, they can get back in line," he said.

Dr. Stan Hardesty, a Raleigh, North Carolina, dentist and president of the state dental society, said it's disappointing to see dentists in other states get the vaccine while he and his colleagues have been told to wait.

"We have been advocating on behalf of our members to have dentists and our team members included in phase 1a as recommended by the CDC," he said. "Unfortunately, the decision-makers [in the state government] have decided to utilize a different prioritization in their vaccine implementation."

North Carolina dentists will be in "phase 1b," which includes adults 75 and older, essential workers such as police officers and firefighters.

Phil Galewitz: pgalewitz@kff.org, @philgalewitz

CVS and Walgreens Under Fire for Slow Pace of Vaccination in Nursing Homes

KFF Health News, January 15, 2021

Across the country, some nursing home directors and healthcare officials say the partnership is actually hampering the vaccination process.

This article was published on Friday, January 15, 2021 in Kaiser Health News.

By Rachel Bluth and Lauren Weber

The effort to vaccinate some of the country's most vulnerable residents against covid-19 has been slowed by a federal program that sends retail pharmacists into nursing homes — accompanied by layers of bureaucracy and logistical snafus.

As of Thursday, more than 4.7 million doses of the Pfizer-BioNTech and Moderna covid vaccines had been allocated to the federal pharmacy partnership, which has deputized pharmacy teams from Walgreens and CVS to vaccinate nursing home residents and workers. Since the program started in some states on Dec. 21, however, they have administered about one-quarter of the doses, according to the Centers for Disease Control and Prevention.

Across the country, some nursing home directors and healthcare officials say the partnership is actually hampering the vaccination process by imposing paperwork and cumbersome corporate policies on facilities that are thinly staffed and reeling from the devastating effects of the coronavirus. They argue that nursing homes are unique medical facilities that would be better served by medical workers who already understand how they operate.

Mississippi's state health officer, Dr. Thomas Dobbs, said the partnership "has been a fiasco."

The state has committed 90,000 vaccine doses to the effort, but the pharmacies had administered only 5% of those shots as of Thursday, Dobbs said. Pharmacy officials told him they're having trouble finding enough people to staff the program.

Dobbs pointed to neighboring Alabama and Louisiana, which he says are vaccinating long-term care residents at four times the rate of Mississippi.

"We're getting a lot of angry people because it's going so slowly, and we're unhappy too," he said.

Many of the nursing homes that have successfully vaccinated willing residents and staff members are doing so without federal help.

For instance, Los Angeles Jewish Home, with roughly 1,650 staff members and 1,100 residents on four campuses, started vaccinating Dec. 30. By Jan. 11, the home's medical staff had administered its 1,640th dose. Even the facility's chief medical director, Noah Marco, helped vaccinate.

The home is in Los Angeles County, which declined to participate in the CVS/Walgreens program. Instead, it has tasked nursing homes with administering vaccines themselves, and is using only Moderna's easier-to-handle product, which doesn't need to be stored at ultracold temperatures, like the Pfizer vaccine. (Both vaccines require two doses to offer full protection, spaced 21 to 28 days apart.)

By contrast, Mariner Health Central, which operates 20 nursing homes in California, is relying on the federal partnership for its homes outside of L.A. County. One of them won't be getting its first doses until next week.

"It's been so much worse than anybody expected," said the chain's chief medical officer, Dr. Karl Steinberg. "That light at the end of the tunnel is dim."

Nursing homes have experienced some of the worst outbreaks of the pandemic. Though they house less than 1% of the nation's population, nursing homes have accounted for 37% of deaths, according to the COVID Tracking Project.

Facilities participating in the federal partnership typically schedule three vaccine clinics over the course of nine to 12 weeks. Ideally, those who are eligible and want a vaccine will get the first dose at the first clinic and the second dose three to four weeks later. The third clinic is considered a makeup day for anyone who missed the others. Before administering the vaccines, the pharmacies require the nursing homes to obtain consent from residents and staffers.

Despite the complaints of a slow rollout, CVS and Walgreens said they're on track to finish giving the first doses by Jan. 25, as promised.

"Everything has gone as planned, save for a few instances where we've been challenged or had difficulties making contact with long-term care facilities to schedule clinics," said Joe Goode, a spokesperson for CVS Health.

Dr. Marcus Plescia, chief medical officer at the Association of State and Territorial Health Officials, acknowledged some delays through the partnership, but said that's to be expected because this kind of effort has never before been attempted.

"There's a feeling they'll get up to speed with it and it will be helpful, as health departments are pretty overstretched," Plescia said.

But any delay puts lives at risk, said Dr. Michael Wasserman, the immediate past president of the California Association of Long Term Care Medicine.

"I'm about to go nuclear on this," he said. "There should never be an excuse about people not getting vaccinated. There's no excuse for delays."

Bringing in Vaccinators

Nursing homes are equipped with resources that could have helped the vaccination effort — but often aren't being used.

Most already work with specialized pharmacists who understand the needs of nursing homes and administer medications and yearly vaccinations. These pharmacists know the patients and their medical histories, and are familiar with the apparatus of nursing homes, said Linda Taetz, chief compliance officer for Mariner Health Central.

"It's not that they aren't capable," Taetz said of the retail pharmacists. "They just aren't embedded in our buildings."

If a facility participates in the federal program, it can't use these or any other pharmacists or staffers to vaccinate, said Nicole Howell, executive director for Ombudsman Services of Contra Costa, Solano and Alameda counties.

But many nursing homes would like the flexibility to do so because they believe it would speed the process, help build trust and get more people to say yes to the vaccine, she said.

Howell pointed to West Virginia, which relied primarily on local, independent pharmacies instead of the federal program to vaccinate its nursing home residents.

The state opted against the partnership largely because CVS/Walgreens would have taken weeks to begin shots and Republican Gov. Jim Justice wanted them to start immediately, said Marty Wright, CEO of the West Virginia Healthcare Association, which represents the state's long-term care facilities.

The bulk of the work is being done by more than 60 pharmacies, giving the state greater control over how the doses were distributed, Wright said. The pharmacies were joined by Walgreens in the second week, he said, though not as part of the federal partnership.

"We had more interest from local pharmacies than facilities we could partner them up with," Wright said. Preliminary estimates show that more than 80% of residents and 60% of staffers in more than 200 homes got a first dose by the end of December, he said.

Goode from CVS said his company's participation in the program is being led by its long-term care division, which has deep experience with nursing homes. He noted that tens of thousands of nursing homes — about 85% nationally, according to the CDC — have found that reassuring enough to participate.

"That underscores the trust the long-term care community has in CVS and Walgreens," he said.

Vaccine recipients don't pay anything out-of-pocket for the shots. The costs of purchasing and administering them are covered by the federal government and health insurance, which means CVS and Walgreens stand to make a lot of money: Medicare is reimbursing $16.94 for the first shot and $28.39 for the second.

Bureaucratic Delays

Technically, federal law doesn't require nursing homes to obtain written consent for vaccinations.

But CVS and Walgreens require them to get verbal or written consent from residents or family members, which must be documented on forms supplied by the pharmacies.

Goode said consent hasn't been an impediment so far, but many people on the ground disagree. The requirements have slowed the process as nursing homes collect paper forms and Medicare numbers from residents, said Tracy Greene Mintz, a social worker who owns Senior Care Training, which trains and deploys social workers in more than 100 facilities around California.

In some cases, social workers have mailed paper consent forms to families and waited to get them back, she said.

"The facilities are busy trying to keep residents alive," Greene Mintz said. "If you want to get paid from Medicare, do your own paperwork," she suggested to CVS and Walgreens.

Scheduling has also been a challenge for some nursing homes, partly because people who are actively sick with covid shouldn't be vaccinated, the CDC advises.

"If something comes up — say, an entire building becomes covid-positive — you don't want the pharmacists coming because nobody is going to get the vaccine," said Taetz of Mariner Health.

Both pharmacy companies say they work with facilities to reschedule when necessary. That happened at Windsor Chico Creek Care and Rehabilitation in Chico, California, where a clinic was pushed back a day because the facility was awaiting covid test results for residents. Melissa Cabrera, who manages the facility's infection control, described the process as streamlined and professional.

In Illinois, about 12,000 of the state's roughly 55,000 nursing home residents had received their first dose by Sunday, mostly through the CVS/Walgreens partnership, said Matt Hartman, executive director of the Illinois Healthcare Association.

While Hartman hopes the pharmacies will finish administering the first round by the end of the month, he noted that there's a lot of "headache" around scheduling the clinics, especially when homes have outbreaks.

"Are we happy that we haven't gotten through round one and West Virginia is done?" he asked. "Absolutely not."

KHN correspondent Rachana Pradhan contributed to this report.

This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Healthcare Foundation.

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