'Are You Going to Keep Me Safe?' Hospital Workers Sound Alarm on Rising Violence

KFF Health News, October 11, 2021

Eighteen months into the pandemic, healthcare workers say they are experiencing an alarming rise in violence in their workplaces.

This article was published on Monday, October 11, 2021 in Kaiser Health News.

By Bram Sable-Smith and Andy Miller  

The San Leandro Hospital emergency department, where nurse Mawata Kamara works, went into lockdown recently when a visitor, agitated about being barred from seeing a patient due to COVID-19 restrictions, threatened to bring a gun to the California facility.

It wasn't the first time the department faced a gun threat during the pandemic. Earlier in the year, a psychiatric patient well known at the department became increasingly violent, spewing racial slurs, spitting toward staffers and lobbing punches before eventually threatening to shoot Kamara in the face.

"Violence has always been a problem," Kamara said. "This pandemic really just added a magnifying glass."

In the earliest days of the pandemic, nightly celebrations lauded the bravery of front-line healthcare workers. Eighteen months later, those same workers say they are experiencing an alarming rise in violence in their workplaces.

A nurse testified before a Georgia Senate study committee in September that she was attacked by a patient so severely last spring she landed in the ER of her own hospital.

At Research Medical Center in Kansas City, Missouri, security was called to the COVID unit, said nurse Jenn Caldwell, when a visitor aggressively yelled at the nursing staff about the condition of his wife, who was a patient.

In Missouri, a tripling of physical assaults against nurses prompted Cox Medical Center Branson to issue panic buttons that can be worn on employees' identification badges.

Hospital executives were already attuned to workplace violence before the pandemic struck. But stresses from COVID have exacerbated the problem, they say, prompting increased security, de-escalation training and pleas for civility. And while many hospitals work to address the issue on their own, nurses and other workers are pushing federal legislation to create enforceable standards nationwide.

Paul Sarnese, an executive at Virtua Health in New Jersey and president of the International Association for Healthcare Security and Safety, said many studies show healthcare workers are much more likely to be victims of aggravated assault than workers in any other industry.

Federal data shows healthcare workers faced 73% of all nonfatal injuries from workplace violence in the U.S. in 2018. It's too early to have comprehensive stats from the pandemic.

Even so, Michelle Wallace, chief nursing officer at Grady Health System in Georgia, said the violence is likely even higher because many victims of patient assaults don't report them.

"We say, 'This is part of our job,'" said Wallace, who advocates for more reporting.

Caldwell said she had been a nurse for less than three months the first time she was assaulted at work — a patient spit at her. In the four years since, she estimated, she hasn't gone more than three months without being verbally or physically assaulted.

"I wouldn't say that it's expected, but it is accepted," Caldwell said. "We have a lot of people with mental health issues that come through our doors."

Jackie Gatz, vice president of safety and preparedness for the Missouri Hospital Association, said a lack of behavioral health resources can spur violence as patients seek treatment for mental health issues and substance use disorders in ERs. Life can also spill inside to the hospital, with violent episodes that began outside continuing inside or the presence of law enforcement officers escalating tensions.

A February 2021 report from National Nurses United — a union in which both Kamara and Caldwell are representatives — offers another possible factor: staffing levels that don't allow workers sufficient time to recognize and de-escalate possibly volatile situations.

COVID unit nurses also have shouldered extra responsibilities during the pandemic. Duties such as feeding patients, drawing blood and cleaning rooms would typically be conducted by other hospital staffers, but nurses have pitched in on those jobs to minimize the number of workers visiting the negative-pressure rooms where COVID patients are treated. While the workload has increased, the number of patients each nurse oversees is unchanged, leaving little time to hear the concerns of visitors scared for the well-being of their loved ones — like the man who aggressively yelled at the nurses in Caldwell's unit.

In September, 31% of hospital nurses surveyed by that union said they had faced workplace violence, up from 22% in March.

Dr. Bryce Gartland, hospital group president of Atlanta-based Emory Healthcare, said violence has escalated as the pandemic has worn on, particularly during the latest wave of infections, hospitalization and deaths.

"Front-line healthcare workers and first responders have been on the battlefield for 18 months," Garland said. "They're exhausted."

Like the increase in violence on airplanes, at sports arenas and school board meetings, the rising tensions inside hospitals could be a reflection of the mounting tensions outside them.

William Mahoney, president of Cox Medical Center Branson, said national political anger is acted out locally, especially when staffers ask people who come into the hospital to put on a mask.

Caldwell, the nurse in Kansas City, said the physical nature of COVID infections can contribute to an increase in violence. Patients in the COVID unit often have dangerously low oxygen levels.

"People have different political views — they're either CNN or Fox News — and they start yelling at you, screaming at you," Mahoney said.

"When that happens, they become confused and also extremely combative," Caldwell said.

Sarnese said the pandemic has given hospitals an opportunity to revisit their safety protocols. Limiting entry points to enable COVID screening, for example, allows hospitals to funnel visitors past security cameras.

Research Medical Center recently hired additional security officers and provided de-escalation training to supplement its video surveillance, spokesperson Christine Hamele said.

In Branson, Mahoney's hospital has bolstered its security staff, mounted cameras around the facility, brought in dogs ("people don't really want to swing at you when there's a German shepherd sitting there") and conducted de-escalation training — in addition to the panic buttons.

Some of those efforts pre-date the pandemic but the COVID crisis has added urgency in an industry already struggling to recruit employees and maintain adequate staffing levels. "The No. 1 question we started getting asked is, 'Are you going to keep me safe?'" Mahoney said.

While several states, including California, have rules to address violence in hospitals, National Nurses United is calling for the U.S. Senate to pass the Workplace Violence Prevention for Healthcare and Social Service Workers Act that would require hospitals to adopt plans to prevent violence.

"With any standard, at the end of the day you need that to be enforced," said the union's industrial hygienist, Rocelyn de Leon-Minch.

Nurses in states with laws on the books still face violence, but they have an enforceable standard they can point to when asking for that violence to be addressed. De Leon-Minch said the federal bill, which passed the House in April, aims to extend that protection to healthcare workers nationwide.

Destiny, the nurse who testified in Georgia using only her first name, is pressing charges against the patient who attacked her. The state Senate committee is now eyeing legislation for next year.

Kamara said the recent violence helped lead her hospital to provide de-escalation training, although she was dissatisfied with it. San Leandro Hospital spokesperson Victoria Balladares said the hospital had not experienced an increase in workplace violence during the pandemic.

For healthcare workers such as Kamara, all this antagonism toward them is a far cry from the early days of the pandemic when hospital workers were widely hailed as heroes.

"I don't want to be a hero," Kamara said. "I want to be a mom and a nurse. I want to be considered a person who chose a career that they love, and they deserve to go to work and do it in peace. And not feel like they're going to get harmed."

Bram Sable-Smith: brams@kff.org, @besables

Andy Miller: amiller@kff.org, @gahealthnews

From Sewers to Golf Courses, Cities See Green With New Federal COVID Relief Dollars

KFF Health News, October 8, 2021

The American Rescue Plan Act provides $130 billion to cities and counties — with few restrictions on how the money can be spent.

This article was published on Friday, October 8, 2021 in Kaiser Health News.

By Phil Galewitz    

Duluth, Minnesota, is hiring a social worker to help people with addiction and mental health problems.

Pueblo, Colorado, started paying homeless residents to clean city streets.

Palm Beach Gardens, Florida — in Palm Beach County, home to 160 golf courses — is building a new golf course.

These are among the thousands of ways cities and counties have started spending the first tranche of COVID relief money from the American Rescue Plan Act passed by Congress in March.

That economic rescue package provides $130 billion to cities and counties — with few restrictions on how the money can be spent. For many, it was their first economic relief directly received from the federal government.

States received $195 billion from ARPA. They had gotten other stimulus funding in earlier relief packages, including the CARES Act last year.

The infusion of dollars to cities and counties is intended to aid residents and businesses hurt by the COVID-19 pandemic, invest in long-term projects or supplement budgets hit by a drop in tax revenue caused by shutdown restrictions and economic slowdowns.

Half the money was made available in May and the rest will be available next year. The localities have until 2026 to spend it.

The money cannot be used to reduce taxes, add to rainy day funds, pay for legal settlements or buttress pension funds.

Other than that, local governments can spend the money virtually as they will. Many cities, such as Buffalo, New York and Houston, are initially classifying large chunks of the allocation as "revenue replacement," meaning they will use the funds to make up for shortfalls over what would have been expected if the pandemic had not occurred. This gives them the most flexibility, according to a Brookings Institution report.

Many jurisdictions, including West Palm Beach, Florida, and Livonia, Minnesota, have allocated some ARPA money for employee bonuses.

Chautauqua County, New York, approved nearly $95,000 for handguns and bulletproof vests for its sheriff's office. The county, which averages 120 inches of snow a year, also approved $480,000 for two snowplows/dump trucks and $810,000 for a snowblower.

Dubois County, Indiana, is using $350,000 of its $8 million to add campsites and a bathroom and make other improvements to a county park.

ARPA — a $1.9 trillion package that in addition to the relief money for localities included funding for COVID testing, unemployment benefits, child tax credits and a host of other programs — was a top priority of President Joe Biden and congressional Democrats after they took control in Washington earlier this year. The law was passed without support from Republicans, who argued that earlier COVID relief funding had not been fully spent and its effects were still being realized.

The echoes of that argument are still reverberating on Capitol Hill as Republicans fight Democrats on their plans to expand spending for social programs such as Medicare and Medicaid and climate change.

In contrast to past federal fiscal relief efforts — including the CARES Act — ARPA provides support to thousands of cities and counties. Cities with more than 50,000 people get money based on population size, poverty rates and overcrowding. Smaller cities receive money based on population.

The CARES Act provided money to 160 of the country's largest 1,300 counties, but ARPA money goes to all 3,000-plus counties, said Eryn Hurley, deputy director of government affairs for the National Association of Counties. "This money is very vital," she said, noting how the pandemic and economic downturn cost counties billions in revenue. "Counties are working hard to invest these funds as fast as possible for their communities and residents," she said.

Alan Berube, a senior fellow at the Brookings Institution who is tracking the relief dollars, said this is the first new massive grant funding program to city and counties in nearly 50 years with such flexible spending requirements. Most local governments, he added, are still trying to figure out how to spend the cash.

"You have to use this money to address the impact of the pandemic or an underlying condition in the community exacerbated by the pandemic, Berube said.

Some cities, including Seattle and Austin, Texas, are using the money to build affordable housing and programs to deal with the rise in the homeless population.

Berube said the Treasury Department may question whether Palm Beach Gardens, a largely upscale city just north of West Palm Beach, can use $2 million of its $2.9 million ARPA money to help build a golf course.

"That is a very aggressive reading of the regulation," he said.

Palm Beach Gardens officials defend the spending as "an investment in our community." Candice Temple, a city spokesperson, noted the money will go to develop the 115-acre site, which will include a par-3 golf course, clubhouse and bike paths. The total cost of the project is $16.8 million, with the rest of the money coming from a bond financing. The city plans to hire seven people to work at the course.

Pueblo, Colorado, Mayor Nicholas Gradisar said his city was grateful for the money even though sales tax revenue rose 3% last year and is up 30% in 2021. He credits the increase to the federal stimulus checks residents received and used to shop and eat out.

"All in all, it could have been a lot worse," Gradisar said.

His city used some of its ARPA funding to give its employees a $500 incentive payment for getting vaccinated. The money helped improve the vaccination rate from 43% in early August to about 66% when the program ended Sept. 15.

"Obviously, we were pleased more people signed up, but we still have a ways to go," Gradisar said.

Pueblo will also use some of the ARPA funding to address homelessness and lack of child care, he said.

The city put $500,000 into a summer reading program that rewards children with $100 for completing their assignments and targeted $376,000 for mental health specialists to work with the police. It's also paying people at a homeless shelter to clean city streets. So far, Pueblo has committed $2.3 million of the $18 million in ARPA money it expects to receive.

Martin Brown, a program manager for the National League of Cities, said city officials have been contacting the organization to ask how they can use the money. "For the $65 billion in revenue, there's probably 65 billion ways to spend it," he said.

Phil Galewitz: pgalewitz@kff.org, @philgalewitz

NY Reaches Agreement With DOJ Over Vaccine Access for Blind People

KFF Health News, October 8, 2021

State officials say they have corrected issues that prevent blind or visually impaired users from accessing forms or navigating vaccine websites.

This article was published on Friday, October 8, 2021 in Kaiser Health News.

By Lauren Weber and Hannah Recht

Five New York state and local government agencies agreed to fix COVID-19 vaccine websites to make them accessible for blind users following a Department of Justice investigation spurred by a KHN story.

New York State's Department of Health, the City of New York's Department of Health, New York City Health and Hospitals Corp., Nassau County and Suffolk County entered into written agreements with the U.S. Attorney's Office for the Eastern District of New York, saying they have corrected issues that prevent blind or visually impaired users from accessing forms or navigating vaccine websites. In the agreements announced Tuesday, they pledged to maintain accessibility on those sites.

KHN's February investigation detailed how COVID vaccination registration and information websites at the federal, state and local levels violated disability rights laws and hindered the ability of blind people to sign up for the potentially lifesaving vaccines.

The investigation was cited in a March letter sent to the Departments of Justice and Health and Human Services from several senators, including Sen. Maggie Hassan (D-N.H.), who also asked HHS and Centers for Disease Control and Prevention leadership about the issue in a congressional hearing. The Department of Justice issued a memo the next month highlighting that "civil rights protections and responsibilities still apply" for those with vision disabilities, and HHS did as well.

In response to the KHN investigation, the Department of Justice reached out to WebAIM, according to the group's associate director, Jared Smith. WebAIM, a nonprofit web accessibility organization, ran an analysis at KHN's request that found accessibility issues on nearly all 50 states' vaccine websites, which provide general vaccine information, lists of vaccine providers and registration forms. WebAIM then helped the U.S. attorney's office in its investigation, Smith said.

Clark Rachfal, director of advocacy for the American Council of the Blind, said the public agreements are vital as they put "other jurisdictions on notice that this is a violation of the civil rights of people with disabilities."

Sachin Dev Pavithran, executive director of the U.S. Access Board, an independent agency of the federal government that works to increase accessibility, said he knew the department had investigations in progress in other states.

Inaccessibility for government websites is unlawful under the Rehabilitation Act of 1973 and the 1990 Americans with Disabilities Act, said Albert Elia, a blind attorney who works with the San Francisco-based TRE Legal Practice on accessibility cases.

He hopes the pandemic has shown just how vital online accessibility can be as so many people shifted to ordering their groceries, clothes and even medicine online.

"The notion that it's fine if online things are inaccessible — I hope we're beyond that now," he said. "I hope the general public realizes that to cut people out of online access is effectively cutting them out of life."

The National Federation of the Blind settled this summer with Curative, a startup that has administered COVID vaccines and tests in cities across the country. Curative admitted no wrongdoing but agreed to make its website accessible within 30 days and pay NFB's attorney fees, plus donate $2,500.

One blind California resident, Byran Bashin, who was unable to use Curative to register for his vaccine appointment online, was featured in the KHN investigation. "We hear a lot of lip service about inclusion and respect for diversity," he said Thursday. "Respect for our diversity begins with intelligently designing these processes."

Andy Imparato, a member of the White House's COVID-19 Health Equity Task Force and executive director of Disability Rights California, said he expects a report on inequities from the task force to be given to President Joe Biden within the month. He said the report will likely call for an outside evaluation of access issues in the COVID response, including website accessibility.

"The story that published had an impact across the country," Imparato said. "It was very specific, it was very detailed, and it was hard to ignore. I think it was incredibly helpful."

The National Federation of the Blind is pushing for a legislative fix to codify online accessibility rights, but Rachfal said a fix can be done without Congress.

"What's needed is some leadership from the administration and the Department of Justice to promulgate regulations that they already have the authority to do," Rachfal said.

Lauren Weber: LaurenW@kff.org, @LaurenWeberHP

Hannah Recht: hrecht@kff.org, @hannah_recht

Organ Centers to Transplant Patients: Get a COVID Shot or Move Down on Waitlist

KFF Health News, October 8, 2021

Many transplant programs have chosen to either bar patients who refuse to take the COVID vaccines from receiving transplants, or give them lower priority on waitlists.

This article was published on Friday, October 8, 2021 in Kaiser Health News.

By JoNel Aleccia  

A Colorado kidney transplant candidate who was bumped to inactive status for failing to get a COVID-19 vaccine has become the most public example of an argument roiling the nation's more than 250 organ transplant centers.

Across the country, growing numbers of transplant programs have chosen to either bar patients who refuse to take the widely available COVID vaccines from receiving transplants, or give them lower priority on crowded organ waitlists. Other programs, however, say they plan no such restrictions — for now.

At issue is whether transplant patients who refuse the shots are not only putting themselves at greater risk for serious illness and death from a COVID infection, but also squandering scarce organs that could benefit others. The argument echoes the demands that smokers quit cigarettes for six months before receiving lung transplants or that addicts refrain from alcohol and drugs before receiving new livers.

"It is a matter of active debate," said Dr. Deepali Kumar, an expert in transplant infectious diseases at the University of Toronto and president-elect of the American Society of Transplantation. "It's really an individual program decision. In many programs, it's in flux."

Leilani Lutali, 56, a late-stage kidney disease patient from Colorado Springs, Colorado, learned in a Sept. 28 letter from UCHealth in Denver that if she didn't begin a COVID vaccine series within 30 days, she would lose her spot on the transplant waiting list. Both she and her living donor, Jaimee Fougner, 45, of Peyton, Colorado, refused to get vaccinated, citing religious objections and uncertainty about the safety and effectiveness of the vaccines.

"I have too many questions that remain unanswered at this point. I feel like I'm being coerced into not being able to wait and see and that I have to take the shot if I want this lifesaving transplant," Lutali said.

She said she offered to be tested for COVID before the surgery or to sign a waiver absolving the hospital of legal risk for her refusal of the vaccine. "At what point do you no longer become a partner in your own care regardless of your own concerns?" she said.

Lutali now hopes to take her transplant quest to Texas, where several hospitals, including Houston Methodist and Baylor University Medical Center in Dallas, said they don't require COVID vaccinations to approve active candidates for the national waiting list.

The difference between policies in Denver and Dallas — and elsewhere — underscore a tense national divide. As of late April, fewer than 7% of transplant programs nationwide reported inactivating patients who were unvaccinated or partially vaccinated against COVID, according to research by Dr. Krista Lentine, a nephrologist at the Saint Louis University School of Medicine.

But that was just a snapshot in late spring, and like all COVID-related practices, it's "rapidly changing," Lentine said.

UCHealth in Denver began requiring COVID vaccinations for transplant patients in late August, citing the American Society of Transplantation's August recommendation that "all solid organ transplant recipients should be vaccinated against SARS-CoV-2."

Patients who undergo transplant surgery have their immune systems artificially suppressed during recovery, to keep their bodies from rejecting the new organ. That leaves unvaccinated transplant patients at "extreme risk" of severe illness if they are infected by COVID, with mortality rates estimated at 20% to 30%, depending on the study, Dan Weaver, a spokesperson for UCHealth said. For the same reason, transplant patients who receive COVID vaccines after surgery may fail to mount a strong immune response, research shows.

UW Medicine in Seattle began mandating COVID vaccines this summer, said Dr. Ajit Limaye, director of the solid organ transplant infectious diseases program. Patients were already required to meet other stringent criteria to be considered for transplantation, including receiving inoculations against several illnesses, such as hepatitis B and influenza.

"For anyone who does not have a medical contraindication, basically, we're requiring it," he said. "There's a very strong sense to make it a requirement, like all the other hoops, straight up."

By contrast, Northwestern Medicine in Chicago, where doctors performed the first double-lung transplant on a COVID patient in June 2020, is encouraging — but not requiring — vaccination against the pandemic disease.

"We don't decline care of transplant based on vaccine status," said Jenny Nowatzke, Northwestern's manager of national media relations. "The patient also doesn't get any lower scores."

The lack of consistent practice across programs sends a mixed message to the public, said Dr. Kapilkumar Patel, director of the lung transplant program at Tampa General Hospital in Florida, where COVID vaccines are not required.

"We mandate hepatitis and influenza vaccines, and nobody has an issue with that," he said. "And now we have this one vaccination that can save lives and make an impact on the post-transplant recovery phase. And we have this huge uproar from the public."

Nearly 107,000 candidates are waiting for organs in the U.S.; dozens die each day still waiting. Transplant centers evaluate which patients are allowed to be placed on the national list, taking into account medical criteria and other factors like financial means and social support to ensure that donor organs won't fail.

"We really make all kinds of selective value judgments," said Dr. David Weill, former director of Stanford University Medical Center's lung and heart-lung transplant program who now works as a consultant. "When we're selecting in the committee room, I hear the most subjective, value-based judgments about people's lives. This is just another thing."

The centers can choose to place candidates on inactive status for a variety of reasons, including medical noncompliance, according to data from the United Network for Organ Sharing, which oversees transplants. As of Sept. 30, that category accounted for 738 of more than 47,000 registrants waiting in inactive status, though it's not clear how many are tied to vaccination status.

A particularly thorny question involves unvaccinated people who need transplants specifically because COVID infections destroyed their organs. As of late September, more than 200 lungs, as well as at least six hearts and two heart-lung combinations, had been transplanted for COVID-related reasons in the U.S., according to UNOS data.

Many of those organs were transplanted earlier in the pandemic, before any COVID vaccine was widely available. That's no longer the case, Weill said. "If you're just now getting vaccinated, you've done it at gunpoint, actually," he said. "It's not just a personal choice; they're making some kind of a statement."

Such patients are usually younger and healthier than other transplant candidates, aside from the COVID-related damage, and they're often acutely ill enough to go to the top of any transplant list. "The sick COVID patient might go ahead of the stable cystic fibrosis patient," Weill said.

Tampa General's Patel said he performed a lung transplant on a patient who was transferred to Florida after being delisted at another center because he wasn't vaccinated for COVID. "I mandated with him basically on a handshake that he will get his vaccine post-transplant," Patel said. "But his family? They haven't agreed."

Eventually, Patel said, he thinks nearly all transplant programs will mandate COVID vaccination, largely because transplant centers are evaluated on the longer-term survival of their patients.

"I think it's going to spread like wildfire across the country," he said. "If you start losing patients in a year due to COVID, it will be mandated sooner rather than later.

JoNel Aleccia: jaleccia@kff.org, @JoNel_Aleccia

COVID Immunity Through Infection or Vaccination: Are They Equal?

KFF Health News, October 8, 2021

Evidence is growing that contracting SARS-CoV-2, the virus that causes COVID-19, is generally as effective as vaccination.

This article was published on Friday, October 8, 2021 in Kaiser Health News.

By Arthur Allen  

Dr. Aaron Kheriaty, a University of California-Irvine psychiatry professor, felt he didn't need to be vaccinated against COVID because he'd fallen ill with the disease in July 2020.

So, in August, he sued to stop the university system's vaccination mandate, saying "natural" immunity had given him and millions of others better protection than any vaccine could.

A judge on Sept. 28 dismissed Kheriaty's request for an injunction against the university over its mandate, which took effect Sept. 3. While Kheriaty intends to pursue the case further, legal experts doubt that his and similar lawsuits filed around the country will ultimately succeed.

That said, evidence is growing that contracting SARS-CoV-2, the virus that causes COVID-19, is generally as effective as vaccination at stimulating your immune system to prevent the disease. Yet federal officials have been reluctant to recognize any equivalency, citing the wide variation in COVID patients' immune response to infection.

Like many disputes during the COVID pandemic, the uncertain value of a prior infection has prompted legal challenges, marketing offers and political grandstanding, even as scientists quietly work in the background to sort out the facts.

For decades, doctors have used blood tests to determine whether people are protected against infectious diseases. Pregnant mothers are tested for antibodies to rubella to help ensure their fetuses won't be infected with the rubella virus, which causes devastating birth defects. Hospital workers are screened for measles and chickenpox antibodies to prevent the spread of those diseases. But immunity to COVID seems trickier to discern than those diseases.

The Food and Drug Administration has authorized the use of COVID antibody tests, which can cost about $70, to detect a past infection. Some tests can distinguish whether the antibodies came from an infection or a vaccine. But neither the FDA nor the Centers for Disease Control and Prevention recommend using the tests to assess whether you're, in fact, immune to COVID. For that, the tests are essentially useless because there's no agreement on the amount or types of antibodies that would signal protection from the disease.

"We don't yet have full understanding of what the presence of antibodies tells us about immunity," said Kelly Wroblewski, director of infectious diseases at the Association of Public Health Laboratories.

By the same token, experts disagree on how much protection an infection delivers.

In the absence of certainty and as vaccination mandates are levied across the country, lawsuits seek to press the issue. Individuals who claim that vaccination mandates violate their civil liberties argue that infection-acquired immunity protects them. In Los Angeles, six police officers have sued the city, claiming they have natural immunity. In August, law professor Todd Zywicki alleged that George Mason University's vaccine mandate violated his constitutional rights given he has natural immunity. He cited a number of antibody tests and an immunologist's medical opinion that it was "medically unnecessary" for him to be vaccinated. Zywicki dropped the lawsuit after the university granted him a medical exemption, which it claims was unrelated to the suit.

Republican legislators have joined the crusade. The GOP Doctors Caucus, which consists of Republican physicians in Congress, has urged people leery of vaccination to instead seek an antibody test, contradicting CDC and FDA recommendations. In Kentucky, the state Senate passed a resolution granting equal immunity status to those who show proof of vaccination or a positive antibody test.

Hospitals were among the first institutions to impose vaccine mandates on their front-line workers because of the danger of them spreading the disease to vulnerable patients. Few have offered exemptions from vaccination to those previously infected. But there are exceptions.

Two Pennsylvania hospital systems allow clinical staff members to defer vaccination for a year after testing positive for COVID. Another, in Michigan, allows employees to opt out of vaccination if they present evidence of previous infection and a positive antibody test in the previous three months. In these cases, the systems indicated they were keen to avoid staffing shortages that could result from the departure of vaccine-shunning nurses.

For Kheriaty, the question is simple. "The research on natural immunity is quite definitive now," he told KHN. "It's better than immunity conferred by vaccines." But such categorical statements are clearly not shared by most in the scientific community.

Dr. Arthur Reingold, an epidemiologist at UC-Berkeley, and Shane Crotty, a virologist at the respected La Jolla Institute for Immunology in San Diego, gave expert witness testimony in Kheriaty's lawsuit, saying the extent of immunity from reinfection, especially against newer variants of COVID, is unknown. They noted that vaccination gives a huge immunity boost to people who've been ill previously.

Yet not all of those pushing for recognition of past infection are vaccine critics or torchbearers of the anti-vaccine movement.

Dr. Jeffrey Klausner, clinical professor of population and public health sciences at the University of Southern California, co-authored an analysis published last week that showed infection generally protects for 10 months or more. "From the public health perspective, denying jobs and access and travel to people who have recovered from infection doesn't make sense," he said.

In his testimony against Kheriaty's case for "natural" immunity to COVID, Crotty cited studies of the massive COVID outbreak that swept through Manaus, Brazil, early this year that involved the gamma variant of the virus. One of the studies estimated, based on tests of blood donations, that three-quarters of the city's population had already been infected before gamma's arrival. That suggested that previous infection might not protect against new variants. But Klausner and others suspect the rate of prior infection presented in the study was a gross overestimate.

A large August study from Israel, which showed better protection from infection than from vaccination, may help turn the tide toward acceptance of prior infection, Klausner said. "Everyone is just waiting for Fauci to say, 'Prior infection provides protection,'" he said.

When Dr. Anthony Fauci, the top federal expert on infectious diseases, was asked during a CNN interview last month whether infected people were as well protected as those who've been vaccinated, he hedged. "There could be an argument" that they are, he said. Fauci did not immediately respond to a KHN request for further comment.

CDC spokesperson Kristen Nordlund said in an email that "current evidence" shows wide variation in antibody responses after COVID infection. "We hope to have some additional information on the protectiveness of vaccine immunity compared to natural immunity in the coming weeks."

A "monumental effort" is underway to determine what level of antibodies is protective, said Dr. Robert Seder, chief of the cellular immunology section at the National Institute of Allergy and Infectious Diseases. Recent studies have taken a stab at a number.

Antibody tests will never provide a yes-or-no answer on COVID protection, said Dr. George Siber, a vaccine industry consultant and co-author of one of the papers. "But there are people who are not going to be immunized. Trying to predict who is at low risk is a worthy undertaking."

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

Arthur Allen: ArthurA@kff.org, @ArthurAllen202

An Arm and a Leg': How One State Protects Patients From Hospital Lawsuits

KFF Health News, October 7, 2021

This episode, the fourth in our series on charity care, focuses on how states are protecting consumers against aggressive hospital debt collections.

This podcast was published on Thursday, October 7, 2021 in Kaiser Health News.

By Dan Weissmann

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

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

In Maryland, hospitals had been suing people — taking them to court and garnishing wages — even though these patients legally qualified for financial assistance, also known as charity care. Those lawsuits are now illegal, because of the state's new Medical Debt Protection Act. But in many other states, it still happens. 

This episode, the fourth in our series on charity care, focuses on how that change came about — as well as the coalition of consumer-protection advocates, riled-up activists and healthcare worker unions that made it happen.

We close out the episode by checking in with Jared Walker and his organization, Dollar For. Walker went super-viral on TikTok, telling people how to "crush medical bills" by understanding and applying for the financial assistance most hospitals are required by law to provide. Ten million people saw that video and now Dollar For is working to build an army of volunteers to tackle more than $100 million in medical debt — one bill at a time. 

Want to learn more, directly from Jared Walker?  Sign up for his next training, scheduled for Oct. 14. 

Here's the transcript for this episode. 

"An Arm and a Leg" is a co-production of KHN 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 healthcare system, the producers would love to hear from you.

To hear all KHN podcasts, click here.

And subscribe to "An Arm and a Leg" on Spotify, Apple Podcasts, Stitcher, Pocket Casts, or wherever you listen to podcasts.

California Vaccine Mandate Extends to Aides for People With Disabilities

KFF Health News, October 6, 2021

Those who work directly with people with disabilities must be fully vaccinated by Nov. 30.

This article was published on Wednesday, October 6, 2021 in Kaiser Health News.

By Jackie Fortiér, KPCC  

Workers in adult and senior care facilities and in-home aides have been added to the list of California health workers who must be fully vaccinated against the coronavirus.

Those who work directly with people with disabilities — such as employees paid through the state's regional center network, aides contracted by agencies, and in-home support service workers who don't live with the person they assist — are now included in the vaccine mandate. This new group must be fully vaccinated by Nov. 30.

Previous health orders covered only people working in licensed congregate settings like nursing homes, leaving out staff members who support 89% of people in California with developmental disabilities living with family, on their own or in group homes.

For months, that left people like Tim Jin who rely on aides for everyday tasks to wonder: Is the person brushing my teeth vaccinated?

"Due to my disability, I cannot do anything like cooking, eating, using the restroom or even using the microwave on my own. I am totally dependent on others to assist me," Jin said.

Jin has cerebral palsy and lacks the use of his arms or hands. He communicates mainly by typing with his toes on an iPad mounted next to his feet on his electric wheelchair. Up to six health aides come in and out of his home every day, helping him with intimate tasks like eating and bathing.

"The staff who come into my home should be vaccinated. It's that simple," he said. "It's a matter of life and death."

Only health workers with religious objections or a qualifying medical condition can be exempted from the vaccine requirement. They will be tested weekly for the virus that causes COVID-19 and must wear high-grade masks when working.

In September, Los Angeles County included those aides in its vaccine mandate, following a KPCC/LAist story that reported on the discrepancy.

But the order applied only to L.A. County, leaving out the 200,000 Californians with developmental disabilities living elsewhere, including Tim Jin, who lives in neighboring Orange County.

Advocates for people with disabilities hoped state health officials would use L.A. County as a model, but California's Sept. 28 health order went further, mandating the vaccine for some in-home support service workers, as well as home health aides.

"These care settings are home to Californians with complex medical conditions, all of whom are at high risk of having severe but preventable outcomes, including hospitalization, severe illness and death," said Dr. Tomás Aragón, California's public health officer.

California has reported 19,830 confirmed COVID outbreaks throughout the pandemic, and nearly 50% of those were reported in healthcare, congregate care and direct care settings, according to the California Department of Public Health. Of these outbreaks, the most (22%) have occurred in adult and senior care facilities and in-home direct care settings.

Studies show that people with intellectual and developmental disabilities often have underlying health conditions that make them more susceptible to COVID.

"And when they do get diagnosed with COVID-19, they are about two to three times more likely to die from the disease," said Scott Landes, an associate professor of sociology at Syracuse University's Maxwell School of Citizenship and Public Affairs.

Landes said cases seem to be dependent on two variables: preexisting conditions and the amount of in-person intimate care that the developmentally disabled person needs.

"Which really just makes sense for COVID," he said. "If you've got a caregiver that's right up next to you, all day, it's going to increase the chances that you could get the disease."

This story is from a reporting partnership that includes Southern California Public Radio, NPR and KHN.

Jackie Fortiér, KPCC: @jackiefortier

Needle Exchanges Are Targeted by Eco-Rooted Lawsuits. A New California Law Will Stop That.

KFF Health News, October 6, 2021

Opponents have deployed a novel strategy to shut them down: using environmental regulations to sue over needle waste.

This article was published on Wednesday, October 6, 2021 in Kaiser Health News.

By Rachel Bluth  

SANTA CRUZ, Calif. — For more than 30 years, public health officials and nonprofits in California have provided clean hypodermic needles to people who use them to inject drugs.

For nearly that entire time, opponents have accused the free needle programs of promoting drug use and homelessness.

But recently, opponents have deployed a novel strategy to shut them down: using environmental regulations to sue over needle waste. They argue that contaminated needles pollute parks and waterways — and their lawsuits have succeeded across the state.

A bill signed Monday by Democratic Gov. Gavin Newsom will thwart that tactic.

Environmental challenges have already forced free needle programs in Orange County, Chico and Eureka to close or modify their operations.

The new law comes at a critical moment for a program in Santa Cruz. A final court ruling that could determine the fate of the program is expected within days, and it's not clear how the law will affect the judge's decision.

"We're in the midst of an opioid crisis," said Assembly member Joaquin Arambula (D-Fresno), a physician who wrote the bill Newsom signed, AB 1344. "We need all the tools that we have available for us to address this crisis head-on."

Despite the legislative victory, lawsuits to challenge needle programs on other grounds are still possible, and local ordinances banning needle exchanges have flourished across California.

Under the new law, which takes effect Jan. 1, opponents of free needle programs will no longer be able to sue over violations of the California Environmental Quality Act, known as CEQA.

CEQA requires projects that need approval from a public agency or receive public funding to be assessed for their potential environmental impacts. This requirement applies to major construction projects, like reservoirs and freeway overpasses, and localized ones such as affordable housing. CEQA is enforced by lawsuits and has been invoked over the years to stop or slow unpopular proposals, like homeless shelters.

California allows licensed physicians to give clean needles to patients without authorization. Free needle programs run by local governments or community groups must be approved by the state, a county or city.

These programs, which allow people to dispose of used "rigs" and get new ones, attempt to reduce the spread of HIV and hepatitis C, which can spread among drug users who share needles, and decrease infections among users. Some are true "exchanges" that require people to turn in a used needle to get a new one. Others allow people to take what they need without returning them.

In the past few years, opponents have started focusing on the programs' environmental impacts because some needles end up on the ground or in creeks and rivers.

Walt McNeill, a lawyer in Nevada City, California, challenged nonprofit-run needle programs in Chico, Eureka and Santa Cruz on behalf of local officials, former law enforcement officers and community groups.

McNeill said his clients aren't opposed to needle programs in general, just ones they believe are run irresponsibly. "You have no idea where the needles are going, and no way of recovering needles effectively," he said.

The trend in environmental challenges began a few years ago when the only needle program in Orange County shut down following a CEQA lawsuit. In 2020, a program created to address needle pollution in Chico closed after it settled a CEQA lawsuit, then later reopened on a smaller scale under a physician's authority. Also in 2020, Eureka officials wouldn't reauthorize a needle program after McNeill challenged it on environmental grounds.

Last year, McNeill sued one of two free needle programs in Santa Cruz County. Run by the Harm Reduction Coalition of Santa Cruz County, it operates out of a van and serves up to 75 people each Sunday on the same street corner in an industrial part of town. The complaint alleged the program "spread tens of thousands of used and unused hypodermic needle 'litter'" throughout the community and has led to "environmental degradation of the creeks, streams, rivers and beaches."

A superior court judge in Sacramento is expected to hand down her ruling soon. McNeill said he's confident the judge will side with his clients despite the new law because of other flaws in the program. If she disagrees, he said, he may file another suit on other grounds.

"No matter how you slice it, the program will be deauthorized," he said.

But Denise Elerick, founder of the coalition, said she believes her program will survive. She said arguments about needle litter mask anti-homeless sentiment.

"They say it's about the environment but it's not. They want people to die and disappear," she said.

Decades of research shows that needle giveaways aren't a major source of pollution, and that people who get needles from an exchange are more likely to dispose of them properly than those who don't.

A 2019 study by Santa Cruz County's Health Services Agency found that for every 10 needles that ended up on the ground or in a river, 1,000 made it into a sharps container, used to collect used needles, or an official disposal point. The report concluded that reducing needle litter would require more syringe programs and disposal sites, not fewer.

The Santa Cruz program, which began in 2018, gives out as many syringes as people request.

In addition to offering nine sizes of syringes, the program gives out sharps containers, ranging in capacity from a quarter gallon to 8 gallons, which can be returned, picked up or left at disposal kiosks around town.

On one Sunday in August, 56 people stopped by the van and 51 sharps containers were distributed. The coalition would not disclose how many needles it typically gives away.

The clients also gathered supplies to protect them from staph infections, COVID and other dangers: condoms, hand sanitizer, masks, alcohol pads, drug-testing strips to ferret out fentanyl, and medication to reverse overdoses. The program even offered clean pipes to encourage that drugs be smoked — rather than injected — and reduce the spread of COVID from sharing pipes.

Many who line up each week live in nearby parks and alongside creeks that are the focus of opponents' environmental concerns. They said they have a vested interest in keeping the environment clean.

"Just because we're drug addicts doesn't mean we don't take care of ourselves," said one woman, 35. (In order to observe how the program works, KHN agreed not to name the people procuring supplies.) "Yeah, I live in a tent, but my tent is clean. I try to take care of other people and I take care of myself."

The new law comes too late for programs like Chico's, because the city has since passed an ordinance banning syringe exchanges. Similar bans have been adopted in Anaheim, Oroville, Butte County, Yuba City and elsewhere in the past few years.

Ryan Coonerty, a Santa Cruz County supervisor, said the county likely won't adopt a ban, though he's disappointed by Newsom's decision. He believes the nonprofit needle program in Santa Cruz contributes to needle pollution more than the county-run program, which requires people to turn in used needles to get fresh ones.

"We will continue to struggle with needle litter and, unfortunately, not get any help from the state to stop needles from going into the ocean, parks and beaches," he said.

But the Centers for Disease Control and Prevention and other public health agencies say one-for-one programs limit the ways people can safely dispose of sharps, forcing them to hang onto their needles until the next needle exchange. That's not realistic, according to the people who lined up to get needles from the Santa Cruz program.

"A lot of us are homeless," said one 40-year-old woman, "and we can only stay someplace for so long."

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

Rachel Bluth: rbluth@kff.org, @RachelHBluth

Major Insurers Running Billions of Dollars Behind on Payments to Hospitals and Doctors

KFF Health News, October 6, 2021

Hospitals are also dealing with a spike in retroactive claims denials by UnitedHealthcare.

This article was published on Wednesday, October 6, 2021 in Kaiser Health News.

By Jay Hancock 

Anthem Blue Cross, the country's second-biggest health insurance company, is behind on billions of dollars in payments owed to hospitals and doctors because of onerous new reimbursement rules, computer problems and mishandled claims, say hospital officials in multiple states.

Anthem, like other big insurers, is using the COVID-19 crisis as cover to institute "egregious" policies that harm patients and pinch hospital finances, said Molly Smith, group vice president at the American Hospital Association. "There's this sense of 'Everyone's distracted. We can get this through,'" she said.

Hospitals are also dealing with a spike in retroactive claims denials by UnitedHealthcare, the biggest health insurer, for emergency department care, AHA says.

Disputes between insurers and hospitals are nothing new. But this fight sticks more patients in the middle, worried they'll have to pay unresolved claims. Hospitals say it is hurting their finances as many cope with COVID surges — even after the industry has received tens of billions of dollars in emergency assistance from the federal government.

"We recognize there have been some challenges" to prompt payments caused by claims-processing changes and "a new set of dynamics" amid the pandemic, Anthem spokesperson Colin Manning said in an email. "We apologize for any delays or inconvenience this may have caused."

Virginia law requires insurers to pay claims within 40 days. In a Sept. 24 letter to state insurance regulators, VCU Health, a system that operates a large teaching hospital in Richmond associated with Virginia Commonwealth University, said Anthem owes it $385 million. More than 40% of the claims are more than 90 days old, VCU said.

For all Virginia hospitals, Anthem's late, unpaid claims amount to "hundreds of millions of dollars," the Virginia Hospital and Healthcare Association said in a June 23 letter to state regulators.

Nationwide, the payment delays "are creating an untenable situation," the American Hospital Association said in a Sept. 9 letter to Anthem CEO Gail Boudreaux. "Patients are facing greater hurdles to accessing care; clinicians are burning out on unnecessary administrative tasks; and the system is straining to finance the personnel and supplies" needed to fight COVID.

Complaints about Anthem extend "from sea to shining sea, from New Hampshire to California," AHA CEO Rick Pollack told KHN.

Substantial payment delays can be seen on Anthem's books. On June 30, 2019, before the pandemic, 43% of the insurer's medical bills for that quarter were unpaid, according to regulatory filings. Two years later that figure had risen to 53% — a difference of $2.5 billion.

Anthem profits were $4.6 billion in 2020 and $3.5 billion in the first half of 2021.

Alexis Thurber, who lives near Seattle, was insured by Anthem when she got an $18,192 hospital bill in May for radiation therapy that doctors said was essential to treat her breast cancer.

The treatments were "experimental" and "not medically necessary," Anthem said, according to Thurber. She spent much of the summer trying to get the insurer to pay up — placing two dozen phone calls, spending hours on hold, sending multiple emails and enduring unmeasurable stress and worry. It finally covered the claim months later.

"It's so egregious. It's a game they're playing," said Thurber, 51, whose cancer was diagnosed in November. "Trying to get true help was impossible."

Privacy rules prevent Anthem from commenting on Thurber's case, said Anthem spokesperson Colin Manning.

When insurers fail to promptly pay medical bills, patients are left in the lurch. They might first get a notice saying payment is pending or denied. A hospital might bill them for treatment they thought would be covered. Hospitals and doctors often sue patients whose insurance didn't pay up.

Hospitals point to a variety of Anthem practices contributing to payment delays or denials, including new layers of document requirements, prior-authorization hurdles for routine procedures and requirements that doctors themselves — not support staffers — speak to insurance gatekeepers. "This requires providers to literally leave the patient['s] bedside to get on the phone with Anthem," AHA said in its letter.

Anthem often hinders coverage for outpatient surgery, specialty pharmacy and other services in health systems listed as in-network, amounting to a "bait and switch" on Anthem members, AHA officials said.

"Demanding that patients be treated outside of the hospital setting, against the advice of the patient's in-network treating physician, appears to be motivated by a desire to drive up Empire's profits," the Greater New York Hospital Association wrote in an April letter to Empire Blue Cross, which is owned by Anthem.

Anthem officials pushed back in a recent letter to the AHA, saying the insurer's changing rules are intended partly to control excessive prices charged by hospitals for specialty drugs and nonemergency surgery, screening and diagnostic procedures.

Severe problems with Anthem's new claims management system surfaced months ago and "persist without meaningful improvement," AHA said in its letter.

Claims have gotten lost in Anthem's computers, and in some cases VCU Health has had to print medical records and mail them to get paid, VCU said in its letter. The cash slowdown imposes "an unmanageable disruption that threatens to undermine our financial footing," VCU said.

United denied $31,557 in claims for Emily Long's care after she was struck in June by a motorcycle in New York City. She needed surgery to repair a fractured cheekbone. United said there was a lack of documentation for "medical necessity" — an "incredibly aggravating" response on top of the distress of the accident, Long said.

The Brooklyn hospital that treated Long was "paid appropriately under her plan and within the required time frame," said United spokesperson Maria Gordon Shydlo. "The facility has the right to appeal the decision."

United's unpaid claims came to 54% as of June 30, about the same level as two years previously.

When Erin Conlisk initially had trouble gaining approval for a piece of medical equipment for her elderly father this summer, United employees told her the insurer's entire prior-authorization database had gone down for weeks, said Conlisk, who lives in California.

"There was a brief issue with our prior-authorization process in mid-July, which was resolved quickly," Gordon Shydlo said.

When asked by Wall Street analysts about the payment backups, Anthem executives said it partly reflects their decision to increase financial reserves amid the health crisis.

"Really a ton of uncertainty associated with this environment," John Gallina, the company's chief financial officer, said on a conference call in July. "We've tried to be extremely prudent and conservative in our approach."

During the pandemic, hospitals have benefited from two extraordinary cash infusions. They and other medical providers have received more than $100 billion through the CARES Act of 2020 and the American Rescue Plan of 2021. Last year United, Anthem and other insurers accelerated billions in hospital reimbursements.

The federal payments enriched many of the biggest, wealthiest systems while poorer hospitals serving low-income patients and rural areas struggled.

Those are the systems most hurt now by insurer payment delays, hospital officials said. Federal relief funds "have been a lifeline, but they don't make people whole in terms of the losses from increased expenses and lost revenue as a result of the COVID experience," Pollack said.

Several health systems declined to comment about claims-payment delays or didn't respond to a reporter's queries. Among individual hospitals "there is a deep fear of talking on the record about your largest business partner," AHA's Smith said.

Alexis Thurber worried she might have to pay her $18,192 radiation bill herself, and she's not confident her Anthem policy will do a better job next time of covering the cost of her care.

"It makes me not want to go to the doctor anymore," she said. "I'm scared to get another mammogram because you can't rely on it."

Jay Hancock: jhancock@kff.org, @JayHancock1

Opinion: The Pandemic Forced My Transgender Wife to Fight Our Insurer Over Hormones

KFF Health News, October 5, 2021

The COVID-19 pandemic has caused millions of people to lose their jobs and private health insurance, particularly LGBTQ adults.

This article was published on Tuesday, October 5, 2021 in Kaiser Health News.

By Helen Santoro   

GUNNISON, Colo. — For the past eight years, my wife, Ky Hamilton, has undergone gender-affirming hormone therapy. As a transgender woman, she injects Depo-Estradiol liquid estrogen into her thigh once a week. This drug has allowed her to physically transition as a woman, and each vial, which lasts around five weeks, was completely covered by insurance.  

That was until she lost her job in April 2020 and we switched to a subsidized private health insurance plan in Colorado's Affordable Care Act marketplace. We discovered that our new insurance from Anthem doesn't cover Depo-Estradiol and it would cost $125 out-of-pocket per vial. With both of us — and our four pets — depending heavily on Ky's weekly $649 unemployment check, such medical expenses proved difficult. And as of Sept. 6, those unemployment checks ran out.

"I'm absolutely stressed. I don't know what to do," Ky said in August as we tried to find a solution.

Because of Ky's physical transition as a transgender woman, her body doesn't make the testosterone it once used to. So, without the medication, she would essentially go through menopause. A decline in estrogen levels can also cause transgender women to lose the physical transitions they've achieved, resulting in gender dysphoria, which is psychological distress from the mismatch between their biological sex and their gender identity.

Unfortunately, Ky's experience is shared by many other transgender Americans. The COVID-19 pandemic has caused millions of people to lose their jobs and private health insurance, particularly LGBTQ adults, who reported at higher rates than non-LGBTQ adults that they lost their jobs during the crisis. Consequently, enrollment surged in ACA plans and Medicaid, the state-federal health program for low-income people. Yet many of those plans don't fully cover gender-affirming care, partly because of conservative policies and lack of scientific research on how crucial this care is for transgender patients.

According to a survey by Out2Enroll, a national initiative to connect LGBTQ people with ACA coverage, 46% of the 1,386 silver marketplace plans polled cover all or some medically necessary treatment for gender dysphoria. However, 7% have trans-specific exclusions, 14% have some exclusions, and 33% don't specify.

"It's this whack-a-mole situation where plans for the most part do not have blanket exclusions, but where people are still having difficulty getting specific procedures, medications, etc., covered," said Kellan Baker, executive director of the Whitman-Walker Institute, a nonprofit that focuses on LGBTQ research, policy and education.

Twenty-three states and Washington, D.C., include gender-affirming care in their Medicaid plans. But 10 states exclude such coverage entirely. In 2019, an estimated 152,000 transgender adults were enrolled in Medicaid, a number that has likely grown during the pandemic.

Yet even in states such as California that require their Medicaid programs to cover gender-affirming care, patients still struggle to get injectable estrogen, said Dr. Amy Weimer, an internist who founded the UCLA Gender Health Program. While California Medicaid, or Medi-Cal, covers Depo-Estradiol, doctors must request treatment authorizations to prove their patients need the drug. Weiner said those are rarely approved.

Such "prior authorizations" are an issue across Medicaid and ACA plans for medications including injectable estrogen and testosterone, which is used by transgender men, Baker said.

The lack of easy coverage may reflect the fact that injectable estrogen, which provides the high doses of the hormone needed for transgender women to physically transition, isn't commonly used by non-trans women undergoing hormone therapy to treat menopause or other issues, Weimer said.

It also may be because cheaper options, including daily estrogen pills, exist, but these increase the risk of blood clots. Estrogen patches release the hormone through the skin but can cause skin reactions, and many people struggle to absorb enough estrogen, Weimer said. Consequently, many of Weimer's patients wear up to four patches at a time, but Medi-Cal limits the number of patches patients can get monthly.

While such insurance gaps have existed for long before the pandemic, the current crisis seems to have amplified the matter, according to Weimer.

The ACA prohibits discrimination based on race, color, national origin, age, disability and sex in health programs and activities that receive federal financial assistance. The Trump administration significantly narrowed the power of that provision, including eliminating health insurance protections for transgender people.

However, in June 2020, before the Trump regulations could take effect, the Supreme Court ruled in Bostock v. Clayton County, Georgia, that employment discrimination based on sex includes sexual orientation and gender identity.

This landmark decision has served as a crucial tool to address LGBTQ discrimination in many aspects of life, including healthcare. As of July, for example, Alaska Medicaid can no longer exclude gender-affirming treatment after Swan Being, a transgender woman, won a class-action lawsuit that relied in part on the Bostock decision.

The Biden administration announced in May that the U.S. Department of Health and Human Services Office for Civil Rights will include gender identity and sexual orientation in its enforcement of the ACA's anti-discrimination provision. The next month, Veterans Affairs health benefits were expanded to include gender confirmation surgery.

But for now, the pressure is still on patients like Ky to fight for their health benefits.

Anthem spokesperson Tony Felts said Depo-Estradiol is not on the list of covered drugs for its ACA plans, though many of its private employer-sponsored plans cover it.

Because we had one of those ACA plans, Ky had to be persistent. After four months of emails and phone calls — and just before unemployment ran out — Anthem finally authorized her Depo-Estradiol. That brings her out-of-pocket cost to $60 per vial for the next year. It's still expensive for us right now, but we'll find a way to make it work.

"The reality is that trans people are more likely to be in poverty and don't have the time or knowledge to spend four months fighting to get their estradiol like I did," Ky said.

Pages