Hospitals Confront Climate Change as Patients Sick From Floods and Fires Crowd ERs

KFF Health News, October 1, 2021

One recent assessment predicts annual U.S. heat deaths could reach nearly 60,000 by 2050.

This article was published on Friday, October 1, 2021 in Kaiser Health News.

By Miranda Green  

When triple-digit temperatures hit the Pacific Northwest this summer, the emergency room at Seattle's Harborview Medical Center was ill prepared. Doctors raced to treat heat-aggravated illness in homeless people, elderly patients with chronic ailments, and overdosing narcotics users.

"The magnitude of the exposure, this was so far off the charts in terms of our historical experience," said Dr. Jeremy Hess, an emergency medicine physician and professor of environmental and occupational health sciences at the University of Washington.

Doctors, nurses and hospitals increasingly are seeing patients sickened by climate-related problems, from overheating to smoke inhalation from wildfires and even infectious diseases. One recent assessment predicts annual U.S. heat deaths could reach nearly 60,000 by 2050.

For some medical professionals, this growing toll has stimulated a reckoning with the healthcare industry's role in global warming. U.S. hospitals and medical centers consume more energy than any industry except for food service, according to the U.S. Energy Information Administration. Hospitals consume 2.5 times as much energy per square foot as typical office buildings, on average. They also contribute mountains of medical waste and emit atmosphere-damaging gases used in surgery and other procedures.

But the healthcare sector is beginning to respond. The Health and Human Services Department's newly created Office of Climate Change and Health Equity, in addition to focusing on climate-related illness, says it will work "to reduce greenhouse gas emissions and criteria air pollution throughout the healthcare sector." The office could help change regulations that restrict sustainability efforts, climate activists say.

Already, many U.S. hospitals have begun installing solar panels, while others are trying to cut surgical waste and phase out ozone-damaging chemicals. Activists are pressing for the industry to cut back on energy-intensive protocols, such as ventilation requirements that mandate a high level of air circulation, measured as air changes per hour. They say they could be reduced without harming patients.

"I think there is recognition among physicians that climate change is likely to continue and worsen over time," said Hess. "We don't necessarily do as much as we could otherwise to reduce our footprint and advance sustainability, and that's where I'd like to see our health systems go."

But the industry is moving cautiously to avoid harm to patients — and legal liability. They "don't want to make any mistakes. And part of not making mistakes is a resistance to change," said Dr. Matthew Meyer, co-chair of University of Virginia Health's sustainability committee.

The University of Vermont Medical Center was one of the first U.S. hospital systems to focus on sustainability initiatives. It has succeeded in reducing emissions by roughly 9% since 2015 by renovating and building structures to be more energy-efficient and converting off-site medical centers to run 50% on renewable natural gas. One of its hospitals cut waste by more than 60% through reuse and recycling.

Managed-care nonprofit Kaiser Permanente, meanwhile, has focused on greening its energy consumption. By September 2020, all of its 39 hospitals and 727 medical offices had achieved carbon neutrality. At most Kaiser Permanente hospitals, solar panels provide one-quarter to one-third of energy needs.

Kaiser Permanente aims eventually to generate enough electricity through solar technology to eliminate the need for diesel-powered backup generators at its hospitals, which are heavily used in areas with stressed power grids. In 2017 and 2019, power company shut-offs in California forced the health network to evacuate its Santa Rosa Medical Center, and electricity was cut to its Vallejo Medical Center.

"To have those facilities be out for a week or more is just not tolerable," said Seth Baruch, Kaiser Permanente's national director for energy and utilities.

Increased energy sustainability has brought a small financial windfall. Kaiser Permanente saves roughly $500,000 a year in electricity costs through its grids and solar panels, Baruch said. (KHN is not affiliated with Kaiser Permanente.)

Reaching consensus on emission-lowering steps can be difficult. It took seven months for UVA's Meyer, an anesthesiologist, to persuade his hospital to phase out most uses of desflurane, a common anesthetic that damages the ozone layer and is a potent greenhouse gas.

Meyer argued other drugs could replace desflurane. But critics warned that the most common alternatives slowed patients' postoperative recovery, when compared with desflurane. They said there were ways to neutralize excess desflurane in operating room air without discontinuing it entirely.

The "first do no harm" ethos of medicine can also be an obstacle to the reduction of medical waste. The Joint Commission, which accredits more than 22,000 U.S. healthcare organizations, has in recent years pushed for hospitals to use more disposable devices instead of sanitizing reusable devices.

The commission's primary objective is to cut hospital infections, but more disposable items means less sustainability. About 80% of U.S. healthcare sector emissions arise from the manufacturers, and their suppliers and distributors, including the production of single-use disposable medical equipment, according to a study.

Complicating the issue, ethylene oxide — a chemical the Food and Drug Administration requires for sterilization of many devices — has been categorized as a carcinogen by the Environmental Protection Agency. In 2019, health concerns led communities to push for the closure of facilities that use the gas, which threatened to create a shortage of clean medical devices.

Maureen Lyons, a spokesperson for the Joint Commission, said the private accreditor lacks the authority to change regulations. The procurement of disposable versus reusable devices is a supply chain issue, "not one that the Joint Commission is able to evaluate for compliance."

For this reason, healthcare activists are lobbying for sustainability through policy changes. Healthcare Without Harm, an environmental advocacy group, seeks to undo state rules that impose what it sees as excessively energy-intensive ventilation, humidification and sterilization requirements.

In California, the group has sought to change a medical building code adopted statewide in July that will require a higher ventilation standard at healthcare facilities. The group says the new standard is unnecessary. While high rates of circulation are needed in intensive care units, operating rooms and isolation chambers, there is no evidence for maintaining such standards throughout a hospital, said Robyn Rothman, associate director of state policy programs at Healthcare Without Harm. She cited a 2020 study from the American Society for Healthcare Engineering.

Hospital groups have resisted sustainability commitments on the grounds they will bring more red tape and costs to their hospitals, Rothman said.

The American Society for Healthcare Engineering, a professional group allied with the American Hospital Association, has developed sustainability goals for reducing emissions. But existing regulations make it difficult to achieve many of them, said Kara Brooks, the group's sustainability program manager.

For example, the Centers for Medicare & Medicaid Services requires hospitals that treat Medicaid and Medicare patients to have backup diesel generators.

"Hospitals will not be able to eliminate their use of fossil fuels based on the current regulations," Brooks said, but "we encourage hospitals to work toward their goals within the parameters given."

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

Miranda Green: mirandac.green@gmail.com, @mirandacgreen

A COVID Test Costing More Than a Tesla? It Happened in Texas.

KFF Health News, September 30, 2021

A Texas couple each had a COVID diagnostic PCR test at SignatureCare Emergency Center and were charged $56,384  owns across Texas.

This article was published on Thursday, September 30, 2021 in Kaiser Health News.

By Aneri Pattani  

When COVID-19 struck last year, Travis Warner's company became busier than ever. He installs internet and video systems, and with people suddenly working from home, service calls surged.

He and his employees took precautions like wearing masks and physically distancing, but visiting clients' homes daily meant a high risk of COVID exposure.

"It was just like dodging bullets every week," Warner said.

In June 2020, an employee tested positive. That sent Warner and his wife on their own hunt for a test.

Because of limited testing availability at the time, they drove 30 minutes from their home in Dallas to a free-standing emergency room in Lewisville, Texas. They received PCR diagnostic tests and rapid antigen tests.

When all their results came back negative, it was a huge relief, Warner said. He eagerly got back to work.

Then the bill came.

The Patient: Travis Warner, 36, is self-employed and bought coverage from Molina Healthcare off the insurance marketplace.

Medical Service: Two COVID tests: a diagnostic PCR test, which typically takes a few days to process and is quite accurate, and a rapid antigen test, which is less accurate but produces results in minutes.

Total Bill: $56,384, including $54,000 for the PCR test and the balance for the antigen test and an ER facility fee. Molina's negotiated rate for both tests and the facility fee totaled $16,915.20, which the insurer paid in full.

Service Provider: SignatureCare Emergency Center in Lewisville, one of more than a dozen free-standing ERs the company owns across Texas.

What Gives: Throughout the pandemic, stories of shockingly high prices for COVID tests have abounded. A recent report from an insurance trade association noted that "price gouging by certain providers continues to be a widespread problem."

But Warner's PCR bill of $54,000 is nearly eight times the most notable charge previously reported, at $7,000 — and his insurer paid more than double that highest reported charge. Health policy experts KHN interviewed called Warner's bill "astronomical" and "one of the most egregious" they'd seen.

Yet it's perfectly legal. For COVID tests — like much else in American healthcare — there is no cap to what providers can charge, said Loren Adler, associate director of the USC-Brookings Schaeffer Initiative for Health Policy.

COVID testing has been in a special category, however. When the pandemic hit, lawmakers worried people might avoid necessary testing for fear of the cost. So they passed bills that required insurers to pay for COVID tests without copays or cost sharing for the patient.

For in-network providers, insurers can negotiate prices for the tests, and for out-of-network providers, they're generally required to pay whatever price the providers list publicly on their websites. The free-standing ER was out of network for Warner's plan.

While the policy was intended to help patients, health experts say, it has unintentionally given providers leeway to charge arbitrary, sometimes absurd prices, knowing that insurers are required to pay and that patients, who won't be billed, are unlikely to complain.

"People are going to charge what they think they can get away with," said Niall Brennan, president and CEO of the Healthcare Cost Institute, a nonprofit that studies healthcare prices. "Even a perfectly well-intentioned provision like this can be hijacked by certain unscrupulous providers for nefarious purposes."

A report from KFF published earlier this year found that hospital charges for COVID tests ranged from $20 to $1,419, not including physician or facility fees, which can often be higher than the cost of the tests themselves. About half the test charges were below $200, the report noted, but 1 in 5 were over $300.

"We observed a broad range of COVID-19 testing prices, even within the same hospital system," the authors wrote.

Realistically, the cost of a COVID test should be in the double digits, Brennan said. "Low triple digits if we're being generous."

Medicare pays $100 for a test, and at-home tests are sold for as little as $24 for an antigen test or $119 for a PCR test.

Warner's charges were fully covered by his insurance.

But insurance policy premiums reflect how much is paid to providers. "If the insurance company is paying astronomical sums of money for your care, that means in turn that you are going to be paying higher premiums," Adler said.

Taxpayers, who subsidize marketplace insurance plans, also face a greater burden when premiums increase. Even those with employer-sponsored health coverage feel the pain. Research shows that each increase of $1 in an employer's health costs is associated with a 52-cent cut to an employee's overall compensation.

Even before the pandemic, wide variability in the prices for common procedures like cesarean sections and blood tests had been driving up the cost of healthcare, Brennan said. These discrepancies "happen every single day, millions of times a day."

Resolution: When Warner saw that his insurance company had paid the bill, he first thought: "At least I'm not liable for anything."

But the absurdity of the $54,000 charge gnawed at him. His wife, who'd received the same tests the same day at the same place, was billed $2,000. She has a separate insurance policy, which settled the claim for less than $1,000.

Warner called his insurer to see if someone could explain the charge. After a game of phone tag with the ER and the ER's billing firm, and several months of waiting, Warner received another letter from his insurer. It said they'd audited the claim and taken back the money they had paid the ER.

In a statement to KHN, a spokesperson for Molina Healthcare wrote, "This matter was a provider billing error which Molina identified and corrected."

SignatureCare Emergency Centers, which issued the $54,000 charge, said it would not comment on a specific patient's bill. However, in a statement, it said its billing error rate is less than 2% and that it has a "robust audit process" to flag errors. At the height of the pandemic, SignatureCare ERs faced "unprecedented demands" and processed thousands of records a day, the company said.

SignatureCare's website now lists the charge for COVID tests as $175.

The Takeaway: COVID testing should be free to consumers during the public health emergency (currently extended through mid-October, and likely to be renewed for an additional 90 days). Warner did his insurer a big favor by looking carefully at his bill, even though he didn't owe anything.

Insurers are supposed to have systems that flag billing errors and prevent overpayment. This includes authorization requirements before services are rendered and audits after claims are filed.

But "there's a question of how well they work," Adler said. "In this case, it's lucky [Warner] noticed."

At least one estimate says 3% to 10% of healthcare spending in the U.S. is lost to overpayment, including cases of fraud, waste and abuse.

Unfortunately, that means the onus is often on the patient.

You should always read your bill carefully, experts say. If the cost seems inappropriate, call your insurer and ask them to double-check and explain it to you.

It's not your job, experts agree, but in the long run, fewer overpayments will save money for you and others in the American healthcare system.

Bill of the Month is a crowdsourced investigation by KHN and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!

Aneri Pattani: apattani@kff.org, @aneripattani

As Democrats Bicker Over Massive Spending Plan, Here's What's at Stake for Medicaid

KFF Health News, September 30, 2021

Twelve Republican-controlled states have yet to adopt the Medicaid expansion, leaving 2.2 million low-income adult residents uninsured.

This article was published on Thursday, September 30, 2021 in Kaiser Health News.

By Phil Galewitz

Hours after the Supreme Court in 2012 narrowly upheld the Affordable Care Act but rejected making Medicaid expansion mandatory for states, Obama administration officials laughed when asked whether that would pose a problem.

In a White House briefing, top advisers to President Barack Obama told reporters states would be foolish to turn away billions in federal funding to help residents lacking the security of health insurance.

Flash-forward nearly a decade, and it's clear to see the consequences of that ruling.

Today, 12 Republican-controlled states have yet to adopt the Medicaid expansion, leaving 2.2 million low-income adult residents uninsured.

Tired of waiting for Republican state lawmakers, congressional Democrats are moving to close the Medicaid coverage gap as they forge a package of new domestic spending that could run as high as $3.5 trillion over 10 years and would significantly enhance other federal health programs. But the cost is raising concerns within the party, and the competition to get initiatives in the package is fierce.

With Democrats controlling both chambers of Congress and the White House, health experts say this could be the only time such a fix to the "Medicaid gap" will be possible for many years.

"This is a last best chance to do this," said Judith Solomon, a senior fellow with the left-leaning Center on Budget and Policy Priorities.

Here are six things to know about what's at stake for Medicaid.

1. Who would be helped?

The adults caught in the coverage gap have incomes that are too high for them to qualify under their states' tight eligibility rules that predated the 2010 health law but are below the federal poverty level ($12,880 a year for an individual). When setting up the ACA, Congress expected that people making less than the poverty guideline would be covered by Medicaid, so the law provides no subsidies for coverage on the ACA marketplaces.

About 59% of adults in the coverage gap are people of color, according to a KFF analysis. Nearly two-thirds live in a household with at least one worker.

The states that have not expanded Medicaid are Alabama, Florida, Georgia, Kansas, Mississippi, North and South Carolina, South Dakota, Tennessee, Texas, Wisconsin and Wyoming.

About three-quarters of those in the coverage gap live in four states: Texas (35%), Florida (19%), Georgia (12%) and North Carolina (10%).

2. Why haven't states expanded?

Republicans in these states have listed a litany of reasons. They assert that Medicaid, a state-federal program launched in 1966 that today covers 1 in 4 Americans, is a broken system that doesn't improve health, despite dozens of studies to the contrary. Or they say working adults don't deserve government help with health insurance. They also complain it's too expensive for states to put up their 10% share (the federal government pays the rest), and they don't trust Congress will keep up its funding promises for expansion states.

Each time Medicaid expansion has made it onto a ballot in a Republican-majority state, it has passed — most recently in 2020 in Oklahoma and Missouri.

3. How would the Democrats' plan work?

The House plan has two phases. Under the bill passed by the Energy and Commerce Committee, starting in 2022, people in the coverage gap with incomes up to 138% of the federal poverty level (about $17,774 for an individual) would be eligible for subsidies to buy coverage on the marketplace.

Enrollees wouldn't pay a monthly premium because the tax credits would be enough to cover the full cost, according to an analysis by Solomon. There would be no deductibles to meet and only minimal copays, like most state Medicaid programs.

Help not typically available under the ACA would be offered. For example, Solomon's analysis notes, low-paid workers wouldn't be barred from enrolling in marketplace plans because they have an offer of employer coverage. In addition, people could enroll at any time during the year, not just during open enrollment season in late fall/early winter.

Phase two would begin in 2025. That's when people in the coverage gap would transition to a federally operated Medicaid program run by managed-care plans and third-party administrators.

Enrollees would not pay any cost sharing in the federal Medicaid plan.

4. Would the coverage be as good as if the states adopted expansion?

It would be very close, Solomon said. The new plan would include coverage for all services defined by the law as "essential" health benefits, such as hospital services and prescription drugs.

One difference is coverage for nonemergency transportation services would not start until 2024. In addition, during those early years of the plan, some long-term services for medically frail people typically covered under Medicaid would not be included and some screening and treatment services for 19- and 20-year-olds would not be offered.

The first phase would also not provide retroactive coverage for the three months prior to application. Medicaid today covers medical expenses incurred in the three months before an individual applies if the person is found to have been eligible during those months.

One potential benefit of using the marketplace plans is they could have broader networks of doctors than those associated with Medicaid programs.

5. How much would it cost?

The Congressional Budget Office has not yet revealed estimates, although the price tag would likely be in the billions of dollars.

The federal cost for covering people by helping them buy marketplace plans is higher than it would be if the states had expanded Medicaid. That's because marketplace plans generally pay higher fees to doctors and hospitals, making them more costly, Solomon explained.

6. Could states that have already expanded Medicaid rescind that policy and require residents to get coverage under the new setup?

The bill offers incentives for states to keep their current Medicaid options. If a state opts to stop spending funds on the Medicaid expansion, it may have to pay a penalty based on the number of enrollees that move to the federal program, potentially amounting to millions of dollars.

Phil Galewitz: pgalewitz@kff.org, @philgalewitz

COVID Is Killing Rural Americans at Twice the Rate of Urbanites

KFF Health News, September 30, 2021

Since the pandemic began, about 1 in 434 rural Americans have died of COVID, compared with roughly 1 in 513 urban Americans.

This article was published on Thursday, September 30, 2021 in Kaiser Health News.

By Lauren Weber

Rural Americans are dying of COVID at more than twice the rate of their urban counterparts — a divide that health experts say is likely to widen as access to medical care shrinks for a population that tends to be older, sicker, heavier, poorer and less vaccinated.

While the initial surge of COVID-19 deaths skipped over much of rural America, where roughly 15% of Americans live, nonmetropolitan mortality rates quickly started to outpace those of metropolitan areas as the virus spread nationwide before vaccinations became available, according to data from the Rural Policy Research Institute.

Since the pandemic began, about 1 in 434 rural Americans have died of COVID, compared with roughly 1 in 513 urban Americans, the institute's data shows. And though vaccines have reduced overall COVID death rates since the winter peak, rural mortality rates are now more than double urban rates — and accelerating quickly.

In rural northeastern Texas, Titus Regional Medical Center CEO Terry Scoggin is grappling with a 39% vaccination rate in his community. Eleven patients died of COVID in the first half of September at his hospital in Mount Pleasant, population 16,000. Typically, three or four non-hospice patients die there in a whole month.

"We don't see death like that," Scoggin said. "You usually don't see your friends and neighbors die."

Part of the problem is that COVID incidence rates in September were roughly 54% higher in rural areas than elsewhere, said Fred Ullrich, a University of Iowa College of Public Health research analyst who co-authored the institute's report. He said the analysis compared the rates of nonmetropolitan, or rural, areas and metropolitan, or urban, areas. In 39 states, he added, rural counties had higher rates of COVID than their urban counterparts.

"There is a national disconnect between perception and reality when it comes to COVID in rural America," said Alan Morgan, head of the National Rural Health Association. "We've turned many rural communities into kill boxes. And there's no movement towards addressing what we're seeing in many of these communities, either among the public or among governing officials."

Still, the high incidence of cases and low vaccination rates don't fully capture why mortality rates are so much higher in rural areas than elsewhere. Academics and officials alike describe rural Americans' greater rates of poor health and their limited options for medical care as a deadly combination. The pressures of the pandemic have compounded the problem by deepening staffing shortages at hospitals, creating a cycle of worsening access to care.

It's the latest example of the deadly coronavirus wreaking more havoc in some communities than others. COVID has also killed Native American, Black and Hispanic people at disproportionately high rates.

Vaccinations are the most effective way to prevent COVID infections from turning deadly. Roughly 41% of rural America was vaccinated as of Sept. 23, compared with about 53% of urban America, according to an analysis by The Daily Yonder, a newsroom covering rural America. Limited supplies and low access made shots hard to get in the far-flung regions at first, but officials and academics now blame vaccine hesitancy, misinformation and politics for the low vaccination rates.

In hard-hit southwestern Missouri, for example, 26% of Newton County's residents were fully vaccinated as of Sept. 27. The health department has held raffles and vaccine clinics, advertised in the local newspaper, and even driven the vaccine to those lacking transportation in remote areas, according to department administrator Larry Bergner. But he said interest in the shots typically increases only after someone dies or gets seriously ill within a hesitant person's social circle.

Additionally, the overload of COVID patients in hospitals has undermined a basic tenet of rural health care infrastructure: the capability to transfer patients out of rural hospitals to higher levels of specialty care at regional or urban health centers.

"We literally have email Listservs of rural chief nursing officers or rural CEOs sending up an SOS to the group, saying, 'We've called 60 or 70 hospitals and can't get this heart attack or stroke patient or surgical patient out and they're going to get septic and die if it goes on much longer,'" said John Henderson, president and CEO of the Texas Organization of Rural & Community Hospitals.

Morgan said he can't count how many people have talked to him about the transfer problem.

"It's crazy, just crazy. It's unacceptable," Morgan said. "From what I'm seeing, that mortality gap is accelerating."

Access to medical care has long bedeviled swaths of rural America — since 2005, 181 rural hospitals have closed. A 2020 KHN analysis found that more than half of U.S. counties, many of them largely rural, don't have a hospital with intensive care unit beds.

Pre-pandemic, rural Americans had 20% higher overall death rates than those who live in urban areas, due to their lower rates of insurance, higher rates of poverty and more limited access to health care, according to 2019 data from the Centers for Disease Control and Prevention's National Center for Health Statistics.

In southeastern Missouri's Ripley County, the local hospital closed in 2018. As of Sept. 27, only 24% of residents were fully vaccinated against COVID. Due to a recent crush of cases, COVID patients are getting sent home from emergency rooms in surrounding counties if they're not "severely bad," health department director Tammy Cosgrove said.

The nursing shortage hitting the country is particularly dire in rural areas, which have less money than large hospitals to pay the exorbitant fees travel nursing agencies are demanding. And as nursing temp agencies offer hospital staffers more cash to join their teams, many rural nurses are jumping ship. One of Scoggin's nurses told him she had to take a travel job — she could pay off all her debt in three months with that kind of money.

And then there's the burnout of working over a year and a half through the pandemic. Audrey Snyder, the immediate past president of the Rural Nurse Organization, said she's lost count of how many nurses have told her they're quitting. Those resignations feed into a relentless cycle: As travel nurse companies attract more nurses, the nurses left behind shouldering their work become more burned out — and eventually quit. While this is true at hospitals of all types, the effects in hard-to-staff rural hospitals can be especially dire.

Rural health officials fear the staffing shortages could be exacerbated by health care vaccination mandates promised by President Joe Biden, which they say could cause a wave of resignations the hospitals cannot afford. About half of Scoggin's staff, for example, is unvaccinated.

Snyder warned that nursing shortages and their high associated costs will become unsustainable for rural hospitals operating on razor-thin margins. She predicted a new wave of rural hospital closures will further drive up the dire mortality numbers.

Staffing shortages already limit how many beds hospitals can use, Scoggin said. He estimated most hospitals in Texas, including his own, are operating at roughly two-thirds of their bed capacity. His emergency room is so swamped, he's had to send a few patients home to be monitored daily by an ambulance team.

Lauren Weber: LaurenW@kff.org, @LaurenWeberHP

The Part of the 'Free Britney' Saga That Could Happen to Anyone

KFF Health News, September 29, 2021

Approximately 2 million psychiatric patients are hospitalized each year in the United States, nearly half involuntarily.

This article was published on Wednesday, September 29, 2021 in Kaiser Health News.

By Christopher Magoon  

When Britney Spears last went before a judge, in June, she bristled as she told of being forced into psychiatric care that cost her $60,000 a month. Though the pop star's circumstances in a financial conservatorship are unusual, every year hundreds of thousands of other psychiatric patients also receive involuntary care, and many are stuck with the bill.

Few have Spears' resources to pay for it, which can have devastating consequences.

To the frustration of those who study the issue, data on how many people are involuntarily hospitalized and how much they pay is sparse. From what can be gathered, approximately 2 million psychiatric patients are hospitalized each year in the United States, nearly half involuntarily. One study found that a quarter of these hospitalizations are covered by private insurance, which often has high copays, and 10% were "self-pay/no charge," where patients are often billed but cannot pay.

I am a psychiatrist in New York City, and I have cared for hundreds of involuntarily hospitalized patients. Cost is almost never discussed. Many patients with serious mental illness have low incomes, unlike Britney Spears. In an informal survey of my colleagues on the issue, the most common response is, "Yeah, that feels wrong, but what else can we do?" When patients pose an acutely high risk of harm to themselves or others, psychiatrists are obligated to hospitalize them against their will, even if it could lead to long-term financial strain.

While hospitals sometimes absorb the cost, patients can be left with ruined credit, endless collection calls and additional mistrust of the mental healthcare system. In cases in which a hospital chooses to sue, patients can even be incarcerated for not showing up in court.  On the hospital side, unpaid bills might further incentivize a hospital to close psych beds in favor of more lucrative medical services, such as outpatient surgeries, with better insurance reimbursement.

Rebecca Lewis, a 27-year-old Ohioan, has confronted this problem for as long as she has been a psychiatric patient. At 24, she began experiencing auditory hallucinations of people calling her name, followed by delusional beliefs about mythological creatures. While these experiences felt very real to her, she nevertheless knew something was off.

Not knowing where to turn, Lewis called a crisis line, which told her to go to an evaluation center in Columbus. When she drove herself there, she found an ambulance waiting for her. "They told me to get into the ambulance," she said, "and they said it would be worse if I ran."

Lewis, who was ultimately diagnosed with schizophrenia, was hospitalized for two days against her will. She refused to sign paperwork acknowledging responsibility for charges. The hospital attempted to obtain her mother's credit card, which Lewis had been given in case of emergencies, but she refused to hand it over. She later got a $1,700 bill in the mail. She did not contact the hospital to negotiate the bill because, she said, "I did not have the emotional energy to return to that battle."

To this day, Lewis gets debt collection calls and letters. When she picks up the calls, she explains she has no intention of paying because the services were forced on her. Her credit is damaged, but she considers herself lucky because she was able to buy a house from a family member, given how challenging it would have been to secure a mortgage.

The debt looms over her psyche. "It's not fun to know that there's this thing out there that I don't feel that I can ever fix. I feel like I have to be extra careful — always, forever — because there's going to be this debt," she said.

Lewis receives outpatient psychiatric care that has stabilized her and prevented further hospitalizations, but she still looks back on her first and only hospitalization with scorn. "They preyed on my desperation," she said.

While it is likely that many thousands of Americans share Lewis' experience, we lack reliable data on debt incurred for involuntary psychiatric care. According to Dr. Nathaniel Morris, an assistant professor of psychiatry at the University of California-San Francisco, we don't know how often patients are charged for involuntary care or how much they end up paying. Even data on how often people are hospitalized against their wishes is limited.

Morris is one of the few researchers who have focused on this issue. He got interested after his patients told him about being billed after involuntary hospitalization, and he was struck by the ethical dilemma these bills represent.

"I've had patients ask me how much their care is going to cost, and one of the most horrible things is, as a physician, I often can't tell them because our medical billing systems are so complex," he said. "Then, when you add on the involuntary psychiatric factor, it just takes it to another level."

Similarly, legal rulings on the issue are sparse. "I've only seen a handful of decisions over the years," said Ira Burnim, legal director of the Bazelon Center for Mental Health Law. "I don't know that there is a consensus."

People who have been involuntarily hospitalized rarely seek a lawyer, Burnim said, but when they do, the debt collection agencies will often drop the case rather than face a costly legal battle.

The media will be obsessed with Britney Spears' next day in court, expected to be Sept. 29. She will likely describe further details of her conservatorship that will highlight the plight of many forced into care.

Others won't get that kind of attention. As Rebecca Lewis put it, reflecting on her decision not to challenge the bills she faces: "They're Goliath and I'm little David."

Dr. Christopher Magoon is a resident physician at the Columbia University Department of Psychiatry in New York City.

An Ad’s Charge That Price Haggling Would ‘Swipe $500B From Medicare’ Is Incorrect

KFF Health News, September 28, 2021

"These guys [insurance companies and Washington bureaucrats] are working together to swipe $500 billion from Medicare to pay for Pelosi and Schumer's out-of-control spending spree." — Video advertisement from the 60 Plus American Association of Senior Citizens

This article was published on Tuesday, September 28, 2021 in Kaiser Health News.

By Victoria Knight

The advertisement opens with a doctor sitting across from his patient and holding a prescription drug pill bottle. "You want to continue with this medication?" the doctor asks while an older patient nods.

The doctor then explains that he can no longer provide the medicine to her because insurance companies and Washington bureaucrats "are working together to swipe $500 billion from Medicare to pay for [House Speaker Nancy] Pelosi and [Senate Majority Leader Chuck] Schumer's out-of-control spending spree."

"They're calling it Medicare negotiation, but, really, it's just a way to cut your benefits and no longer pay for lifesaving medicines," the doctor says.

Medicare negotiation refers to the federal government bargaining directly with pharmaceutical companies on the price of prescription drugs. Currently, Medicare is prohibited from using its vast market-share muscle to set prices. But supporters of Medicare drug negotiations eye the Democratic-backed budget reconciliation bill now being discussed in Congress as a means to reverse the policy.

This ad, seen on television and online, is part of a multiplatform campaign by the 60 Plus American Association of Senior Citizens, a conservative group that lobbies on senior issues and brands itself as the "right alternative to AARP." It's one example of a swath of ads that have popped up in the past month about Medicare drug price negotiations.

Since drug pricing is a hot topic and a critical piece of the broad, politically charged debate in Congress, we thought it was important to dig into the ad's messages.

The $500B Number

First, the ad claims that Medicare drug price negotiation will take "$500 billion from Medicare."

All five of the Medicare and drug pricing experts we consulted said that was a misleading way to frame this policy.

The reference to $500 billion most likely comes from a Congressional Budget Office estimate of a provision in H.R. 3, the Elijah E. Cummings Lower Drug Costs Now Act. It's an estimate of how much the government would save over 10 years if drug price negotiations were enacted.

That is, the government would be paying pharmaceutical companies $500 billion less for prescription drugs.

And, in that bill, $300 billion to $400 billion of the savings were to be used to expand benefits to include dental, hearing and vision coverage, said Juliette Cubanski, deputy director of the program on Medicare policy at KFF. Right now, Medicare doesn't provide that coverage to seniors.

If this policy were to make it into the pending budget reconciliation, some of the savings would also likely address other Democratic healthcare priorities, such as permanently closing the Medicaid coverage gap and improving Affordable Care Act coverage and subsidies.

So the ad's charged language — that Pelosi and Schumer are planning to "swipe" this money from Medicare — is incorrect. That $500 billion in savings would be slated for reinvestment in the program. And some experts said the changes to drug pricing could also translate into lower premiums and out-of-pocket costs for seniors.

The point of negotiations is "to spend less on the drugs we're already buying and put the money back into the health system," said Rachel Sachs, a law professor and expert on drug policy at Washington University in St. Louis.

But what about the ad's other main point — that Medicare negotiation will result in seniors no longer being able to get their medications?

Since 60 Plus did not return requests for comment, it's hard to know exactly what it is asserting will come between seniors and their medication.

It's possible the ad is implying that drugmakers may walk away from the negotiating table if they don't like the prices the government promotes. But experts said it's likely a financial penalty would be in place to motivate the companies to work with the government. H.R. 3 proposed an escalating excise tax.

The U.S. has the world's largest prescription market, so it seems unlikely companies would stop selling drugs here completely, said Stacie Dusetzina, an associate professor of health policy at Vanderbilt University.

And the number of drugs subject to negotiation would probably be a small subset of all drugs on the market, based on the negotiation method that was proposed in H.R. 3.

In real life, the scenario shown in the ad is unlikely to happen, said Joseph Antos, senior fellow in healthcare policy at the American Enterprise Institute.

"The question of whether a drug would be taken off the market — it's always a little hard to say and, clearly, that is a possibility," said Antos. "But it's much more plausible to say this is the kind of policy that would lead to some new drugs not coming out to the market."

That's an argument often wielded by the pharmaceutical industry.

Evidence suggests there's a grain of truth in the assessment that lower industry profits results in less research and development, said Paul Van de Water, a senior fellow in healthcare policy at the Center on Budget and Policy Priorities. But only a grain. For the most part, the drug industry overstates the effect of lost profits.

"A lot of these drugs are what's known as 'me-too' medicines, which means the drugmakers are making small innovations on existing drugs," said Van de Water. "The loss to Medicare beneficiaries of those types of drugs would be relatively small."

In a separate analysis, the CBO examined to what extent negotiated drug prices could squeeze the pharmaceutical industry's R&D capacity. The agency, using a 30-year window, estimated that 59 drugs wouldn't come to market. That's against a baseline of about 900 drugs being released per year, said Sachs, which means it would stymie only a tiny fraction of otherwise expected drugs.

Still, some experts say the CBO report can't precisely predict the future and a loss in profits would have a larger effect on smaller, start-up pharmaceutical companies.

"At the small operations, a scientist thinks they have an insight into some biological process and they attract venture capitalists to develop a drug," said Antos. "But drug development is a complicated business, and the drug might not make it to market. With less funds for that type of research, that is the part of the drug business most directly affected by the drug pricing policy."

Why It Matters

The political stakes surrounding the Medicare drug price negotiations are high.

Currently, the idea is seen as a way to help pay for the Democratic-backed health initiatives being discussed as part of the reconciliation bill.

And, a recent poll from KFF shows that almost 90% of the public supports the government's ability to negotiate for lower drug prices.

But allowing Medicare to bargain on drugs is controversial, even among Democrats, some of whom say they don't want to stifle drug companies' innovation, especially if it's a big industry in the area of the country they represent.

Meanwhile, PhRMA, the powerful pharmaceutical industry trade group, announced Sept. 15 it would be launching a seven-figure ad campaign against the drug pricing proposals, according to The Hill.

Our Rating

The 60 Plus Association ran an advertisement that claimed Medicare drug price negotiations were "swiping" $500 billion from Medicare and going to be used as a way to "cut benefits and no longer pay for lifesaving medicines."

While the $500 billion number is based on facts, everything else this ad says is misleading.

If Congress approves a plan to let Medicare negotiate drug prices, Democrats are calling for most of the savings to be funneled directly back into the Medicare program to provide vision, dental and hearing benefits. So, it's not true that the plan for the money is to steal from Medicare. Experts also agreed it is specious to say seniors could no longer get the medications they're currently taking.

We rate this claim False.

Sources

60 Plus American Association of Senior Citizens, "Our Mission," accessed Sept. 22, 2021

60 Plus American Association of Senior Citizens, "Protecting Medicare," accessed Sept. 22, 2021

Center on Budget and Policy Priorities, Build Back Better Legislation Would Close the Medicaid Coverage Gap, Sept. 13, 2021

Congressional Budget Office, CBO's Simulation Model of New Drug Development, August 2021

Congressional Budget Office, H.R. 3, Elijah E. Cummings Lower Drug Costs Now Act Cost Estimate, Dec. 10, 2019

Congress.gov, H.R.3 — Elijah E. Cummings Lower Drug Costs Now Act — 116th Congress (2019-2020), accessed Sept. 22, 2021

Email interview with Stacie Dusetzina, associate professor of health policy at Vanderbilt University, Sept. 21, 2021

Fierce Pharma, "Advocates Roll Pricey Ad Campaigns as Biden, Congress Push for Medicare Drug Negotiations," Aug. 17, 2021

The Hill, "PhRMA Launches 7-Figure Ad Campaign Against Democrats' Drug Pricing Measures," Sept. 15, 2021

KFF, What's the Latest on Medicare Drug Price Negotiations?, July 23, 2021

KFF, Public Opinion on Prescription Drugs and Their Prices, June 15, 2021

KHN/PolitiFact, "Pharma's Take on the Pelosi Drug-Pricing Bill: Fair Warning or Fearmongering?" Dec. 5, 2019

KHN/PolitiFact, "Biden Promise Tracker — Promise: Lower Cost of Prescription Drugs," updated July 15, 2021

Open Secrets, "Pharmaceutical Industry Backs Democratic Holdouts on Drug Pricing Plan," Sept. 17, 2021

Politico, "House Leadership Looks to Jam Holdouts on Drug Pricing," Sept. 21, 2021

Phone interview with Juliette Cubanski, deputy director of the program on Medicare policy at KFF, Sept. 21, 2021

Phone interview with Joseph Antos, senior fellow and Wilson H. Taylor Scholar in healthcare and retirement policy at the American Enterprise Institute, Sept. 21, 2021

Phone interview with Paul N. Van de Water, senior fellow at the Center on Budget and Policy Priorities, Sept. 21, 2021

Phone interview with Rachel Sachs, Treiman professor of law at Washington University in St. Louis School of Law, Sept. 21, 2021

The Washington Post, "Three Democrats Say They'll Oppose Party's Drug-Price Plan, Creating Roadblock for Larger Package," Sept. 14, 2021

YouTube, 60 Plus Association Official Account, "Doctor's Visit," Sept. 10, 2021

Victoria Knight: vknight@kff.org, @victoriaregisk

These Schools Use Weekly Testing to Keep Kids in Class — And COVID Out

KFF Health News, September 27, 2021

Hillside School was among the first in Illinois to start regular testing. Now, almost half of Illinois' 2 million K-12 students attend schools rolling out similar programs.

This article was published on Monday, September 27, 2021 in Kaiser Health News.

By Christine Herman, WILL / Illinois Public Media  

On a recent Monday morning, a group of preschoolers filed into the gymnasium at Hillside School in the west Chicago suburbs. These 4- and 5-year-olds were the first of more than 200 students to get tested for the coronavirus that day — and every Monday — for the foreseeable future.

At the front of the line, a girl in a unicorn headband and sparkly pink skirt clutched a zip-close bag with her name on it. She pulled out a plastic tube with a small funnel attached. Next, Hillside superintendent Kevin Suchinski led the student to a spot marked off with red tape. Suchinski coached her how to carefully release — but not "spit" — about a half-teaspoon's worth of saliva into the tube.

"You wait a second, you build up your saliva," he told her. "You don't talk, you think about pizza, hamburgers, French fries, ice cream. And you drop it right in there, OK?"

The results will come back within 24 hours. Any students who test positive are instructed to isolate, and the school nurse and administrative staff carry out contact tracing.

Hillside was among the first in Illinois to start regular testing. Now, almost half of Illinois' 2 million students in grades K through 12 attend schools rolling out similar programs. The initiative is supported by federal funding channeled through the state health department.

Schools in other states — such as Massachusetts, Maryland, New York and Colorado — also offer regular testing; Los Angeles public schools have gone further by making it mandatory.

These measures stand in sharp contrast to the confusion in states where people are still fighting about wearing masks in the classroom and other anti-COVID strategies, places where some schools have experienced outbreaks and even teacher deaths.

Within a few weeks of schools reopening, tens of thousands of students across the U.S. were sent home to quarantine. It's a concern because options for K-12 students in quarantine are all over the map — with some schools offering virtual instruction and others providing little or no at-home options.

Suchinski hopes this investment in testing prevents virus detected at Hillside School from spreading into the wider community — and keeps kids learning.

"What we say to ourselves is: If we don't do this program, we could be losing instruction because we've had to close down the school," he said.

So far, the parents and guardians of two-thirds of all Hillside students have consented to testing. Suchinski said the school is working hard to get the remaining families on board by educating them about the importance — and benefit — of regular testing.

Every school that can manage it should consider testing students weekly — even twice a week, if possible, said Becky Smith. She's an epidemiologist at the University of Illinois in Urbana-Champaign, which developed the saliva test Hillside and other Illinois schools are using. Smith pointed to several studies — including both peer-reviewed and preliminary research — that suggest rigorous testing and contact tracing are key to keeping the virus at bay in K-12 schools.

"If you're lucky, you can get away without doing testing, [if] nobody comes to school with a raging infection and takes their mask off at lunchtime and infects everybody sitting at the table with them," Smith said. "But relying on luck isn't what we like to do."

Julian Hernandez, a Hillside seventh grader, said he feels safer knowing that classmates infected with the virus will be prevented from spreading it to others.

"One of my friends — he got it a couple months ago while we was in school," Julian recalled. "[He] and his brother had to go back home. … They were OK. They only had mild symptoms."

Brandon Muñoz, who's in the fifth grade, said he's glad to get tested because he's too young for the vaccine — and he really doesn't want to go back to Zoom school.

"Because I wanna really meet more people and friends and just not stay on the computer for too long," Brandon explained.

Suchinski, the superintendent, said Hillside also improved ventilation throughout the building, installing a new HVAC system and windows with screens in the cafeteria to bring more fresh air in the building.

Regular testing is an added layer of protection, though not the only thing Hillside is relying on: About 90% of Hillside staff are vaccinated, Suchinski said, and students and staffers also wear masks.

Setting up a regular mass-testing program inside a K-12 school takes a good amount of coordination, which Suchinski can vouch for.

Last school year, Hillside school administrators facilitated the saliva sample collection without outside help. This year, the school tapped funding earmarked for K-12 coronavirus testing to hire COVID testers — who coordinate the collecting, transporting and processing of samples, and reporting results.

A couple of Hillside administrators help oversee the process on Mondays, and also facilitate testing for staff members, plus more frequent testing for a limited group of students: Athletes and children in band and extracurriculars test twice a week because they face greater risks of exposure to the virus from these activities.

Compared with a year ago, COVID testing is now both more affordable and much less invasive, said Mara Aspinall, who studies biomedical testing at Arizona State University. There's also more help to cover costs.

"The Biden administration has allocated $11 billion to different programs for testing," Aspinall said. "There should be no school — public, private or charter — that can't access that money for testing."

Creating a mass testing program from scratch is a big lift. But more than half of all states have announced programs to help schools access the money and handle the logistics.

If every school tested every student once a week, the roughly $11 billion earmarked for testing would likely run out in a couple of months. (This assumes $20 to buy and process each test.) Put another way, if a quarter of all U.S. schools tested students weekly, the funds could last the rest of the school year, Aspinall said.

In its guidance to K-12 schools, updated Aug. 5, the Centers for Disease Control and Prevention does not make a firm recommendation for this surveillance testing.

Instead, the CDC advises schools that choose to offer testing to work with public health officials to determine a suitable approach, given rates of community transmission and other factors.

The agency previously recommended screening at least once a week in all areas experiencing moderate to high levels of community transmission. As of Sept. 21, that included 95% of U.S. counties.

For school leaders looking to explore options, Aspinall suggests a resource she helped write, which is cited within the CDC guidance to schools: the Rockefeller Foundation's National Testing Action Plan.

This spring — when Hillside was operating at about half capacity and before the more contagious delta variant took over — the school identified 13 positive cases among students and staffers via its weekly testing program. The overall positivity rate of about half a percent made some wonder if all that testing was necessary.

But Suchinski said that by identifying the 13 positive cases, the school perhaps avoided more than a dozen potential outbreaks. Some of the positive cases were among people who weren't showing symptoms but still could've spread the virus.

A couple of weeks into the new school year at Hillside, operating at full capacity, Suchinski said the excitement is palpable. Nowadays he's balancing feelings of optimism with caution.

"It is great to hear kids laughing. It's great to see kids on playgrounds," Suchinski said.

"At the same time," he added, "we know that we're still fighting against the delta variant and we have to keep our guard up."

This story is from a partnership that includes Illinois Public Media, Side Effects Public Media, NPR, and KHN.

Firefighters on Front Lines, No Strangers to Risk, Push Back Against COVID Vaccine Mandates

KFF Health News, September 27, 2021

Firefighter leadership and the rank and file are divided over vaccine mandates.

This article was published on Monday, September 27, 2021 in Kaiser Health News.

By Sandy West   

Kentucky firefighter Jimmy Adams saw the ravages of the coronavirus pandemic when he served as a medic who helped care for the sick on medical calls amid surging COVID cases. He knew retired firefighters who died of complications from COVID-19. But he reasoned that they were older and likely had underlying health issues, making them susceptible to the virus.

"That's how you make peace with those things," said Adams, 51, a lieutenant. He believed the precautions his department was taking kept him safe. But he refused to get a COVID vaccine. The reason wasn't strictly political, he said. He had grown weary of the debate around masks, mitigation, caseloads and vaccines.

In mid-August, both Adams and his wife, Sara, who was fully vaccinated, tested positive for COVID. She experienced mild symptoms; however, he was hospitalized with bilateral interstitial pneumonia. His potassium spiked, causing cardiac arrhythmia. He was on oxygen throughout his hospitalization.

"I was wrong," Adams said several days after leaving the hospital. "I suffered a lot. I don't even know at this point in the game if I am going to suffer any long-term effects. Does this change who I am for the rest of my life? I don't know the answer to that. I will be sad if it does."

Adams now plans to get vaccinated as soon as his doctor allows it, post-recovery. Still, he, like many other firefighters nationwide, does not support mandates for COVID vaccines.

Firefighter leadership and the rank and file are divided over such mandates. The International Association of Fire Chiefs has expressed support for mandatory vaccinations. Conversely, the International Association of Fire Fighters has said it "strongly" encourages firefighters to get vaccinated, but does not think it should be mandated.

Firefighters, who more often than not are certified emergency medical providers, have been on the pandemic's front lines since the beginning. Officials pushed to ensure they would be among the first to receive the vaccines, given their role in the medical system. Yet why, after having seen so much, do so many who are trained to save lives still refuse to get vaccinated — while actively fighting against mandates?

JT Sullivan, a firefighter in Wyandotte County, Kansas, said that while he took precautions not to bring home the coronavirus when his wife was pregnant, he believed the pandemic was largely "vamped up" by the media — even as he saw its effects in his professional life. He understood something was happening; he just didn't believe it was quite as bad as was being reported. He believed it affected mostly the elderly and medically fragile. The 28-year-old had no plans to get vaccinated until a paramedic at his department died from COVID complications on Jan. 1. Sullivan got vaccinated soon after.

"It just caught me off guard because he was younger than my folks," said Sullivan, who encourages vaccinations but also disagrees with mandates.

Several firefighters said first responders reluctant to get vaccinated reflect the range of views held by many average Americans: Some view both the pandemic and vaccine through a political lens, some believe misinformation and conspiracies, some are generally wary of vaccines, and others don't like being told what to do. Both Adams and Sullivan attributed some vaccine resistance to having a "Type A" personality and harboring a belief that they can exert control over what happens to them.

Houston Fire Chief Samuel Peña, frustrated with his own department's vaccination rate, which he guesses to be about 50%, suspects there is some truth to that.

"Through the course of a first responder's career — whether you're a firefighter, police officer, EMT — you kind of get a higher tolerance for acceptable risk because you respond to all kinds of stuff that puts your life in dangerous situations and the majority of the time you come out unscathed," he said. "The level of acceptable risk that we're willing to take is at a different threshold than a normal, reasonable individual."

Peña said Houston officials have discussed mandating vaccinations despite Texas Republican Gov. Greg Abbott's efforts to prevent schools and cities from instituting COVID mitigation policies. The city's strained relationship with the local firefighters union could complicate matters. Such mandates elsewhere have met fierce resistance.

A Los Angeles City Fire Department captain is under investigation after posting a video denouncing the "tyranny" of an expected vaccine mandate there. The city of San Francisco's Department of Human Resources has recommended 10-day unpaid suspensions for 20 employees, including seven firefighters, for noncompliance with that city's mandate, according to the San Francisco Chronicle. News reports in multiple cities quote employees questioning the legality of such mandates.

A long-standing legal precedent exists for public health and vaccine mandates, said Sharona Hoffman, a professor of law and bioethics at Case Western Reserve University in Cleveland.

"It's not true that 'This is America and we have 100% freedom.' We have a million laws and regulations you have to comply with," she said, citing, among them, traffic laws and employer dress codes. "That's what it means to be in a civilized society. That's what's called the 'social contract.'"

Allyson Hinzman, a firefighter and the president of Tacoma Firefighters Local 31 in Washington, said local unions oppose Democratic Gov. Jay Inslee's vaccine mandate. Hinzman said it was rushed and doesn't allow for alternatives, such as weekly COVID testing. State workers filed a lawsuit this month against the governor over the mandate.

Firefighters are threatening to quit rather than comply, which Hinzman said would further strain short-staffed departments providing emergency services.

She said firefighters take precautions to prevent virus transmission when responding to calls. A University of Washington study indicates the risk of spreading the virus between first responders and patients is low, because of safety protocols followed in the field.

"This isn't about the vaccine," said Hinzman, who did get vaccinated. "This is about providing our members the opportunity to choose and make decisions for themselves. We are pro-vaccine, we are pro-public safety, but we're just anti-mandate. The fact is you can be all three things at the exact same time."

Bob McDonald, executive director of the Denver Department of Public Health, sees it differently and said vaccines are the only way to move from a COVID pandemic to a health concern that, like influenza, can be managed. Denver has implemented a vaccine mandate for all city employees, including firefighters.

"One of the things that I think is very, very important is to get people to understand that these vaccines, especially with the delta variant, are no longer just about the individual," said McDonald, adding that hospitals around Denver are at or beyond capacity due to surging COVID cases. It is everyone's responsibility to mitigate their risk to reduce strain on the nation's medical system, he said.

Peña said public servants owe it to taxpayers to get vaccinated given that taxpayers ultimately pay the bills for their workers' compensation payouts or hospitalizations.

Even if employees quit in the event of a vaccine mandate in Houston, Peña said, his department has operated throughout the pandemic with reduced staffing because of members quarantining after exposure or isolating because of illness. Four Houston firefighters have died of COVID.

"I have been doing this for 27 years, and I can tell you that I have never buried a firefighter for a line-of-duty death because of the flu," said Peña, adding that if the deaths had been from other duty-related activities, the union would push for action. "Just because this is a medical issue does not mean that we should not be looking for how to better protect our firefighters. The vaccine is one way we can achieve that."

According to the National Fallen Firefighters Foundation, which honors and recognizes firefighters who die in the line of duty, 170 firefighters and 78 EMS workers had died of COVID complications as of Sept. 17.

Sandy West: sandywestwriter@gmail.com, @_SandyWest

KHN on air: Who qualifies for a COVID booster? The list grows longer

KFF Health News, September 27, 2021

As many as 87% vaccinated adults said they would get an additional dose if it were available.

This audio report was released on Monday, September 27, 2021 by Kaiser Health News.

On Friday, CDC Director Rochelle Walensky said people whose jobs put them at risk of coronavirus infection qualify for a shot to boost the protection of their COVID-19 vaccination.

That step to include people with “institutional and occupational exposure” overrules the recommendation of her agency’s advisory panel, and the move was a surprise to many.

“It was not expected, but I think the director, Walensky, wanted to go along with what the FDA had said earlier in the week and to kind of back up the plan that President Biden had laid out in August,” said KHN senior correspondent Sarah Jane Tribble.

Others who can line up first for a covid booster include Americans age 65 and older, younger people who have underlying health conditions and nursing home residents.

So far, regulators have done a poor job of defining the universe of people considered at risk because of institutional and occupational exposure, said Arthur Allen, an editor for KHN’s California Healthline.

“We don’t know exactly who they all are. But we can think of some obvious groups who would have been very upset if they couldn’t be qualified for a booster. That includes healthcare workers and teachers,” Allen said.

“We have to remember this is not really just a purely scientific decision,” he said.

During the Sept. 23 meeting of the CDC’s Advisory Committee on Immunization Practices, members tried to get a handle on Americans’ demand for covid boosters: In surveys from August, as many as 87% vaccinated adults said they would get an additional dose if it were available. Another later survey found that 93% of adults would get the shot if a primary care provider recommended it.

Mounting COVID Deaths Fuel School Bus Drivers' Fears

KFF Health News, September 24, 2021

At least 12 school bus workers in Georgia have died of COVID since the beginning of the school year.

This article was published on Friday, September 24, 2021 in Kaiser Health News.

By Andy Miller and Phil Galewitz 

GRIFFIN, Ga. — Natalia D'Angelo got sick right after school started in August.

She was driving a school bus for special education students in Griffin-Spalding County School System about 40 miles south of Atlanta and contracted COVID-19.

One of her three sons, Julian Rodriguez-D'Angelo, said his mother, who was not vaccinated against the COVID virus, had a history of health problems, including Graves' disease and cancer.

Rodriguez-D'Angelo said his mother "was pretty certain" she got COVID from her work duties. He added that D'Angelo's assistant on the same bus also had the disease, and that his mother said some kids on the bus did not wear masks, even though it is required.

The virus spread through the whole family, including her husband, Americo Rodriguez, who came with her to the U.S. from Uruguay 20 years ago. But D'Angelo's illness grew worse, and she was hospitalized at a Griffin hospital in mid-August. On Aug. 28, she died. She was 43.

D'Angelo is among at least 12 school bus workers in Georgia — including three in the Griffin-Spalding district — who have died of COVID since the beginning of the school year. News reports and a Twitter feed called "School Personnel Lost to COVID" show that school bus drivers in at least 10 states have died of the disease since August.

The deaths raise questions about whether school bus drivers are at higher risk of getting COVID. But medical experts are split. It's difficult, if not impossible when local infection rates are high, to determine how any particular bus worker became infected — whether it occurred at home, in a community setting or on the job.

The buses should be relatively safe. The Centers for Disease Control and Prevention requires that masks be worn on public transportation, including all school buses, public or private and regardless of whether the schools themselves require masks.

"There's no enforcement of that,'' said Ronna Weber, executive director of the National Association of State Directors of Pupil Transportation Services. "Police are not going to board a school bus" to make sure the students are wearing masks.

As with school employees in general, statistics on the number of COVID deaths are sparse, without any central government repository, according to the National Education Association union. The Florida Education Association, though, lists seven bus workers among the more than 70 school staffers in the state who have died since July. The School Personnel Lost to COVID account says more than 185 bus drivers have died of the disease during the pandemic.

An estimated 500,000 school buses nationwide operate on a given day. Many drivers are retirees from previous occupations, so age and health conditions could contribute to the deaths. "Every life is an unfortunate loss," said Weber.

Xiaoyan Song, chief infection control officer at Children's National Hospital in Washington, D.C., said drivers are not at increased risk of getting COVID from students because they see children up close for only a second or two, when the kids board and exit the bus.

It typically takes several minutes of exposure to an infected person to transmit the virus, she said, adding that drivers face forward with their backs to students while driving, which also diminishes their risk. She said driving with windows open is another factor that can limit transmission of the virus.

But Ye Shen, an associate professor at the University of Georgia College of Public Health, believes drivers face a greater risk.

Shen, lead author of a JAMA Internal Medicine study on COVID transmission on buses in China, noted that the vehicles are enclosed spaces in which ventilation can be poor, creating an environment with a high risk of COVID transmission.

The danger of airborne transmission is significantly reduced if the kids and the driver are all wearing masks, Shen said. In the China study, no one was wearing a mask and there was a high rate of virus transmission. "Kids often don't fully comply with the mask rule," Shen added.

Risks may climb within school districts that lack mask mandates, he said.

The Bulloch County school district in southeastern Georgia has no mask mandate in classrooms or buses. In early September, Bulloch district bus driver Norma Jean Carter, 55, died of COVID.

Besides mask-wearing, the CDC recommends that, whenever possible, drivers and monitors open bus windows to increase air circulation. Bus surfaces should be cleaned and disinfected after each use of the vehicle, the agency said.

Even when precautions are taken, the fears surrounding COVID have worsened a nationwide shortage of school bus drivers.

Michael Cordiello, president of the Amalgamated Transit Union local chapter in New York City, representing more than 8,000 school bus workers, said more drivers have retired in 2021 than in previous years.

Officials in several states are working to find solutions to the shortages, and some are requesting that their governors send National Guard troops to help. A Wilmington, Delaware, school is paying its students' parents to drive buses. Some regular drivers have had to work extra shifts.

"Our drivers are scared to death," said Jamie Michael, president of Support Personnel Association of Lee County, a union in southwestern Florida that represents bus drivers and other school staffers.

One county school bus driver there died of COVID in mid-August, she said. It is unknown where the woman was infected. She said five drivers then quit Sept. 7 and the county school district is about 100 drivers short of what it needs.

The district requires drivers to wear masks, and they try to ensure that at least some windows are kept open on the bus no matter the weather.

"It's a scary time for anyone working with students," Michael said.

Drivers in the district get paid between $16 and $23 an hour depending on seniority, amounting to $31,000 to about $45,000 annually.

Michael said drivers like to keep the seat behind them vacant to allow for physical distancing, but that is not always possible due to demand for rides, especially amid driver shortages.

The Griffin-Spalding district temporarily switched to remote learning for students after D'Angelo, another bus driver and a bus monitor died of COVID. Several more have been infected since school started Aug. 4, said Adam Pugh, spokesperson for the Griffin-Spalding County School System. The school district added a mask requirement early in the school year.

"No one has an exact answer" as to why the district's bus workers have been hit so hard, he said. Many buses are being driven with windows open, and the vehicles are sanitized between routes, Pugh added.

Julian Rodriguez-D'Angelo said his mother "loved being a bus driver and never missed work. She drove for years."

He said he doesn't blame the students but does feel anger about district policies. The delta variant, the dominant strain of COVID, "is spreading like crazy," he said. He added he doesn't think students should have been in school amid the surge.

The vaccination rate in Spalding County for all residents, 37%, is far below the state's 46% rate. Both rates are below the national average.

Andy Miller: amiller@kff.org, @gahealthnews

Phil Galewitz: pgalewitz@kff.org, @philgalewitz

Pages