Black and Hispanic Americans Suffer Most in Biggest US Decline in Life Expectancy Since WWII

KFF Health News, June 24, 2021

The pandemic has exacerbated the discrepancies already seen in the country between the wealth and health of Black and Hispanic Americans and those of white Americans.

This article was published on Thursday, June 24, 2021 in Kaiser Health News.

By Liz Szabo

Although James Toussaint has never had COVID, the pandemic is taking a profound toll on his health.

First, the 57-year-old lost his job delivering parts for a New Orleans auto dealership in spring 2020, when the local economy shut down. Then, he fell behind on his rent. Last month, Toussaint was forced out of his apartment when his landlord — who refused to accept federally funded rental assistance — found a loophole in the federal ban on evictions.

Toussaint recently has had trouble controlling his blood pressure. Arthritis in his back and knees prevents him from lifting more than 20 pounds, a huge obstacle for a manual laborer.

Toussaint worries about what will happen when his pandemic unemployment benefits run out, which could happen as early as July 31.

"I've been homeless before," said Toussaint, who found a room to rent nearby after his eviction. "I don't want to be homeless again."

With coronavirus infections falling in the U.S., many people are eager to put the pandemic behind them. But it has inflicted wounds that won't easily heal. In addition to killing 600,000 in the United States and afflicting an estimated 3.4 million or more with persistent symptoms, the pandemic threatens the health of vulnerable people devastated by the loss of jobs, homes and opportunities for the future. It will, almost certainly, cast a long shadow on American health, leading millions of people to live sicker and die younger due to increasing rates of poverty, hunger and housing insecurity.

In particular, it will exacerbate the discrepancies already seen in the country between the wealth and health of Black and Hispanic Americans and those of white Americans. Indeed, new research published Wednesday in the BMJ shows just how wide that gap has grown. Life expectancy across the country plummeted by nearly two years from 2018 to 2020, the largest decline since 1943, when American troops were dying in World War II, according to the study. But while white Americans lost 1.36 years, Black Americans lost 3.25 years and Hispanic Americans lost 3.88 years. Given that life expectancy typically varies only by a month or two from year to year, losses of this magnitude are "pretty catastrophic," said Dr. Steven Woolf, a professor at Virginia Commonwealth University and lead author of the study.

Over the two years included in the study, the average loss of life expectancy in the U.S. was nearly nine times greater than the average in 16 other developed nations, whose residents can now expect to live 4.7 years longer than Americans. Compared with their peers in other countries, Americans died not only in greater numbers but at younger ages during this period.

The U.S. mortality rate spiked by nearly 23% in 2020, when there were roughly 522,000 more deaths than normally would be expected. Not all of these deaths were directly attributable to COVID-19. Fatal heart attacks and strokes both increased in 2020, at least partly fueled by delayed treatment or lack of access to medical care, Woolf said. More than 40% of Americans put off treatment during the early months of the pandemic, when hospitals were stretched thin and going into a medical facility seemed risky. Without prompt medical attention, heart attacks can cause congestive heart failure; delaying treatment of strokes raises the risk of long-term disability.

Much of the devastating public health impact during the pandemic can be chalked up to economic disparity. Although stock prices have recovered from last year's decline — and have recently hit all-time highs — many people are still suffering financially, especially Black and Hispanic Americans. In a February report, economic analysts at McKinsey & Co. predicted that, on average, Black and Hispanic workers won't recover their pre-pandemic employment and salaries until 2024. The lowest-paid workers and those with less than a high school education may not recover even by then.

And while federal and state relief programs have cushioned the impact of pandemic job losses, 11.3% of Americans today live in poverty — compared with 10.7% in January 2020. A federal eviction moratorium, which has helped an estimated 2.2 million people remain in their homes, expires June 30. Without protection from evictions, "millions of Americans could fall off the cliff," said Vangela Wade, president and CEO of the Mississippi Center for Justice, a nonprofit advocacy group.

Being evicted erodes a person's health in multiple ways. "Poverty causes a lot of cancer and chronic disease, and this pandemic has caused a lot more poverty," said Dr. Otis Brawley, a professor at Johns Hopkins University who studies health disparities. "The effect of this pandemic on chronic diseases, such as cardiovascular disease and diabetes, will be measured decades from now."

Twenty million adults recently have had trouble putting food on the table. The inability to afford healthy food — which is usually more expensive than salty, starchy fare — can cause both short-term and long-term harm. People with low incomes, for example, are more likely to be hospitalized for low blood sugar toward the end of the month, when they run out of money for food.

In the long term, food insecurity is associated with an increased risk of diabetes, high cholesterol, hypertension, depression, anxiety and other chronic diseases, especially in children.

"Once the acute phase of this crisis has passed, we will face an enormous wave of death and disability," said Dr. Robert Califf, former commissioner of the Food and Drug Administration, who wrote about post-pandemic health risks in an April editorial in Circulation, a medical journal. "These will be the aftershocks of COVID."

Less Wealth, Poorer Health

American health was poor even before the pandemic, with 60% of the population suffering from a chronic condition, such as obesity, diabetes, high blood pressure or heart failure. These four conditions were associated with nearly two-thirds of hospitalizations from COVID, according to a February study in the Journal of the American Heart Association.

Deaths from some chronic diseases began rising in lower-income Americans in the 1990s, Woolf said. That trend was exacerbated by the Great Recession of 2007-09, which undermined the health not just of those who lost their homes or jobs but the population as a whole. Still, the Great Recession, and its resultant health effects, did not affect all Americans equally. Black people in the U.S. today control less wealth than they did before that recession, while the gap in financial security between Black and white Americans has widened, according to a Nonprofit Quarterly article published last year. And the unemployment rate among Black workers did not recover to pre-recession levels until 2016.

Researchers have developed a better understanding in recent years of how chronic stress — such as that caused by poverty, job loss and homelessness — leads to disease. Unrelenting stress causes inflammation that can damage blood vessels, the heart and other organs.

Research shows that people with low incomes live an average of seven to eight years less than those who are financially secure. The richest 1% of Americans live nearly 15 years longer than the poorest 1%.

People who are poor tend to smoke more; have higher risks of chronic illnesses such as cardiovascular disease, diabetes, kidney disease and mental illness; and are more likely to become victims of violence.

The stress of the pandemic also has led many people to smoke, drink and gain weight, increasing the risk of chronic disease. Fatal drug overdoses spiked 30% from October 2019 to October 2020.

Jennifer Drury, 40, has struggled with substance abuse, particularly prescription painkillers, since her 20s. She blames the isolation and stress of the pandemic for causing her to relapse — and leading several of her friends to fatally overdose.

"Idle time is not good for addiction," said Drury, who fell behind on rent and was evicted from her previous home. She said drug dealers are never far away, especially at the New Orleans motel where she and her husband are now staying. "Drug dealers don't care about pandemics."

Women Losing Ground

The American Rescue Plan, which provides $1.9 trillion in pandemic relief, was designed to help displaced workers and cut child poverty rates in half. The actual benefits of the law may prove less sweeping.

Twenty-five states have opted to cut off additional federal unemployment payments, citing concerns that such generous benefits pay people more to stay home than they can earn by working.

Many women say they would like to return to work but have no one to take care of their children. Nearly half of child care centers have closed and others have reduced the number of children they serve.

The Federal Reserve Bank of Minneapolis concluded that "economic recovery depends on child care availability." A March report from the National Women's Law Center estimates "women have lost a generation of labor force participation gains," which could leave them and their children financially disadvantaged for years.

Ruth Bermudez is one of millions of women who have left the workforce in the past year. Bermudez, who was laid off from her job as a behavioral health caseworker in New Orleans last year, said her child care needs have prevented her from finding work. The care of her 6-year-old daughter became her full-time job after the pandemic closed schools.

Although her daughter has returned to class, Bermudez said school shutdowns due to COVID outbreaks have been frequent and unpredictable.

"I had to be the teacher, the lunch lady, the school bus driver, all at one time," said Bermudez, 27. "It is exhausting."

Life-Altering Evictions

James Toussaint had just two weeks to find a new place to live after a judge ordered him evicted. His family was unable to take him in.

"I've got family, but everybody has their own issues and problems," said Toussaint, who had to throw away all his clothes and furniture because they had become infested with bedbugs. "Everyone is trying their best to help themselves."

Toussaint is now renting a room in a boarding house with no kitchen and a shared bathroom for $160 a week. He's had to buy cleaning supplies with his own money in order to sanitize the bathroom, which he said is often too dirty to use.

Sharing communal space is often unsanitary and increases the risk of being exposed to the coronavirus, said Emily Benfer, a visiting professor at Wake Forest University School of Law. Even moving in with family poses risks, she said, because it's impossible to isolate or quarantine in crowded homes.

Benfer co-wrote a November study that found COVID infection rates grew twice as high in states that lifted moratoriums on evictions, compared with states that continued to ban them. About 14% of tenants have fallen behind on rent — double the rate before the pandemic.

Toussaint's annual lease expired during the pandemic, leaving him to rent on a month-to-month basis. While some states require landlords to show "just cause" for eviction, Louisiana landlords can evict tenants for any reason once their annual lease has expired.

Property owners have filed for more than 378,000 evictions during the pandemic in just the five states and 29 cities tracked by Princeton University's Eviction Lab. A growing body of evidence shows that eviction is toxic to health, causing immediate and long-term damage that increases the risk of death.  Studies show that evicted people are more likely to be in poor general health or have mental health concerns even years later.

"This singular event alters the course of one's life for the worse," Benfer said. "If we don't intervene" to prevent mass evictions when the moratorium ends, "it will be catastrophic for generations to come."

Eviction's harms can be measured at every stage of life:

When pregnant women are evicted, their newborns are more likely to be born early or very small and have a higher risk of dying in the first year. Women who are evicted are more likely to suffer sexual assault, Benfer said.

Kids who are evicted are at greater risk of lead poisoning from substandard housing, Benfer said. They're also more likely than others to be hospitalized.

Evicted adults report worse mental health and are more likely to be hospitalized for a mental health crisis, studies show. They also have higher mortality rates from suicide. Although the causes of addiction are complex, research shows that counties with higher eviction rates have significantly higher rates of drug- and alcohol-related deaths.

People who are evicted often move into substandard housing in neighborhoods with higher crime rates. These homes are sometimes plagued by mold and roaches, lack sufficient heating, or have plumbing that doesn't work. Landlords have no incentive to make repairs for tenants who are behind on their rent, Benfer said. In fact, tenants who request repairs or report safety hazards risk eviction.

Although middle-class Americans take their kitchens for granted — and rely on them to cook healthful meals — more than 1 million homes lack complete kitchens, according to the U.S. Census Bureau.

New Orleans doesn't require that rental units include stoves, said Hannah Adams, also a lawyer with Southeast Louisiana Legal Services. Toussaint's new room is equipped with a microwave and small refrigerator, but no sink, oven or stove. He washes dinner dishes in the bathroom. His landlord doesn't allow residents to have electric hot plates, so most of his meals involve cold cereal, deli sandwiches or meals he can heat in the microwave. His doctor has urged Toussaint, who is borderline diabetic, to lose weight, eat less salt and starch, and stop smoking.

Toussaint, who lived on the street for two years, said he's determined not to return there. He hopes to apply for disability insurance, which would provide him with an income if his arthritis prevents him from finding steady work.

Woolf said he hopes Americans won't forget about the suffering of people like Toussaint as cases of COVID decline. "My worry is that people will feel the crisis is behind us and it's all good," Woolf said. His research connecting four decades of declining economic opportunity with falling life expectancy shows "we are in really big trouble, and that was true before we knew a pandemic was coming."

The pandemic doesn't have to doom a generation of Americans to disease and early death, said Dr. Richard Besser, president and CEO of the Robert Wood Johnson Foundation. By addressing issues such as poverty, racial inequality and the lack of affordable housing, the country can improve American health and reverse the trends that caused communities of color to suffer. "How the pandemic will affect people's future health depends on what we do coming out of this," Besser said. "It will take an intentional effort to make up for the losses that have occurred over the past year."

Liz Szabo: lszabo@kff.org, @LizSzabo

Biden Quietly Transforms Medicaid Safety Net

KFF Health News, June 24, 2021

Biden's efforts — which have been largely overshadowed by other economic and health initiatives — represent an abrupt reversal of the Trump administration's moves to scale back the safety-net program.

This article was published on Thursday, June 24, 2021 in Kaiser Health News.

By Noam N. Levey and Phil Galewitz

The Biden administration is quietly engineering a series of expansions to Medicaid that may bolster protections for millions of low-income Americans and bring more people into the program.

Biden's efforts — which have been largely overshadowed by other economic and health initiatives — represent an abrupt reversal of the Trump administration's moves to scale back the safety-net program.

The moves, some of which were funded by the COVID relief bill that passed in March, could further boost Medicaid enrollment — which the pandemic pushed to a record 80.5 million in January, including those served by the related Children's Health Insurance Program. That's up from 70 million before the COVID crisis began. New mothers, inmates and undocumented immigrants are among those who could gain coverage. At the same time, the Biden administration is opening the door to new Medicaid-funded services such as food and housing that the government insurance plan hasn't traditionally offered.

"There is a paradigm change underway," said Jennifer Langer Jacobs, Medicaid director in New Jersey, one of a growing number of states trying to expand home-based Medicaid services to keep enrollees out of nursing homes and other institutions.

"We've had discussions at the federal level in the last 90 days that are completely different from where we've ever been before," Langer Jacobs said.

Taken together, the Medicaid moves represent some of the most substantive shifts in federal health policy undertaken by the new administration.

"They are taking very bold action," said Rutgers University political scientist Frank Thompson, an expert on Medicaid history, noting, in particular, the administration's swift reversal of Trump policies. "There really isn't a precedent."

The Biden administration seems unlikely to achieve what remains the holy grail for Medicaid advocates: getting 12 holdout states, including Texas and Florida, to expand Medicaid coverage to low-income working-age adults through the Affordable Care Act. 

And while some recent expansions — including for new mothers — were funded by close to $20 billion in new Medicaid funding in the COVID relief bill Biden signed in March, much of that new money will stop in a few years unless Congress appropriates additional money.

The White House strategy has risks. Medicaid, which swelled after enactment of the 2010 health law, has expanded further during the economic downturn caused by the pandemic. The programs now cost taxpayers more than $600 billion a year. And although the federal government will cover most of the cost of the Biden-backed expansions, surging Medicaid spending is a growing burden on state budgets.

The costs of expansion are a frequent target of conservative critics, including Trump officials like Seema Verma, the former administrator of the Centers for Medicare & Medicaid Services, who frequently argued for enrollment restrictions and derided Medicaid as low-quality coverage.

But even less partisan experts warn that Medicaid, which was created to provide medical care to low-income Americans, can't make up for all the inadequacies in government housing, food and education programs.

"Focusing on the social drivers of health … is critically important in improving the health and well-being of Medicaid beneficiaries. But that doesn't mean that Medicaid can or should be responsible for paying for all of those services," said Matt Salo, head of the National Association of Medicaid Directors, noting that the program's financing "is simply not capable of sustaining those investments."

However, after four years of Trump administration efforts to scale back coverage, Biden and his appointees appear intent on not only restoring federal support for Medicaid, but also boosting the program's reach.

"I think what we learned during the repeal-and-replace debate is just how much people in this country care about the Medicaid program and how it's a lifeline to millions," Biden's new Medicare and Medicaid administrator, Chiquita Brooks-LaSure, told KHN, calling the program a "backbone to our country."

The Biden administration has already withdrawn permission the Trump administration had granted Arkansas and New Hampshire to place work requirements on some Medicaid enrollees.

In April, Biden blocked a multibillion-dollar Trump administration initiative to prop up Texas hospitals that care for uninsured patients, a policy that many critics said effectively discouraged Texas from expanding Medicaid coverage through the Affordable Care Act, often called Obamacare. Texas has the highest uninsured rate in the nation.

The moves have drawn criticism from Republicans, some of whom accuse the new administration of trampling states' rights to run their Medicaid programs as they choose.

"Biden is reasserting a larger federal role and not deferring to states," said Josh Archambault, a senior fellow at the conservative Foundation for Government Accountability.

But Biden's early initiatives have been widely hailed by patient advocates, public health experts and state officials in many blue states.

"It's a breath of fresh air," said Kim Bimestefer, head of Colorado's Department of Healthcare Policy and Financing.

Chuck Ingoglia, head of the National Council for Mental Wellbeing, said: "To be in an environment where people are talking about expanding healthcare access has made an enormous difference."

Mounting evidence shows that expanded Medicaid coverage improves enrollees' health, as surveys and mortality data in recent years have identified greater health improvements in states that expanded Medicaid through the 2010 health law versus states that did not.

In addition to removing Medicaid restrictions imposed by Trump administration officials, the Biden administration has backed a series of expansions to broaden eligibility and add services enrollees can receive.

Biden supported a provision in the COVID relief bill that gives states the option to extend Medicaid to new mothers for up to a year after they give birth. Many experts say such coverage could help reduce the U.S. maternal mortality rate, which is far higher than rates in other wealthy nations.

Several states, including Illinois and New Jersey, had sought permission from the Trump administration for such expanded coverage, but their requests languished.

The COVID relief bill — which passed without Republican support — also provides additional Medicaid money to states to set up mobile crisis services for people facing mental health or substance use emergencies, further broadening Medicaid's reach.

And states will get billions more to expand so-called home and community-based services such as help with cooking, bathing and other basic activities that can prevent Medicaid enrollees from having to be admitted to expensive nursing homes or other institutions.

Perhaps the most far-reaching Medicaid expansions being considered by the Biden administration would push the government health plan into covering services not traditionally considered healthcare, such as housing.

This reflects an emerging consensus among health policy experts that investments in some non-medical services can ultimately save Medicaid money by keeping patients out of the hospital.

In recent years, Medicaid officials in red and blue states — including Arizona, California, Illinois, Maryland and Washington — have begun exploring ways to provide rental assistance to select Medicaid enrollees to prevent medical complications linked to homelessness.

The Trump administration took steps to support similar efforts, clearing Medicare Advantage health plans to offer some enrollees non-medical benefits such as food, housing aid and assistance with utilities.

But state officials across the country said the new administration has signaled more support for both expanding current home-based services and adding new ones.

That has made a big difference, said Kate McEvoy, who directs Connecticut's Medicaid program. "There was a lot of discussion in the Trump administration," she said, "but not the capital to do it."

Other states are looking to the new administration to back efforts to expand Medicaid to inmates with mental health conditions and drug addiction so they can connect more easily to treatment once released.

Kentucky health secretary Eric Friedlander said he is hopeful federal officials will sign off on his state's initiative.

Still other states, such as California, say they are getting a more receptive audience in Washington for proposals to expand coverage to immigrants who are in the country without authorization, a step public health experts say can help improve community health and slow the spread of communicable diseases.

"Covering all Californians is critical to our mission," said Jacey Cooper, director of California's Medicaid program, known as Medi-Cal. "We really feel like the new administration is helping us ensure that everyone has access."

The Trump administration moved to restrict even authorized immigrants' access to the healthcare safety net, including the "public charge" rule that allowed immigration authorities to deny green cards to applicants if they used public programs such as Medicaid. In March, Biden abandoned that rule.

KHN correspondent Julie Rovner contributed to this report.

Noam N. Levey: nlevey@kff.org, @NoamLevey

At Texas Border, Pandemic's High Toll Lays Bare Gaps in Health and Insurance

KFF Health News, June 23, 2021

Texas' refusal to expand Medicaid under the ACA, a shortage of healthcare options and the state's lax strategy toward the pandemic have contributed to a higher death rate at the border.

This article was published on Wednesday, June 23, 2021 in Kaiser Health News.

By René Kladzyk, El Paso Matters and Phil Galewitz and Elizabeth Lucas

EL PASO, Texas — Alfredo "Freddy" Valles was an accomplished trumpeter and a beloved music teacher for nearly four decades at one of the city's poorest middle schools.

He was known for buying his students shoes and bow ties for their band concerts, his effortlessly positive demeanor and a suave personal style — "he looked like he stepped out of a different era, the 1950s," said his niece Ruby Montana.

While Valles was singular in life, his death at age 60 in February was part of a devastating statistic: He was one of thousands of deaths in Texas border counties — where coronavirus mortality rates far outpaced state and national averages.

In the state's border communities, including El Paso, not only did people die of COVID-19 at significantly higher rates than elsewhere, but people under age 65 were also more likely to die, according to a KHN-El Paso Matters analysis of COVID death data through January. More than 7,700 people died of COVID in the border area during that period.

In Texas, COVID death rates for border residents younger than 65 were nearly three times the national average for that age group and more than twice the state average. And those ages 18-49 were nearly four times more likely to die than those in the same age range across the U.S.

"This was like a perfect storm," said Heide Castañeda, an anthropology professor at the University of South Florida who studies the health of border residents. She said a higher-than-normal prevalence of underlying health issues combined with high uninsurance rates and flagging access to care likely made the pandemic even more lethal for those living along the border than elsewhere.

That pattern was not as stark in neighboring New Mexico. Border counties there recorded COVID death rates 41% lower than those in Texas, although the New Mexico areas were well above the national average as of January, the KHN-El Paso Matters analysis found. Texas border counties tallied 282 deaths per 100,000, compared with 166 per 100,000 in New Mexico.

That stark divide could be seen even when looking at neighboring El Paso County, Texas, and Doña Ana County, New Mexico. The death rate for residents under 65 was 70% higher in El Paso County.

Health experts said Texas' refusal to expand Medicaid under the Affordable Care Act, a shortage of healthcare options and the state's lax strategy toward the pandemic also contributed to a higher death rate at the border. Texas GOP leaders have opposed Medicaid expansion for a litany of economic and political reasons, though largely because they object to expanding the role or size of government.

"Having no Medicaid expansion and an area that is already underserved by primary care and preventive care set the stage for a serious situation," Castañeda said. "A lot of this is caused by state politics."

Texas was one of the first states to reopen following the nationwide coronavirus shutdown in March and April last year. Last June — even as cases were rising — Gov. Greg Abbott allowed all businesses, including restaurants, to operate at up to 50% capacity, with limited exceptions. And he refused to put any capacity restrictions on churches and other religious facilities or let local governments impose mask requirements.

In November, Texas Attorney General Ken Paxton filed an injunction to stop a lockdown order implemented by the El Paso county judge, the top administrative officer, at a time when El Paso hospitals were so overwhelmed with COVID patients that 10 mobile morgues had to be set up at an area hospital to accommodate the dead.

Unlike Texas, New Mexico expanded Medicaid under the ACA and, as a result, has a much lower uninsured rate than Texas for people under age 65 — 12% compared with Texas' 21%, according to Census figures. And New Mexico had aggressive rules for face masks and public gatherings. Still, that didn't spare New Mexico from the crisis. Outbreaks in and around the Navajo reservation hit hard. Overall, its state death rate exceeded the state rate for Texas, but along the border New Mexico's rates were lower in all age groups.

For some border families, the immense toll of the pandemic meant multiple deaths among loved ones. Ruby Montana lost not only her uncle to COVID in recent months, but also her cousin Julieta "Julie" Apodaca, a former elementary school teacher and speech therapist.

Montana said Valles' death surprised the family. He had been teaching remotely at Guillen Middle School in El Paso's Segundo Barrio neighborhood, an area known as "the other Ellis Island" because of its adjacency to the border and its history as an enclave for Mexican immigrant families.

When Valles first got sick with COVID in December, Montana and the family were not worried, not only because he had no preexisting health conditions, but also because they knew his lungs were strong from practicing his trumpet daily over the course of decades.

In early January, he went to an urgent care center after his condition deteriorated. He had pneumonia and was told to go straight to the emergency room.

"When I took him to the [hospital], I dropped him off and went to go park," said his wife, Elvira. But when she returned, she was not allowed inside. "I never saw him again," she said.

Valles, a father of three, had been teaching one of his three grandchildren, 5-year-old Aliq Valles, to play the trumpet.

They "were joined at the hip," Montana said. "That part has been really hard to deal with too. [Aliq] should have a whole lifetime with his grandpa."

Hispanic adults are more than twice as likely to die of COVID as white adults, according to the Centers for Disease Control and Prevention. In Texas, Hispanic residents died of COVID at a rate four times as high as that of non-Hispanic white people, according to a December analysis by The Dallas Morning News.

Ninety percent of residents under 65 in Texas border counties are Hispanic, compared with 37% in the rest of the state. Latinos have high rates of chronic conditions like diabetes and obesity, which increases their risks of COVID complications, health experts say.

Because they were more likely to die of COVID at earlier ages, Latinos are losing the most years of potential life among all racial and ethnic groups, said Coda Rayo-Garza, an advocate for policies to aid Hispanic populations and a professor of political science at the University of Texas-San Antonio.

Expanding Medicaid, she said, would have aided the border communities in their fight against COVID, as they have some of the highest rates of residents without health coverage in the state.

"There has been a disinvestment in border areas long before that led to this outcome that you're finding," she said. "The legislature did not end up passing Medicaid expansion, which would have largely benefited border towns."

The higher death rates among border communities are "unfortunately not surprising," said Rep. Veronica Escobar (D-El Paso).

"It's exactly what we warned about," Escobar said. "People in Texas died at disproportionate rates because of a dereliction on behalf of the governor. He chose not to govern … and the results are deadly."

Abbott spokesperson Renae Eze said the governor mourns every life lost to COVID.

"Throughout the entire pandemic, the state of Texas has worked diligently with local officials to quickly provide the resources needed to combat COVID and keep Texans safe," she said.

Ernesto Castañeda, a sociology professor at American University in Washington, D.C., who is not related to Heide Castañeda, said structural racism is integrally linked to poor health outcomes in border communities. Generations of institutional discrimination — through policing, educational and job opportunities, and healthcare — worsens the severity of crisis events for people of color, he explained.

"We knew it was going to be bad in El Paso," Ernesto Castañeda said. "El Paso has relatively low socioeconomic status, relatively low education levels, high levels of diabetes and overweight [population]."

In some Texas counties along the border more than a third of workers are uninsured, according to an analysis by Georgetown University's Center for Children and Families.

"The border is a very troubled area in terms of high uninsured rates, and we see all of those are folks put at increased risk by the pandemic," said Joan Alker, director of the center.

In addition, because of a shortage of health workers along much of the border, the pandemic surge was all the deadlier, said Dr. Ogechika Alozie, an El Paso specialist in infectious diseases.

"When you layer on top not having enough medical personnel with a sicker-on-average population, this is really what you find happens, unfortunately," he said.

The federal government has designated the entire Texas border region as both a health professional shortage area and a medically underserved area.

Jagdish Khubchandani, a professor of public health at New Mexico State University in Las Cruces, about 40 miles northwest of El Paso, said the two cities were like night and day in their response to the crisis.

"Restrictions were far more rigid in New Mexico," he said. "It almost felt like two different countries."

Manny Sanchez, a commissioner in Doña Ana County, credits the lower death rates in New Mexico to state and local officials' united message to residents about COVID and the need to wear masks and maintain physical distance. "I would like to think we made a difference in saving lives," Sanchez said.

But, because containing a virus requires community buy-in, even El Paso residents who understood the risks were susceptible to COVID. Julie Apodaca, who had recently retired, had been especially careful, in part because her asthma and diabetes put her at increased risk. As the primary caregiver for her elderly mother, she was likely exposed to the virus through one of the nurse caretakers who came to her mother's home and later tested positive, said her sister Ana Apodaca.

Julie Apodaca had registered for a COVID vaccine in December as soon as it was available but had not been able to get an appointment for a shot by the time she fell ill.

Montana found out that Apodaca had been hospitalized the day after her uncle died. One month later, and after 16 days on a ventilator, she too died on March 13.

She was 56.

This story was done in partnership with El Paso Matters, a member-supported, nonpartisan media organization that focuses on in-depth and investigative reporting about El Paso, Texas, Ciudad Juárez across the border in Mexico, and neighboring communities.

Methodology

To analyze COVID deaths rates along the border with Mexico, KHN and El Paso Matters requested COVID-related death counts by age group and county from Texas, New Mexico, California and Arizona. California and Arizona were unable to fulfill the requests. The Texas Department of State Health Services and the New Mexico Department of Health provided death counts as of Jan. 31, 2021.

Texas' data included totals by age group for border counties as a group and for the state with no suppression of data. New Mexico provided data for individual counties, and small numbers were suppressed, totaling 1.6% of all deaths in the state. (Data on deaths is commonly suppressed when it involves very small numbers to protect individual identities.)

National death counts by age group were calculated using provisional death data from the Centers for Disease Control and Prevention, and included deaths as of Jan. 31, 2021.

Rates were calculated per 100,000 people using the 2019 American Community Survey.

The ethnic breakdown in Texas' border counties comes from the Census Bureau's 2019 population estimates.

Phil Galewitz: pgalewitz@kff.org, @philgalewitz

Elizabeth Lucas: elucas@kff.org, @eklucas

Thousands of Young Children Lost Parents to COVID. Where's Help for Them?

KFF Health News, June 23, 2021

Researchers calculate that more than 46,000 children have lost one or both parents to COVID since February 2020.

This article was published on Wednesday, June 23, 2021 in Kaiser Health News.

By JoNel Aleccia

Five months after her husband died of COVID-19, Valerie Villegas can see how grief has wounded her children.

Nicholas, the baby, who was 1 and almost weaned when his father died, now wants to nurse at all hours and calls every tall, dark-haired man "Dada," the only word he knows. Robert, 3, regularly collapses into furious tantrums, stopped using the big-boy potty and frets about sick people giving him germs. Ayden, 5, recently announced it's his job to "be strong" and protect his mom and brothers.

Her older kids — Kai Flores, 13, Andrew Vaiz, 16, and Alexis Vaiz, 18 — are often quiet and sad or angry and sad, depending on the day. The two eldest, gripped by anxiety that makes it difficult to concentrate or sleep, were prescribed antidepressants soon after losing their stepfather.

"I spend half the nights crying," said Villegas, 41, a hospice nurse from Portland, Texas. She became a widow on Jan. 25, just three weeks after Robert Villegas, 45, a strong, healthy truck driver and jiujitsu expert, tested positive for the virus.

"My kids, they're my primary concern," she said. "And there's help that we need."

But in a nation where researchers calculate that more than 46,000 children have lost one or both parents to COVID since February 2020, Villegas and other survivors say finding basic services for their bereaved kids — counseling, peer support groups, financial assistance — has been difficult, if not impossible.

"They say it's out there," Villegas said. "But trying to get it has been a nightmare."

Interviews with nearly two dozen researchers, therapists and other experts on loss and grief, as well as families whose loved ones died of COVID, reveal the extent to which access to grief groups and therapists grew scarce during the pandemic. Providers scrambled to switch from in-person to virtual visits and waiting lists swelled, often leaving bereft children and their surviving parents to cope on their own.

"Losing a parent is devastating to a child," said Alyssa Label, a San Diego therapist and program manager with SmartCare Behavioral Health Consultation Services. "Losing a parent during a pandemic is a special form of torture."

Children can receive survivor benefits when a parent dies if that parent worked long enough in a job that required payment of Social Security taxes. During the pandemic, the number of minor children of deceased workers who received new benefits has surged, reaching nearly 200,000 in 2020, up from an average of 180,000 in the previous three years. Social Security Administration officials don't track cause of death, but the latest figures marked the most awards granted since 1994. COVID deaths "undoubtedly" fueled that spike, according to the SSA's Office of the Chief Actuary.

And the number of children eligible for those benefits is surely higher. Only about half of the 2 million children in the U.S. who have lost a parent as of 2014 received the Social Security benefits to which they were entitled, according to a 2019 analysis by David Weaver of the Congressional Budget Office.

Counselors said they find many families have no idea that children qualify for benefits when a working parent dies, or don't know how to sign up.

In a country that showered philanthropic and government aid on the 3,000 children who lost parents to the 9/11 terror attacks, there's been no organized effort to identify, track or support the tens of thousands of kids left bereaved by COVID.

"I'm not aware of any group working on this," said Joyal Mulheron, the founder of Evermore, a nonprofit foundation that focuses on public policy related to bereavement. "Because the scale of the problem is so huge, the scale of the solution needs to match it."

COVID has claimed more than 600,000 lives in the U.S., and researchers writing in the journal JAMA Pediatrics calculated that for every 13 deaths caused by the virus, one child under 18 has lost a parent. As of June 15, that would translate into more than 46,000 kids, researchers estimated. Three-quarters of the children are adolescents; the others are under age 10. About 20% of the children who've lost parents are Black, though they make up 14% of the population. 

"There's this shadow pandemic," said Rachel Kidman, an associate professor at Stony Brook University in New York, who was part of the team that found a way to calculate the impact of COVID deaths. "There's a huge amount of children who have been bereaved."

The Biden administration, which launched a program to help pay funeral costs for COVID victims, did not respond to questions about offering targeted services for families with children.

Failing to address the growing cohort of bereaved children, whether in a single family or in the U.S. at large, could have long-lasting effects, researchers said. The loss of a parent in childhood has been linked to higher risks of substance use, mental health problems, poor performance in school, lower college attendance, lower employment and early death.

"Bereavement is the most common stress and the most stressful thing people go through in their lives," said clinical psychologist Christopher Layne of the UCLA/Duke University National Center for Child Traumatic Stress. "It merits our care and concern."

Perhaps 10% to 15% of children and others bereaved by COVID might meet the criteria of a new diagnosis, prolonged grief disorder, which can occur when people have specific, long-lasting responses to the death of a loved one. That could mean thousands of children with symptoms that warrant clinical care. "This is literally a national, very public health emergency," Layne said.

Still, Villegas and others say they have been left largely on their own to navigate a confusing patchwork of community services for their children even as they struggle with their own grief.

"I called the counselor at school. She gave me a few little resources on books and stuff," Villegas said. "I called some crisis hotline. I called counseling places, but they couldn't help because they had waiting lists and needed insurance. My kids lost their insurance when their dad died."

The social disruption and isolation caused by the pandemic overwhelmed grief care providers, too. Across the U.S., nonprofit agencies that specialize in childhood grief said they have scrambled to meet the need and to switch from in-person to virtual engagement.

"It was a huge challenge; it was very foreign to the way we work," said Vicki Jay, CEO of the National Alliance for Grieving Children. "Grief work is based on relationships, and it's very hard to get a relationship with a piece of machinery."

At Experience Camps, which each year offers free weeklong camps to about 1,000 bereaved kids across the country, the waiting list has grown more than 100% since 2020, said Talya Bosch, an Experience Camps associate. "It is something that we are concerned about — a lot of kids are not getting the support they need," she said.

Private counselors, too, have been swamped. Jill Johnson-Young, co-owner of Central Counseling Services in Riverside, California, said her nearly three dozen therapists have been booked solid for months. "I don't know a therapist in the area who isn't full right now," she said.

Dr. Sandra McGowan-Watts, 47, a family practice doctor in Chicago, lost her husband, Steven, to COVID in May 2020. She feels fortunate to have found an online therapist for her daughter, Justise, who helped explain why the 12-year-old was suddenly so sad in the mornings: "My husband was the one who woke her up for school. He helped her get ready for school."

Justise was also able to get a spot at an Experience Camps session this summer. "I am nervous about going to camp, but I am excited about meeting new kids who have also lost someone close in their life," she said.
 

Jamie Stacy, 42, of San Jose, California, was connected with an online counselor for her daughter, Grace, 8, and twin sons, Liam and Colm, 6, after their father, Ed Stacy, died of COVID in March 2020 at age 52. Only then did she learn that children can grieve differently than adults. They tend to focus on concrete concerns, such as where they'll live and whether their favorite toys or pets will be there. They often alternate periods of play with sadness, cycling rapidly between confronting and avoiding their feelings of loss.

"The boys will be playing Legos, having a great time, and all of a sudden drop a bomb on you: 'I know how I can see Daddy again. I just have to die, and I'll see Daddy again,'" she said. "And then they're back to playing Legos."

Stacy said counseling has been crucial in helping her family navigate a world where many people are marking the end of the pandemic. "We can't escape the topic of COVID-19 even for one day," she said. "It's always in our face, wherever we go, a reminder of our painful loss."

Villegas, in Texas, has returned to her work in hospice care and is starting to reassemble her life. But she thinks there should be formal aid and grief support for families like hers whose lives have been indelibly scarred by the deadly virus.

"Now everybody's lives are going back to normal," she said. "They can get back to their lives. And I'm thinking my life will never be normal again."

This story was produced by KHN (Kaiser Health News), a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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

JoNel Aleccia: jaleccia@kff.org, @JoNel_Aleccia

In a Murky Sea of Mental Health Apps, Consumers Left Adrift

KFF Health News, June 22, 2021

For tech startups looking to cash in on unmet need, that translates into more than 50 million potential customers.

This article was published on Tuesday, June 22, 2021 in Kaiser Health News.

By Jenny Gold

In the eyes of the tech industry, mental health treatment is an area ripe for disruption.

In any given year, 1 in 5 adults in the U.S. experience a form of mental illness, according to federal estimates. And research indicates only about half of them receive treatment in a system that is understaffed and ill distributed to meet demand.

For tech startups looking to cash in on unmet need, that translates into more than 50 million potential customers.

Venture capital firms invested more than $2.4 billion in digital behavioral health apps in 2020 — more than twice the amount invested in 2019 — touting support or treatment for issues from burnout and depression to ADHD and bipolar disorder. At least seven mental health app companies have achieved “unicorn” status and are valued at more than $1 billion.

But even as industry hype mounts, researchers and companies are scrambling to prove these apps actually work. Of the estimated 20,000 mental health apps available for download on personal computers and smartphones, just five have been formally vetted and approved by the Food and Drug Administration, which largely has taken a hands-off approach to regulating the space.

“Development has really outpaced the science,” said Stephen Schueller, a clinical psychologist at the University of California-Irvine who specializes in the development and evaluation of digital mental health products.

Type “depression” or “anxiety” into an app store, and you’ll be met with a dizzying list of results. There are thousands of “wellness” apps like Headspace that counsel people on breathing exercises and other techniques to help them feel more mindful. Apps such as Woebot and TalkLife profess to help manage conditions like anxiety and postpartum depression using games, mood journaling or text exchanges with peers or automated bots.

Some apps are meant to be used alongside in-person therapy, and others on their own. Several of the most popular, like Talkspace, BetterHelp and Ginger, promise access to treatment with a licensed therapist over text message, phone or video. Others, including Brightside and Cerebral, connect users to psychiatrists who can prescribe antidepressants.

Most products make their money by charging consumers a monthly or annual fee, with the option to purchase extras like video sessions with a therapist. Others contract directly with employers or insurers.

And, yes, a small portion of these apps have promising research to back them up. Several studies, for example, have found that cognitive behavioral therapy, a mainstay of treatment for depression and anxiety that seeks to help patients change negative thought patterns, is as effective when delivered using web-based platforms as when done in person by a licensed professional. And the pandemic has bolstered claims that patients are willing to trade in-person visits for the ease of online connection.

“Digital mental health can be viewed as a way to extend the mental resources that we have,” said David Mohr, who directs the Center for Behavioral Intervention Technologies at the Northwestern University Feinberg School of Medicine. A step-care model, for example, would allow patients with milder symptoms to be treated via technology while reserving in-person care for patients who need something more.

The challenge for consumers is separating the apps that might help from those that offer little more than distraction — or could actually do harm.

Some companies offering mental health treatment had recently been doing something totally different — for example, an online seller of erectile dysfunction and hair loss treatments has started offering psychiatric evaluations and prescribing and selling antidepressants.

Tech companies are by nature for-profit and, in the rush to compete in a saturated market, many are selling a product with an appealing user interface but little evidence of effectiveness. A 2020 analysis by Australian researchers reviewing nearly 300 apps for anxiety and depression found just 6% of the companies that boasted an evidence-based framework in the app store description for their products had published any evidence.

Nor do star ratings and download totals offer much context: An April study from Beth Israel Deaconess Medical Center and Harvard Medical School found little correlation between app store metrics and treatment quality.

“No one is competing based on privacy, safety or evidence. They’re competing on aesthetics, in part, on page ranking, marketing on brand awareness,” said Dr. John Torous, director of the digital psychiatry division at Beth Israel Deaconess Medical Center and one of the authors of the April study. “There’s an implicit assumption that the app is better than nothing. But what if it isn’t better than nothing?”

One problem, said Dr. Ipsit Vahia, a geriatric psychiatrist and medical director of the McLean Institute for Technology in Psychiatry, is that randomized control studies of the kind that might prove an app’s effectiveness can take years, far slower than the rapid innovation in tech. “In general, the health care industry and the technology industry work at very different paces,” Vahia said.

Dr. David Mou, a psychiatrist at Massachusetts General Hospital who is chief medical officer at Cerebral, said he agrees that everything new in health care must be done deliberately and conservatively to avoid patient harm. But he said some people in the mental health field are painting all companies with the same brush and failing to differentiate those that are data-driven from those trying to grow at any cost.

“They look at us and say we’re all VC-backed bros in a basement trying to redesign health care. And that’s not true. It may have been true 10 years ago, but it isn’t true today,” said Mou. The long-term winners, he said, will be those that are “evidence-based and measure quality like crazy.”

Cerebral offers online therapy and medication management and delivery for a range of mental illnesses. The monthly subscription fees range from $29 to $325, depending on the level and frequency of care, as well as insurance coverage. Mou said Cerebral is already able to demonstrate some advantages. While many top hospital systems might have a months-long wait for care, he said, someone in crisis can reach a Cerebral provider almost immediately. “Within minutes you are able to talk with someone with one of our instant live visits. That in itself is a huge win.”

Even critics of the tech explosion are quick to acknowledge that the current brick-and-mortar system of mental health is dated and inadequate. In recent years, the issues surrounding mental illness and lack of access to treatment have infiltrated public dialogue. Brain illnesses that many families once squirreled away from view have become the stuff of celebrity culture and dinner-table chatter.

Yet even as advocates have made strides in acceptance, truly improving the lives of people with mental illness has proven stubbornly difficult. Over the past several decades — while the U.S. successfully lowered death rates for cancer, heart disease and other major illnesses — deaths by suicide and drug overdose have continued to climb.

Federal law theoretically requires insurance companies to cover brain illness as they would any other illness. But finding affordable care remains a challenge, largely because of a shortage of licensed mental health professionals and ongoing inequities in insurance coverage.

In a nation where huge swaths of the population lack a primary care doctor and health insurance — but most everyone has a cellphone — connecting people to treatment via mobile apps would seem a logical solution. And, for some, the opportunity to talk about their mental health challenges anonymously makes online treatment an attractive alternative.

Still, many of the experts who welcome the potential for innovation in mental health treatment acknowledge that consumers are getting little guidance in how to choose a reputable option. “Wellness” apps that promote a healthy lifestyle or apps that help people manage their disease without providing specific treatment suggestions can avoid FDA regulation. But even those that offer patient-specific diagnoses and treatment recommendations that would seem to fall squarely under the FDA’s authority do not seem to garner the agency’s attention, according to industry experts.

“The FDA has been really, really lax on enforcing in digital health for reasons that are not entirely clear to me,” said Bradley Merrill Thompson, a lawyer at Epstein Becker Green who advises companies on FDA regulations. “Anybody could spend 20 minutes on the app store and find dozens of examples of apps that make medical device claims, and that have been doing so for some time, without any effort by the FDA to rein them in.”

In response to questions from KHN about its approach to regulating mental health apps, the FDA sent a brief statement. “As circumstances change and new needs arise, FDA is ready to meet and address these challenges, especially in the areas of mental health,” the statement reads in part. “We would like to see more evidence-based products in this area, which is why we remain committed to facilitating the development of additional safe and effective therapies for patients who rely on these products.”

Dr. Tom Insel, a psychiatrist and neuroscientist, has a unique view of the evolving landscape. In 2015, Insel left his job as director of the National Institute of Mental Health, a post he had held since 2002, trading the halls of government for the open floor plans of Silicon Valley to work in digital mental health. He started at Google’s Verily, then co-founded Mindstrong Health, a startup researching how smartphone technology could be used to predict and diagnose mental health crises. He has since left to advise California officials on behavioral health issues.

Insel said he believes in the promise of digital mental health but that it will take time to find its highest and best use. He noted, for example, that most of the apps on the market focus on the problem of access: They make care more convenient. But they’re overlooking a more basic problem: quality. Unlike most fields of medicine, mental health providers rarely measure whether the care they provide makes patients better.

“A lot of what we need is not just more access. It’s not just recreating the brick-and-mortar system and letting people do it by phone or Zoom,” Insel said. Instead, he argued, digital health should focus on measuring whether treatments improve people’s lives.

“I have no doubt that this field will transform mental health treatment and diagnosis,” Insel said, “but we’re in the first act of a five-act play. I don’t think we’re anywhere near the kinds of solutions that we need in the real world.”

Jenny Gold: jgold@kff.org, @JennyAGold

Is Rand Paul Mixing Up the Vaccine Message for COVID Survivors?

KFF Health News, June 22, 2021

Paul's social media communication represented his latest salvo in the ongoing debate over whether natural immunity is equivalent or even better than vaccination.

This article was published on Tuesday, June 22, 2021 in Kaiser Health News.

By Victoria Knight

Last week, Sen. Rand Paul (R-Ky.) posted a Twitter thread asserting that people who have survived a COVID-19 infection were unlikely to be reinfected and have better immunity against variants than those who have been vaccinated against — but not infected by — SARS-CoV-2, the virus that causes COVID.

The social media communication represented his latest salvo in the ongoing debate over whether natural immunity is equivalent or even better than vaccination.

While the science on the subject is still evolving, a look at the evidence behind Paul's series of tweets seemed in order. After all, though almost 65% of Americans have received at least one dose of a COVID vaccine, some people who have recovered from COVID may not feel a need to get shot. Paul, who was the first senator to be diagnosed with the virus, is among them. Here's a deeper look at what Paul said on Twitter, the studies he cited and how researchers characterized his comments.

Breaking Down the Twitter Thread

In his first tweet, Paul referenced a recent Cleveland Clinic study finding that among subjects who were unvaccinated but had already had COVID-19, there were no re-infections in a five-month observation period: "Great news! Cleveland clinic study of 52,238 employees shows unvaccinated people who have had COVID 19 have no difference in re-infection rate than people who had COVID 19 and who took the vaccine."

In subsequent tweets, the senator said: "The immune response to natural infection is highly likely to provide protective immunity even against the SARS-CoV-2 variants. … Thus, recovered COVID-19 patients are likely to better defend against the variants than persons who have not been infected but have been immunized with spike-containing vaccines only." All three vaccines authorized for emergency use in the U.S. (Pfizer-BioNTech, Moderna and Johnson & Johnson) contain genetic instructions that tell our cells how to make a spike protein associated with the coronavirus. The presence of that spike protein then causes our bodies to make antibodies to protect against COVID.

At the end of his final tweet, Rand then linked to a second study led by scientists at the Fred Hutchinson Cancer Research Center in Seattle to support his assertions.

Digesting the Scientific Papers

Paul referenced two scientific papers in his tweet thread — both of which are preprints, meaning they have not yet been published in scientific journals or been peer-reviewed.

One was a study from the Cleveland Clinic following four categories of healthcare workers: unvaccinated but previously infected; unvaccinated but not previously infected; vaccinated and previously infected; and vaccinated but not previously infected. The workers were followed for five months.

The researchers found that no one who was unvaccinated but had previously been infected with COVID became infected again during the five-month study period. Infections were almost zero among those who were vaccinated, while there was a steady increase in infections among those who were unvaccinated and previously uninfected.

When asked whether he believed Paul's tweet had interpreted his study results correctly, the study's lead author, Dr. Nabin Shrestha, an infectious diseases specialist at Cleveland Clinic, said "it was an accurate interpretation of the study's findings."

However, Dr. George Rutherford, an epidemiologist at the University of California-San Francisco, wrote in an email that he would add one caveat to the wording of Paul's tweet: "Note that in his tweet Senator Paul seems to suggest that the denominator of previously infected healthcare workers at the Cleveland Clinic was 52,238 — that was the total number in the whole study. There were 1,359 that were previously infected and never vaccinated, and there were no reinfections noted over a median follow up of 143 days. So, the tweet itself is accurate if read literally but the denominator is really 1,359."

As for the other study Paul mentioned, researchers analyzed COVID-19 immunity in those who had been infected with the COVID virus and those who hadn't and found that infection activated a range of immune cells and immunity lasted at least eight months.

In his last two tweets in the thread, Paul quotes directly from the study's "discussion" section: "The immune response to natural infection is highly likely to provide protective immunity even against the SARS-CoV-2 variants. … Thus, recovered COVID-19 patients are likely to better defend against the variants than persons who have not been infected but have been immunized with spike-containing vaccines only."

The lead study author, Kristen Cohen, a senior staff scientist in the Vaccine and Infectious Disease Division at the Fred Hutchinson Cancer Research Center in Seattle, acknowledged that Paul's tweet was a direct quote from the study. Still, she said, in her view, the quote was taken out of context and presented to suit Paul's objective — but does not accurately reflect the overall take-home message from the study's findings.

That's because, she said, Paul was quoting from the discussion section of the paper. The discussion is the final section of a scientific paper, and Cohen said its purpose here was to project what the study's findings could imply for a broader scientific significance.

"We wrote that recovering COVID patients are "likely" to better defend against variants than those who have just been immunized, but it's not saying they do," said Cohen. "It's not saying they have been known to. It's making a hypothesis or basically saying this could be the case."

In fact, Cohen's study did not include any subjects who had been vaccinated. The researchers were merely reasoning in the sentence Paul quoted that, based on the data showing the immune system's broad natural response, those who recover from COVID-19 and then receive a vaccine may be better protected against COVID variants than those who had only vaccine-induced immunity.

"We did not intend to argue that infected people do not need to get vaccinated or that their immune responses are superior," Cohen wrote in an email.

However, Cohen recognized the sentence was confusing when taken out of context and said she will eliminate it from the paper when it gets submitted for publication.

Cohen pointed us to another Fred Hutchinson-led study with which she was involved. It did show that people who previously had COVID-19 benefited from also getting vaccinated, because there was a significant boost in immune response, especially against variants.

The Conventional Wisdom on Natural Immunity

So, what's known from these two studies is that surviving a COVID infection confers a significant amount of immunity against the virus. Other studies also support this assertion.

"Existing literature does show natural immunity provides protection against COVID-19," said Shane Crotty, a professor at the Center for Infectious Disease and Vaccine Research at the La Jolla Institute for Immunology who has published numerous peer-reviewed studies on natural immunity against COVID-19. He said such immunity particularly protects against hospitalizations and severe illness.

In Crotty's own recent study, the largest yet to measure the molecules and cells involved in immune protection, his team found that natural immunity against COVID lasted at least eight months. Based on projections, it could last up to a couple of years.

While that is good news, Crotty said, there are three points of caution.

First, though natural immunity appears to be very effective against the current dominant U.S. variant (known as alpha), it also appears weaker than vaccine immunity against some of the variants circulating, such as the delta variant, first detected in India. That means if those variants eventually become dominant in the U.S., people relying on natural immunity would be less protected than those who are vaccinated.

Second, there is a lack of data about whether natural immunity prevents asymptomatic transmission and infection. Several other studies, though, show vaccines do.

Third, Crotty said his studies have shown that levels of natural immunity can vary widely in individuals. His team even found a hundredfold difference in the number of immune cells among people.

"If you thought about the immune system as a basketball game and you thought about that as a team scoring 1 point, and another team scoring 100 points, that's a big difference," said Crotty. "We're not so confident that people at the low end of immunity levels would be as protected against COVID-19."

But those who receive a vaccine shot have a much more consistent number of immune cells, since everyone receives the same dose amount, said Crotty.

With all that in mind, the Centers for Disease Control and Prevention recommends that those who previously had COVID-19 should get vaccinated and receive both doses of a vaccine, whether it's the Pfizer-BioNTech or Moderna vaccine. Fauci, the nation's leading infectious disease expert, reiterated this message during a White House COVID-19 briefing last month.

Victoria Knight: vknight@kff.org, @victoriaregisk  

Hospitals, Insurers Invest Big Dollars to Tackle Patients' Social Needs

KFF Health News, June 22, 2021

After years of testing, the evidence is mixed that these efforts work.

This article was published on Tuesday, June 22, 2021 in Kaiser Health News.

By Phil Galewitz

PHILADELPHIA — When doctors at a primary care clinic here noticed many of its poorest patients were failing to show up for appointments, they hoped giving out free rides would help.

But the one-time complimentary ride didn't reduce these patients' 36% no-show rate at the University of Pennsylvania Health System clinics.

"I was super surprised it did not have any effect," said Dr. Krisda Chaiyachati, the Penn researcher who led the 2018 study of 786 Medicaid patients.

Many of the patients did not take advantage of the ride because they were either saving it for a more important medical appointment or preferred their regular travel method, such as catching a ride from a friend, a subsequent study found.

It was not the first time that efforts by a healthcare provider to address patients' social needs — such as food, housing and transportation — failed to work.

In the past decade, dozens of studies funded by state and federal governments, private hospitals, insurers and philanthropic organizations have looked into whether addressing patients' social needs improves health and lowers medical costs.

But so far it's unclear which of these strategies, focused on so-called social determinants of health, are most effective or feasible, according to several recent academic reports by experts at Columbia, Duke and the University of California-San Francisco that evaluated existing research.

And even when such interventions show promising results, they usually serve only a small number of patients. Another challenge is that several studies did not go on long enough to detect an impact, or they did not evaluate health outcomes or health costs.

"We are probably at a peak of inflated expectations, and it is incumbent on us to find the innovations that really work," said Dr. Laura Gottlieb, director of the UCSF Social Interventions Research and Evaluation Network. "Yes, there's a lot of hype, and not all of these interventions will have staying power."

With healthcare providers and insurers eager to find ways to lower costs, the limited success of social-need interventions has done little to slow the surge of pilot programs — fueled by billions of private and government dollars.Bottom of Form

Paying for Health, Not Just Healthcare

Across the country, both public and private health insurance programs are launching large initiatives aimed at improving health by helping patients with unmet social needs. One of the biggest efforts kicks off next year in North Carolina, which is spending $650 million over five years to test the effect of giving Medicaid enrollees assistance with housing, food and transportation.

California is redesigning its Medicaid program, which covers nearly 14 million residents, to dramatically increase social services to enrollees.

These moves mark a major turning point for Medicaid, which, since its inception in 1965, largely has prohibited government spending on most nonmedical services. To get around this, states have in recent years sought waivers from the federal government and pushed private Medicaid health plans to address enrollees' social needs.

The move to address social needs is gaining steam nationally because, after nearly a dozen years focused on expanding insurance under the Affordable Care Act, many experts and policymakers agree that simply increasing access to healthcare is not nearly enough to improve patients' health.

That's because people don't just need access to doctors, hospitals and drugs to be healthy, they also need healthy homes, healthy food, adequate transportation and education, a steady income, safe neighborhoods and a home life free from domestic violence — things hospitals and doctors can't provide, but that in the long run are as meaningful as an antibiotic or an annual physical.

Researchers have known for decades that social problems such as unstable housing and lack of access to healthy foods can significantly affect a patient's health, but efforts by the health industry to take on these challenges didn't really take off until 2010 with the passage of the ACA. The law spurred changes in how insurers pay health providers — moving them away from receiving a set fee for each service to payments based on value and patient outcomes.

As a result, hospitals now have a financial incentive to help patients with nonclinical problems — such as housing and food insecurity — that can affect health.

Temple University Health System in Philadelphia launched a two-year program last year to help 25 homeless Medicaid patients who frequently use its emergency room and other ERs in the city by providing them free housing, and caseworkers to help them access other health and social services. It helps them furnish their apartments, connects them to healthy delivered meals and assists with applications for income assistance such as Social Security.

To qualify, participants had to have used the ER at least four times in the previous year and had at least $10,000 in medical claims that year.

Temple has seen promising results when comparing patients' experiences before the study to the first five months they were all housed. In that time, the participants' average number of monthly ER visits fell 75% and inpatient hospital admissions dropped 79%.

At the same time, their use of outpatient services jumped by 50% — an indication that patients are seeking more appropriate and lower-cost settings for care.

Living Life as 'Normal People Do'

One participant is Rita Stewart, 53, who now lives in a one-bedroom apartment in Philadelphia's Squirrel Hill neighborhood, home to many college students and young families.

"Everyone knows everyone," Stewart said excitedly from her second-floor walk-up. It's "a very calm area, clean environment. And I really like it."

Before joining the Temple program in July and getting housing assistance, Stewart was living in a substance abuse recovery home. She had spent a few years bouncing among friends' homes and other recovery centers. Once she slept in the city bus terminal.

In 2019, Stewart had visited the Temple ER four times for various health concerns, including anxiety, a heart condition and flu.

Stewart meets with her caseworkers at least once a week for help scheduling doctor appointments, arranging group counseling sessions and managing household needs.

"It's a blessing," she said from her apartment with its small kitchen and comfy couch.

"I have peace of mind that I am able to walk into my own place, leave when I want to, sleep when I want to," Stewart said. "I love my privacy. I just look around and just wow. I am grateful."

Stewart has sometimes worked as a nursing assistant and has gotten her healthcare through Medicaid for years. She still deals with depression, she said, but having her own home has improved her mood. And the program has helped keep her out of the hospital.

"This is a chance for me to take care of myself better," she said.

Her housing assistance help is set to end next year when the Temple program ends, but administrators said they hope to find all the participants permanent housing and jobs.

"Hopefully that will work out and I can just live my life like normal people do and take care of my priorities and take care of my bills and things that a normal person would do," Stewart said.

"Housing is the second-most impactful social determinant of health after food security," said Steven Carson, a senior vice president at Temple University Health System. "Our goal is to help them bring meaningful and lasting health improvement to their lives."

Success Doesn't Come Cheap

Temple is helping pay for the program; other funding comes from two Medicaid health plans, a state grant and a Pittsburgh-based foundation. A nonprofit human services organization helps operate the program.

Program organizers hope the positive results will attract additional financing so they can expand to help many more homeless patients.

The effort is expensive. The "Housing Smart" program cost $700,000 to help 25 people for one year, or $28,000 per person. To put this in perspective, a single ER visit can cost a couple of thousands of dollars. And "frequent flyer" patients can tally up many times that in ER visits and follow-up care.

If Temple wants to help dozens more patients with housing, it will need tens of millions of dollars more per year.

Still, Temple officials said they expect the effort will save money over the long run by reducing expensive hospital visits — but they don't yet have the data to prove that.

The Temple program was partly inspired by a similar housing effort started at two Duke University clinics in Durham, North Carolina. That program, launched in 2016, has served 45 patients with unstable housing and has reduced their ER use. But it's been unable to grow because housing funding remains limited. And without data showing the intervention saves on healthcare costs, the organizers have been unable to attract more financing.

Often there is a need to demonstrate an overall reduction in healthcare spending to attract Medicaid funding.

"We know homelessness is bad for your health, but we are in the early stages of knowing how to address it," said Dr. Seth Berkowitz, a researcher at the University of North Carolina-Chapel Hill.

Results Remain to Be Seen

"We need to pay for health not just healthcare," said Elena Marks, CEO of the Houston-based Episcopal Health Foundation, which provides grants to community clinics and organizations to help address the social needs of vulnerable populations.

The nationwide push to spend more on social services is driven first by the recognition that social and economic forces have a greater impact on health than do clinical services like doctor visits, Marks said. A second factor is that the U.S. spends far less on social services per capita compared with other large, industrialized nations.

"This is a new and emerging field," Marks said when reviewing the evaluations of the many social determinants of health studies. "The evidence is weak for some, mixed for some, and strong for a few areas."

But despite incomplete evidence, Marks said, the status quo isn't working either: Americans generally have poorer health than their counterparts in other industrialized countries with more robust social services.

"At some point we keep paying you more and more, Mr. Hospital, and people keep getting less and less. So, let's go look for some other solutions" Marks said.

The COVID-19 pandemic has shined further light on the inequities in access to health services and sparked interest in Medicaid programs to address social issues. Over half of states are implementing or expanding Medicaid programs that address social needs, according to a KFF study in October 2020. (The KHN newsroom is an editorially independent program of KFF.)

The Medicaid interventions are not intense in many states: Often they involve simply screening patients for social needs problems or referring them to another agency for help. Only two states — Arizona and Oregon — require their Medicaid health plans to directly invest money into pilot programs to address the social problems that screening reveals, according to a survey by consulting firm Manatt.

The Centers for Medicare & Medicaid Services, which is funding a growing number of efforts to help Medicaid patients with social needs, said it "remains committed" to helping states meet enrollees' social challenges including education, employment and housing.

On Jan. 7, CMS officials under the Trump administration sent guidance to states to accelerate these interventions. In May, under President Joe Biden, a CMS spokesperson told KHN: "Evidence indicates that some social interventions targeted at Medicaid and CHIP beneficiaries can result in improved health outcomes and significant savings to the healthcare sector."

The agency cited a 2017 survey of 17 state Medicaid directors in which most reported they recognized the importance of social determinants of health. The directors also noted barriers to address them, such as cost and sustainability.

In Philadelphia, Temple officials now face the challenge of finding new financing to keep their housing program going.

"We are trying to find the magic sauce to keep this program running," said Patrick Vulgamore, project manager for Temple's Center for Population Health.

Sojourner Ahebee, health equity fellow at WHYY's health and science show, "The Pulse," contributed to this report.

This story is part of a partnership that includes WHYY, NPR and KHN.

Phil Galewitz: pgalewitz@kff.org, @philgalewitz  

Hemmed In at Home, Nonprofit Hospitals Look for Profits Abroad

KFF Health News, June 22, 2021

Around three dozen of America's elite health systems are searching with a missionary zeal for patients and insurers able to pay high prices that will preserve their financial successes.

This article was published on Tuesday, June 22, 2021 in Kaiser Health News.

By Jordan Rau

Across the street from the Buckingham Palace Garden and an ocean away from its Ohio headquarters, Cleveland Clinic is making a nearly $1 billion bet that Europeans will embrace a hospital run by one of America's marquee health systems.

Cleveland Clinic London, scheduled to open for outpatient visits later this year and for overnight stays in 2022, will primarily offer elective surgeries and other profitable treatments for the heart, brain, joints and digestive system. The London strategy attempts to attract a well-off, privately insured population: American expatriates, Europeans drawn by the clinic's reputation, and Britons impatient with the waits at their country's National Health Service facilities. The hospital won't offer less financially rewarding business lines, like emergency services.

"There are very few people out there in the world who would not choose to have Cleveland Clinic as their healthcare provider," said chief executive Dr. Tomislav Mihaljevic.

Facing the prospect of stagnant or declining revenues at home, around three dozen of America's elite hospitals and health systems are searching with a missionary zeal for patients and insurers able to pay high prices that will preserve their financial successes.

For years, a handful of hospitals have partnered with foreign companies or offered consulting services in places like Dubai, where Western-style healthcare was rare and money plentiful. Now a few, like the clinic, are taking on a bigger risk — and a potentially larger financial reward.

These foreign forays prompt questions about why American nonprofit health systems, which pay little or no taxes in their hometowns, are indulging in such nakedly commercial ventures overseas. The majority of U.S. hospitals are exempt from taxes because they provide charity care and other benefits to their communities. Nonprofit hospitals routinely tout these contributions, though studies have found they often amount to less than the tax breaks.

Despite their tax designation, nonprofit hospitals are as aggressive as commercial hospitals in seeking to dominate their healthcare markets and extract prices as high as possible from private insurers. Though they do not pay dividends, some nonprofits amass large surpluses most years even as more and more patients are covered by Medicare and Medicaid, the U.S. government's insurance programs for the elderly, disabled and poor, which pay less than commercial insurance. Cleveland Clinic, one of the wealthiest, ran an 11% margin in the first three months of this year and paid Mihaljevic $3.3 million in 2019, the most recent salary disclosed.

The advantages of international expansion for their local communities are tenuous. Venturing overseas does not provide Americans with the direct or trickle-down benefits that investing locally does, such as construction work and healthcare jobs. Even when hospitals abroad add to the bottom line, the profits funneled home are minimal, according to the few financial documents and tax returns that disclose details of the operations.

"It's a distraction from the local mission at a minimum," said Paul Levy, a former chief executive at Boston's Beth Israel Deaconess Medical Centerand now a consultant. "People get into them at the beginning, thinking this is easy money. The investment bankers get involved because they get the financing, and the senior faculty get on board and say, 'This is great; it means I can go to Italy for two years' — and there's not a real business plan."

There are financial hazards. For instance, Cleveland Clinic has warned bondholders that its performance could suffer if its London project does not launch as planned. There are also risks to a system's reputation if a foreign venture goes awry.

Finance experts temper expectations that operations of overseas hospitals will have a major bearing on a system's balance sheet. "Even though they do well, they're small hospitals — they're never part of the overall picture," said Olga Beck, a senior director at Fitch Ratings. "It does help [the U.S. operations] because it gives a global name and presence in other markets."

Hospital executives say their foreign ventures provide an additional source of revenue, thus adding stability, and benefit the care of their hometown patients.

"As we go to different areas around the world, we learn and we continuously improve for all our patients," said Dr. Brian Donley, CEO of Cleveland Clinic London. He said the clinic has learned from U.K. practices more efficient ways to sterilize surgical instruments and perform X-rays.

For decades, wealthy foreigners — who are willing to pay the list prices for specialized surgeries and cancer care that domestic insurers bargain down — have been appealing targets for U.S. hospitals. Hospitals like MedStar Health's Georgetown University Hospital in Washington, D.C., solicit and assist foreign patients with special offices staffed by people with job titles such as "international services coordinator" and "international services finance administrator."

Between July 2019 and June 2020, U.S. hospitals treated more than 53,000 foreign patients, charging them more than $2.8 billion, according to a survey of members by the Chicago-based U.S. Cooperative for International Patient Programs. In addition, instead of just importing patients, 37 of 51 health systems in the survey said they offer international advisory or consulting services abroad.

"'Send us your patients' is pretty much a dying approach," said Steven Thompson, a consultant who has spearheaded international programs for Baltimore's Johns Hopkins Medicine and Boston's Brigham and Women's Hospital. "People see it on both sides for what it is: a one-way relationship."

One of the oldest foreign ventures is the organ transplant program the Pittsburgh-based nonprofit system UPMC has run in Palermo, Italy, since 1997, when Sicily's government and Italian insurers realized it would be cheaper to perform those procedures there than continue to send patients to the U.S. Since then, UPMC's Palermo facility has performed more than 2,300 transplants.

In this initial expansion, the U.S. hospital was providing a highly specialized type of surgery — one that UPMC is renowned for — that was not available locally. But UPMC, one of the most entrepreneurial U.S. health systems, didn't stop there. In Ireland, UPMC owns a cancer center and provides care for concussions through sports medicine clinics. Since 2018, the system has acquired hospitals in Waterford, Clane and Kilkenny. They are staffed mostly by independent Irish physicians, but UPMC regularly sends over its leading U.S. specialists to lend expertise, according to Wendy Zellner, a UPMC spokesperson.

UPMC has company in Ireland: in 2019, Bon Secours Mercy Health, a Roman Catholic system with hospitals in Eastern states, merged with a five-hospital Catholic system there.

Over the past two decades, UPMC did advisory and consulting work in 15 countries but ultimately decided to narrow its involvement to four: Italy, Ireland, China and Kazakhstan, where UPMC is helping a university develop a medical teaching hospital. Charles Bogosta, president of UPMC International, said UPMC wanted to focus its efforts where it was confident it could improve the quality of care, bolster UPMC's reputation and earn profit margins greater than its U.S. hospitals do.

UPMC officials said the economics are favorable abroad because labor is cheaper and the mix of patients is heavily tilted toward those with commercial insurance, which pays better than government programs.

"What we've been doing overseas has been really helpful in addressing what everyone in the U.S. is trying to do, which is come up with diversified revenue sources," Bogosta said.

Even so, that extra revenue remains a small part of UPMC's earnings. The health system's foreign hospital business generated gross revenues of $96 million, or 1% of UPMC's $9.3 billion total hospital revenues in 2019, according to a KHN analysis of a UPMC financial disclosure. Since that figure is before accounting for the costs of running the hospitals, taxes and other expenses, the actual profits the foreign hospitals might send back to Pittsburgh are much smaller. In Ireland, where corporations are required to disclose audited financial statements, UPMC Investments Ltd., an umbrella group that owns the Waterford hospital operation and property, reported net profits of about a half-million dollars in 2019 on more than $47 million in gross revenues.

In an email, Zellner said the Ireland statements "do not give you the totality of the picture in Ireland or International, where our results are far better than these documents would suggest." UPMC declined to provide more detailed financial data.

Like other systems, UPMC has expanding ambitions in China. In 2019 it signed an agreement with the multinational corporation Wanda Group to help manage several "world-class" hospitals, starting with one opening in Chengdu next year.

But foreign ventures can misfire. "These partnerships can turn into nightmares, as Hopkins has learned," Thompson wrote in a 2012 article for the Harvard Business Review that described his observations as the founder and first CEO of Johns Hopkins Medicine International, a for-profit venture jointly owned by Johns Hopkins Medicine and Johns Hopkins University.

Anadolu Medical Center, which Hopkins helped establish in Istanbul in 2005, was "plagued by quality problems," including overbooked operating rooms and physicians who refused to follow evidence-based procedures and quality protocols, he wrote. Thompson attributed the problem to the Turkish mandate that the hospital be run by a Turkish citizen and wrote that the problems did not dissipate until Hopkins was allowed to install its own manager in the second-highest position and dissolve the top position to get around the citizenship requirement "while remaining in technical compliance with the law."

While "the project is now thriving," he warned that "lending the Hopkins name to a hospital that delivers unimpressive care could significantly damage our 135-year-old brand — and that's a real danger in developing areas, especially in a project's early days."

Hopkins has remained skittish about outright ownership or even management responsibilities. Instead, it has affiliations with hospitals and health systems in 13 countries, including Vietnam, China, Turkey, Lebanon, Brazil and Saudi Arabia. Hopkins does not run any of the hospitals but helps develop hospital master plans and clinical programs, trains doctors, and advises on patient safety and infection control.

Even so, in 2014 it created a joint venture with the oil and gas company Saudi Aramco to provide healthcare to 255,000 employees and their dependents and retirees. Hopkins, which owns a fifth of the venture, said all foreign net revenue is returned to the system's parent organizations to fund research, expansion of care and scholarships. But its public records report meager income from its foreign subsidiary, just $7 million in 2018 — a tenth of a percent of the health system's $7 billion revenues.

Charles Wiener, the current president of Johns Hopkins Medicine International, focused on other benefits. "If we can put in robust quality and safety at one of our affiliates, their patients do better," he said. "If we can export our education and training models, we believe that allows our people to benefit from learning from other cultures, and some of their people come here to train."

Cleveland Clinic London is unusual in that U.S. health systems rarely build a hospital abroad from scratch without a local partner. The clinic chose that more cautious approach with Cleveland Clinic Abu Dhabi, a 364-bed hospital owned by the Mubadala Investment Co. that the clinic manages. It also has a consulting practice that is helping a Singapore healthcare company build a hospital in Shanghai.

Foreign enterprises appeal to the clinic because it has limited growth opportunities in Ohio, where the population is growing slowly and aging, meaning more patients are leaving high-paying commercial insurers for lower-paying Medicare. The clinic has expanded in Florida, acquiring five hospitals to take advantage of population increases and wealthier patients there.

The London project will have 184 beds and eight operating rooms. Donley said it will be staffed primarily by U.K. physicians, including ones who also work for the National Health Service.

"The clinic has a long track record of being able to execute on its strategies," said Lisa Martin, an analyst at the bond rating agency Moody's Investors Service. "The London project is obviously the biggest venture and the biggest financial risk that they've made abroad."

Jordan Rau: jrau@kff.org, @JordanRau

Montana Tribe Welcomes Back Tourists After Risky Shutdown Pays Off

KFF Health News, June 21, 2021

Last year, the number of Glacier visitors plunged to 1.7 million after a record 3 million people visited in 2019. 

This article was published on Monday, June 21, 2021 in Kaiser Health News.

By Aaron Bolton

Millions of people will flock to Montana’s Glacier National Park this summer after last year’s pandemic-caused tourism skid, and they will once more be able sightsee and camp nearby on the recently reopened Blackfeet Indian Reservation.

The tourists’ return is a relief to the owners of the restaurants, campgrounds and hotels forced to shut down last summer when Blackfeet tribal leaders closed the roads leading to the eastern side of the popular park.

Those closures fed worries that a major economic driver for residents on the reservation would be crippled. But the tribe’s priority was protecting its elders and stemming the spread of the coronavirus. It worked: The closures and the tribe’s strictly enforced stay-at-home orders and mask mandate led to a low daily case rate held up as an example by federal health officials. Now, boasting one of the highest vaccination rates in the nation, the reservation is back open for business.

On a recent day at the Two Sisters Café, a stone’s throw from Glacier National Park’s eastern boundary, workers stacked dishes and stocked freezers in preparation for a busy season as demand soars for the wide-open spaces national parks can offer during the lingering pandemic.

Susan Higgins, co-owner of the cafe, said she’s seen more traffic whiz past her door than she’s seen at this time of year in nearly three decades. Some passersby stopped and poked their heads through the front door of the restaurant known for fresh huckleberry pies, only to leave disappointed because the restaurant didn’t open for the season until mid-June.

The situation is nothing like last year, when Higgins and sister Beth worried they would rack up massive debt just to survive. With the help of government loans and other grants, they were able to cover their bills and maintain their savings to expand the business.

“When everything happened, we were initially, of course, just concerned about just making it to this year,” Susan Higgins said.

Despite the uncertainty of the past year, Higgins said she supported the stringent measures taken by Blackfeet tribal leaders. The pandemic has disproportionately affected Native Americans, something Higgins is keenly aware of.

“With such a vulnerable population, I would have hated to see what would have happened last year if we had been open, especially with the issue of getting people to mask up,” Higgins said.

Last year, the number of Glacier visitors plunged to 1.7 million after a record 3 million people visited in 2019. Those who did come stayed and spent their money in non-Blackfeet communities on the western side of the Continental Divide.

The measures the tribe took slowed but didn’t stop the spread of covid. Daily cases surged in September, after the Northwest Montana Fair and Rodeo in August and Labor Day weekend, leading to a strictly enforced stay-at-home order, the tribe’s third, issued Sept. 28.

Daily cases then dropped from a peak of 6.4 per 1,000 per day on Oct. 5 to 0.19 on Nov. 7, a 33-fold drop that the Centers for Disease Control and Prevention held up as an example that such restrictions work.

Out of roughly 10,000 reservation residents, fewer than 50 Blackfeet tribal members have died of covid to date. Kimberly Boy, Blackfeet department of revenue director and a member of the incident command team that leads the tribe’s pandemic response, said she is certain their actions saved lives.

“It was the toughest job I’ve had so far in my life,” Boy said. “We had moved aggressively and extremely restrictive[ly] only due to the fact that our primary goal was to save as many lives as we can.”

The efforts bought time until the covid vaccines became available. Then, the tribe mounted a serious campaign that has resulted in about 85% of the total population — over 90% of adults — being fully vaccinated, according to tribal officials. The national average is about 44%, according to the CDC.

The Blackfeet’s vaccination campaign then stretched into Canada when tribal officials set up a clinic at the border for their counterparts in the Blackfoot Confederacy. The Blackfoot Confederacy, of which the Montana Blackfeet nation is a part, includes affiliated First Nations tribes who live on the Canadian side of the border.

The idea for the makeshift clinic was conceived after U.S. and Canadian officials denied requests to ship vaccines over the border, Blackfoot Confederacy Health Director Bonnie Healy said.

“We were joking, and I said that we’ll just have the Canadians from the confederacy stand on one side of the border and you guys vaccinate us over the fence and we’ll get it done,” Healy said.

Healy said that’s exactly happened in a sense, and the clinic was aptly named the “medicine line vaccine clinic,” referencing what the Blackfeet and Blackfoot call the U.S.-Canadian border that separates the different bands of the tribe.

Mark Pollock, a member of the Blackfeet Tribal Business Council, and others said the strong vaccination rate on the reservation in Montana is giving the tribe the confidence to open to tourists this summer.

Pollock hopes the season will go smoothly and covid can be eliminated among tribal members or cases remain very low. However, if cases rise, he said, the tribe could reduce the current 75% capacity limit on dine-in restaurants and bars, as well as reintroduce restrictive measures like curfews and limits on gatherings.

“Whatever it takes to get that number back down, get a handle on it,” Pollock said.

Jackie Conway owns the Heart of Glacier Campground near Glacier’s east gate with her husband, Steve, a tribal member. Conway said even with all 40 of her RV and camping sites booked for the season, she still can’t make up for last year’s 100% loss. Government relief helped the business survive over the past year.

She’s happy there will be a tourism season this summer but knows in the back of her mind that tribal leaders could shut things down anytime.

“The tribe gets spooked pretty easy. So, you just don’t know,” she said.

Angelika Harden-Norman owns the Lodgepole Gallery & Tipi Village just outside Browning, the reservation’s largest city. Standing in the gallery full of artwork by her late husband, Darrell Norman, and other Blackfeet tribal members, she said it’s up to business owners to keep guests safe and make sure this pandemic tourist season goes smoothly.

She used grant money to move her art gallery from the center of her home to another room with better ventilation. She’s also renovated the bathrooms of the two cabins for overnight guests so they are no longer shared.

“I will do my best to take the responsibility … by asking people to wear a mask when they come indoors to check in, to have hand sanitizers,” she explained.

At Two Sisters Café, Susan Higgins stood inside an unfinished drive-thru coffee stand just outside the restaurant. Higgins said she and her sister had thought about building a coffee stand in the past, but it was the uncertainty of how this season would go that pushed them to do it.

Higgins added she is requiring her workers to be vaccinated and hopes that will allow her to avoid shutting down her business this summer. So, for now, the coffee stand will serve as an addition to her business, but it’s also a Plan B should there be another shutdown.

“Primarily it is to assure ourselves of a continued cash flow should we get shut down again,” she explained.

What It Means When Celebrities Stay Coy About Their Vaccine Status

KFF Health News, June 21, 2021

While fans often know intricate details about athletes' knee joints and concussions, COVID vaccinations are another story.

This article was published on Monday, June 21, 2021 in Kaiser Health News.

By Eric Berger

When two St. Louis Blues hockey players were sidelined because of COVID-19 just days before this year's NHL playoffs, the team said young defenseman Jake Walman had been vaccinated against the deadly illness. But it was mum about the vaccination status of a more well-known player: star forward David Perron.

It wasn't until 10 days later — and after the Colorado Avalanche buried the team, without Perron touching the ice in any of the series' four games — that he begrudgingly acknowledged he had been vaccinated.

"I don't want to talk about that anymore," Perron, the team's leading scorer, said at a press conference.

While fans often know intricate details about athletes' knee joints and concussions, COVID vaccinations are another story. Reticence is common among professional athletes. Vaccination status is also a point of secrecy among some Republican lawmakers, other public figures and even many regular people.

Public health leaders say that people in the limelight do not have an obligation to announce or answer media questions about their vaccination status, but many add that they hoped more well-known names would become role models for getting the vaccines.

Instead, they say, the politicization of the shots, misinformation and flawed public messaging from the federal government have made the vaccines controversial and something some public figures are reluctant to endorse, which then ripples across society.

President Joe Biden is trying to get at least 70% of the nation vaccinated by July 4. So far, according to the Centers for Disease Control and Prevention, 53% of Americans have received at least one dose.

"I continue to be hopeful that celebrities will share their vaccination status and use their platform to encourage people to get vaccinated," said Thomas LaVeist, a sociologist and the dean of the School of Public Health and Tropical Medicine at Tulane University. "But I haven't seen a lot of celebrities really embrace that role."

LaVeist and others in public health hoped someone would step up as Elvis Presley did in 1956 to help increase the low rate of polio vaccinations. He received his shot on "The Ed Sullivan Show."

But that occurred years after the polio vaccine was developed, whereas the COVID vaccines became available less than a year after the onset of the pandemic.

"We still have not done a good enough job of explaining to people how and why it is that we were able to have a vaccine developed so quickly, and a lot of people have questions about whether corners were cut," said LaVeist, who criticized the Trump administration's decision to call its vaccine development program Operation Warp Speed.

Former President Donald Trump also hurt vaccination efforts among Republicans when he received his vaccine privately rather than in a public setting like Biden and other former presidents, said Gregory Zimet, a behavioral scientist who studies vaccination at Indiana University School of Medicine.

When CNN conducted a survey of congressional lawmakers in May, 95 of the 212 Republican House members said they had received the vaccines and 112 Republican offices did not respond at all. (All congressional Democrats said they had received the vaccines.)

"For some individuals, particularly if their social circle is very anti-vaccine or skeptical of the vaccine, it can feel very uncomfortable to come out and say, 'I got vaccinated,'" Zimet said.

Sports stars, who are often asked about their health, could change public perceptions of the vaccines, said Nancy Berlinger, a bioethicist at the Hastings Center, a research institute in Garrison, New York.

"In the worst days of HIV-AIDS, the fact that Magic Johnson was willing to talk about being HIV-positive changed public conversation in this country," Berlinger said. "Not everyone is able to step into that role."

Basketball king LeBron James, when asked if he planned to get a COVID vaccine, told reporters in March, "That's a conversation that my family and I will have. Pretty much keep that to a private thing."

Jennifer Reich, a sociologist at the University of Colorado-Denver who has studied vaccine hesitancy, thinks that James and other NBA stars could be reluctant to promote the vaccines because of the way athletes have been castigated in recent years for taking stands on hot-button issues.

But James has expressed support for the Black Lives Matter movement and called for the prosecution of police officers who shot and killed Breonna Taylor, a Black medical worker, in her Kentucky apartment.

"It's not like he is someone who has been a shrinking violet and has not stepped into the public arena to make very strong statements about inequities and problems in our society," Zimet said. "So, it's a little hypocritical that he would now say, 'This is a private issue.'"

Not everyone in public health is convinced, though, that what James, Perron and other celebrities say is crucial to vaccination efforts.

Sandra Crouse Quinn, a professor of family science at University of Maryland, studied the role of communication in vaccine acceptance during events such as the 2009 H1N1 pandemic. She found that while public figures' disclosures can make a difference, they are not as important as endorsements from "people we care about and people who care about us," she said.

"If Beyoncé came out with a vaccine video, would people watch it? Yes," Quinn said. "Is it entertainment? Yes. Does it move somebody? Not necessarily, because her life is so dramatically different" than that of an ordinary person.

But Timothy Caulfield, a law professor at the University of Alberta and the author of a book on vaccine myths, believes celebrities can make a big difference, pointing to actor Jenny McCarthy's role in the anti-vaccine movement.

"The role that pop culture can play in normalization is a constructive role," Caulfield said. "We are getting close to that hesitancy hurdle in jurisdictions where you are getting 60-65% of people vaccinated, so this messaging may seem trivial, but it matters when you are talking about trying to get another 2% or 3% of the population vaccinated."

During the time when Perron was quiet during the playoff series, sportswriters and fans speculated about his vaccination status. At the press conference where he revealed his vaccination after being questioned about it, Perron said, "I don't know why it's a big deal." He pointed out that he and two other players had gotten COVID despite being vaccinated.

"It's unfortunate and shows that it's not perfect," he said, adding that, among his teammates, "I can tell you that we support each individual to make their own decision."

Even if Perron had declined a vaccine or not revealed his status, some fans would likely not have held it against him.

Thomas Welch, who hosts a hockey podcast, "Locked On Blues," quickly decided to get vaccinated because his father and brother have Crohn's disease, which means they could face a greater risk from the coronavirus. But Welch said he understands that for some people the vaccines might not make sense for various reasons.

"As much as we love talking about these players and breaking down the analytics of the sport, at the end of the day, each of these players are people," said Welch, who lives in Jefferson County, outside St. Louis. "We lose sight of that a lot."

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