Bonta in April succeeded former state Attorney General Xavier Becerra, who was tapped by President Joe Biden to serve as secretary of HHS.

This article was published on Wednesday, June 2, 2021 in Kaiser Health News.

By Angela Hart

California Attorney General Rob Bonta, a longtime Democratic state lawmaker, comes to his new role well known for pursuing an unabashedly progressive agenda on criminal justice issues. He has pushed for legislation to eliminate cash bail and to ban for-profit prisons and detention centers. But Bonta also has a distinctive record on healthcare, successfully advancing legislation to protect consumers from so-called surprise medical bills when they inadvertently get treatment from out-of-network providers and framing environmental hazards like pollution as issues of social justice.

He was among the Democratic lawmakers leading the charge at the California Capitol to take on Big Soda, pushing to cut consumption of sugary drinks through taxes and warning labels. Such proposals so far have faltered under the influence of the soda industry.

Bonta, 49, was an infant when his family, in 1971, moved to California from the Philippines, where his parents worked as missionaries. His father, Warren Bonta, a native Californian, worked for the state for decades as a healthcare official, setting up clinics to expand access to medical care in rural and refugee communities. Rob Bonta's first elected position was to the Alameda Healthcare District, overseeing local medical services.

Appointed by Gov. Gavin Newsom this year, Bonta in April succeeded former state Attorney General Xavier Becerra, who was tapped by President Joe Biden to serve as secretary of the U.S. Department of Health and Human Services. In the weeks since, Bonta has beefed up the number of lawyers working in the Department of Justice's Bureau of Environmental Justice and has created a Racial Justice Bureau that he said will play a pivotal role in ensuring equal access to healthcare for Black and Latino residents.

A graduate of Yale Law School, Bonta spent nine years as a deputy city attorney in San Francisco before his election to the state Assembly in 2012, representing Oakland and the East Bay. He was the first Filipino American elected to the California legislature, and is now the first Filipino American to serve as the state's chief law enforcement officer.

As attorney general, Bonta said he envisions a far different relationship with the Biden administration than his predecessor had with the Trump administration. Becerra emerged as one of former President Donald Trump's fiercest critics during his tenure as the state's top cop, filing more than 120 lawsuits to oppose Trump administration policies on the environment and healthcare, including leading the ongoing fight to preserve the Affordable Care Act in its case before the U.S. Supreme Court. Vice President Kamala Harris also once served as California's attorney general, and Bonta said he sees tremendous opportunity to shape a more progressive agenda on issues such as reproductive health and universal, single-payer healthcare working in concert with the new administration.

Bonta spoke with KHN about how healthcare would shape his agenda as attorney general. The interview has been edited for length and clarity.

Q: Your predecessor made healthcare a priority. Will it be one of yours?

It's going to be a top priority for me, and it was a top priority for me as a legislator. I was chair of the Assembly Health Committee or a health committee member the entire time I was there, almost nine years. Before that, I was on a healthcare district board. My very first elected office I ever had was making sure we provided true access to high-quality, affordable healthcare to the community that I served.

This is a really foundational part of who I am, and who my family is — our legacy and our values and what we stood for. I think healthcare is a right, not a privilege. It's for all, not the few.

Q: You've said you would make racial justice a priority. Do you believe racism is a public health crisis?

Yes, I do. COVID-19 revealed a lot of what was inequitable and racist about our systems — the disparate impacts that we saw, the inequity that we saw. And I think racism is not just a public health crisis — it is a public health crisis — but it also infects our economic system, it infects our criminal justice system, it infects all of our systems. And it has led to a public health crisis.

Q: What does that look like in healthcare? How does inequity show up?

It looks like making sure that in healthcare there aren't disparate impacts on communities of color. That race is not correlated to less access or less quality, and making sure that no one is left out. That can look like access to reproductive healthcare; that can look like access to real health insurance as opposed to sham health insurance plans. It can look like a charge that is inappropriately placed on a vaccine — vaccines are supposed to be free. That's something else we worked on recently.

Q: Can you elaborate?

Through a joint investigation with U.S. Health and Human Services, as well as the U.S. attorney's office, we identified that vaccines — which should be provided to individuals for free under the law — that a charge was being placed on the vaccine.

The vaccine should be universally accessible. And when that isn't being done, barriers are being put up in vulnerable communities, keeping people from their vaccine that we all need right now. That is a problem. We put out an alert and reminded people of the laws that provide free vaccines to all individuals under the Centers for Disease Control and Prevention program.

Q: What areas of environmental health might you look into?

The building of huge warehouses. In the Inland Empire, there are quite a few being built. They're being built adjacent to or in disadvantaged communities. And all the goods movement activity — and all of the emissions that are created from the goods movement — create a threat, and a risk to those communities.

Q: Like Amazon, for instance? The corporation has come under scrutiny for environmental harms associated with its sprawling warehouses.

Yeah. These warehouses have really created problems for disadvantaged communities in California. We expanded the Bureau of Environmental Justice to provide more resources and more ability to go after big polluters, and to protect communities that live at the intersection of poverty and pollution who are being forced to drink dirty water and breathe unhealthy air.

I see the role of the attorney general as standing up for everyday people who are abused or hurt and neglected or mistreated, and generally protecting the little guy from the overreach and abuse of power of the big guy.

We have more authority in the environmental realm than in many other areas. And we want to use those tools — that authority, that influence, that power — to protect communities, often low-income communities, often communities of color, who are being hurt by polluters.

Q: Becerra filed a lawsuit and sponsored legislation going after health industry mergers alleged to be anti-competitive, a practice he argues drives up healthcare prices. Will you continue to go after anti-competitive practices in healthcare?

That's definitely a priority. That's a critical tool in the toolbox that the California attorney general uniquely has to approve — or put conditions on, or not approve — proposed mergers involving a nonprofit hospital.

The lens to see that through is: How does it impact patients? How does it impact access to quality care, and cost of care? And so that is exactly why the attorney general has that role, to review these proposed mergers with an eye towards patients and communities that don't necessarily have a voice in the merger.

Q: As attorney general, do you support single-payer healthcare?

My involvement will be different. Having said that, I co-authored the single-payer bill from a few years back. And I was a co-author of this year's single-payer bill that Assemblyman Ash Kalra was leading that I think is no longer moving. [Kalra has withdrawn the bill from consideration for this year.]

I support single-payer healthcare. I support universal healthcare. I think single-payer healthcare is a way to get to that aspiration.

As the attorney general, I enforce the law. We don't have a single-payer law in California. So, I'll enforce the existing laws, which are very strong, to help make sure Californians have the most accessible, affordable, highest-quality healthcare.

Q: The U.S. Supreme Court has agreed to hear a Mississippi abortion case that some say could threaten abortion rights at the state level. If upheld, how could that affect the abortion protections in California?

That's going to be a really important case for reproductive freedom, and important, in my view, for California to be involved in given our leadership in this space. As the case gets briefed and prepped for consideration and argument before the U.S. Supreme Court, I expect we will be very active in making arguments to the court to help guide [the justices'] thinking and their decisions.

Q: What will California's relationship with the federal government be like?

I think the posture and the relationship between the federal administration and California over the last four years are very different than what they will be for the next four.

Attorney General Becerra was the warrior and the champion that we needed, and that was necessary as we faced a full-frontal assault on California, our people, our values and our resources, and he fought back and protected us and defended us and stood up for our values time and time again.

Now, I think we have a Biden-Harris administration that largely does agree that we should have, certainly, the Affordable Care Act, that we should have reproductive freedom, that we should address the inequities in our healthcare system, that we should have affordable, accessible, high-quality healthcare for all — and will help us get there.

So, with the new administration, I look to collaboration. California can and should continue to be who we are. We lead. We go first. We pioneer. We're bold and we're big in how we think. That's who we are, so that leading role is our natural place to be, including in healthcare.

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

Angela Hart: ahart@kff.org, @ahartreports

With nearly 600,000 in the U.S. lost to COVID-19 — now a leading cause of death — researchers estimate that more than 5 million Americans are in mourning.

This article was published on Wednesday, June 2, 2021 in Kaiser Health News.

By Liz Szabo

Cassandra Rollins' daughter was still conscious when the ambulance took her away.

Shalondra Rollins, 38, was struggling to breathe as COVID overwhelmed her lungs. But before the doors closed, she asked for her cellphone, so she could call her family from the hospital.

It was April 7, 2020 — the last time Rollins would see her daughter or hear her voice.

The hospital rang an hour later to say she was gone. A chaplain later told Rollins that Shalondra had died on a gurney in the hallway. Rollins was left to break the news to Shalondra's children, ages 13 and 15.

More than a year later, Rollins said, the grief is unrelenting.

Rollins has suffered panic attacks and depression that make it hard to get out of bed. She often startles when the phone rings, fearing that someone else is hurt or dead. If her other daughters don't pick up when she calls, Rollins phones their neighbors to check on them.

"You would think that as time passes it would get better," said Rollins, 57, of Jackson, Mississippi. "Sometimes, it is even harder. … This wound right here, time don't heal it."

With nearly 600,000 in the U.S. lost to COVID-19 — now a leading cause of death — researchers estimate that more than 5 million Americans are in mourning, including more than 43,000 children who have lost a parent.

The pandemic — and the political battles and economic devastation that have accompanied it — have inflicted unique forms of torment on mourners, making it harder to move ahead with their lives than with a typical loss, said sociologist Holly Prigerson, co-director of the Cornell Center for Research on End-of-Life Care.

The scale and complexity of pandemic-related grief have created a public health burden that could deplete Americans' physical and mental health for years, leading to more depression, substance misuse, suicidal thinking, sleep disturbances, heart disease, cancer, high blood pressure and impaired immune function.

"Unequivocally, grief is a public health issue," said Prigerson, who lost her mother to COVID in January. "You could call it the grief pandemic."

Like many other mourners, Rollins has struggled with feelings of guilt, regret and helplessness — for the loss of her daughter as well as Rollins' only son, Tyler, who died by suicide seven months earlier.

"I was there to see my mom close her eyes and leave this world," said Rollins, who was first interviewed by KHN a year ago in a story about COVID's disproportionate effects on communities of color. "The hardest part is that my kids died alone. If it weren't for this COVID, I could have been right there with her" in the ambulance and emergency room. "I could have held her hand."

The pandemic has prevented many families from gathering and holding funerals, even after deaths caused by conditions other than COVID. Prigerson's research shows that families of patients who die in hospital intensive care units are seven times more likely to develop post-traumatic stress disorder than loved ones of people who die in home hospice.

The polarized political climate has even pitted some family members against one another, with some insisting that the pandemic is a hoax and that loved ones must have died from influenza, rather than COVID. People in grief say they're angry at relatives, neighbors and fellow Americans who failed to take the coronavirus seriously, or who still don't appreciate how many people have suffered.

"People holler about not being able to have a birthday party," Rollins said. "We couldn't even have a funeral."

Indeed, the optimism generated by vaccines and falling infection rates has blinded many Americans to the deep sorrow and depression of those around them. Some mourners say they will continue wearing their face masks — even in places where mandates have been removed — as a memorial to those lost.

"People say, 'I can't wait until life gets back to normal,'" said Heidi Diaz Goff, 30, of the Los Angeles area, who lost her 72-year-old father to COVID. "My life will never be normal again."

Many of those grieving say celebrating the end of the pandemic feels not just premature, but insulting to their loved ones' memories.

"Grief is invisible in many ways," said Tashel Bordere, a University of Missouri assistant professor of human development and family science who studies bereavement, particularly in the Black community. "When a loss is invisible and people can't see it, they may not say 'I'm sorry for your loss,' because they don't know it's occurred."

Communities of color, which have experienced disproportionately higher rates of death and job loss from COVID, are now carrying a heavier burden.

Black children are more likely than white children to lose a parent to COVID. Even before the pandemic, the combination of higher infant and maternal mortality rates, a greater incidence of chronic disease and shorter life expectancies made Black people more likely than others to be grieving a close family member at any point in their lives.

Rollins said everyone she knows has lost someone to COVID.

"You wake up every morning, and it's another day they're not here," Rollins said. "You go to bed at night, and it's the same thing."

A Lifetime of Loss

Rollins has been battered by hardships and loss since childhood.

She was the youngest of 11 children raised in the segregated South. Rollins was 5 years old when her older sister Cora, whom she called "Coral," was stabbed to death at a nightclub, according to news reports. Although Cora's husband was charged with murder, he was set free after a mistrial.

Rollins gave birth to Shalondra at age 17, and the two were especially close. "We grew up together," Rollins said.

Just a few months after Shalondra was born, Rollins' older sister Christine was fatally shot during an argument with another woman. Rollins and her mother helped raise two of the children Christine left behind.

Heartbreak is all too common in the Black community, Bordere said. The accumulated trauma — from violence to chronic illness and racial discrimination — can have a weathering effect, making it harder for people to recover.

"It's hard to recover from any one experience, because every day there is another loss," Bordere said. "Grief impacts our ability to think. It impacts our energy levels. Grief doesn't just show up in tears. It shows up in fatigue, in working less."

Rollins hoped her children would overcome the obstacles of growing up Black in Mississippi. Shalondra earned an associate's degree in early childhood education and loved her job as an assistant teacher to kids with special needs. Shalondra, who had been a second mother to her younger siblings, also adopted a cousin's stepdaughter after the child's mother died, raising the girl alongside her two children.

Rollins' son, Tyler, enlisted in the Army after high school, hoping to follow in the footsteps of other men in the family who had military careers.

Yet the hardest losses of Rollins' life were still to come. In 2019, Tyler killed himself at age 20, leaving behind a wife and unborn child.

"When you see two Army men walking up to your door," Rollins said, "that's unexplainable."

Tyler's daughter was born the day Shalondra died.

"They called to tell me the baby was born, and I had to tell them about Shalondra," Rollins said. "I don't know how to celebrate."

Shalondra's death from COVID changed her daughters' lives in multiple ways.

The girls lost their mother, but also the routines that might help mourners adjust to a catastrophic loss. The girls moved in with their grandmother, who lives in their school district. But they have not set foot in a classroom for more than a year, spending their days in virtual school, rather than with friends.

Shalondra's death eroded their financial security as well, by taking away her income. Rollins, who worked as a substitute teacher before the pandemic, hasn't had a job since local schools shut down. She owns her own home and receives unemployment insurance, she said, but money is tight.

Makalin Odie, 14, said her mother, as a teacher, would have made online learning easier. "It would be very different with my mom here."

The girls especially miss their mom on holidays.

"My mom always loved birthdays," said Alana Odie, 16. "I know that if my mom were here my 16th birthday would have been really special."

Asked what she loved most about her mother, Alana replied, "I miss everything about her."

Grief Complicated by Illness

The trauma also has taken a toll on Alana and Makalin's health. Both teens have begun taking medications for high blood pressure. Alana has been on diabetes medication since before her mom died.

Mental and physical health problems are common after a major loss. "The mental health consequences of the pandemic are real," Prigerson said. "There are going to be all sorts of ripple effects."

The stress of losing a loved one to COVID increases the risk for prolonged grief disorder, also known as complicated grief, which can lead to serious illness, increase the risk of domestic violence and steer marriages and relationships to fall apart, said Ashton Verdery, an associate professor of sociology and demography at Penn State.

People who lose a spouse have a roughly 30% higher risk of death over the following year, a phenomenon known as the "the widowhood effect." Similar risks are seen in people who lose a child or sibling, Verdery said.

Grief can lead to "broken-heart syndrome," a temporary condition in which the heart's main pumping chamber changes shape, affecting its ability to pump blood effectively, Verdery said.

From final farewells to funerals, the pandemic has robbed mourners of nearly everything that helps people cope with catastrophic loss, while piling on additional insults, said the Rev. Alicia Parker, minister of comfort at New Covenant Church of Philadelphia.

"It may be harder for them for many years to come," Parker said. "We don't know the fallout yet, because we are still in the middle of it."

Rollins said she would have liked to arrange a big funeral for Shalondra. Because of restrictions on social gatherings, the family held a small graveside service instead.

Funerals are important cultural traditions, allowing loved ones to give and receive support for a shared loss, Parker said.

"When someone dies, people bring food for you, they talk about your loved one, the pastor may come to the house," Parker said. "People come from out of town. What happens when people can't come to your home and people can't support you? Calling on the phone is not the same."

While many people are afraid to acknowledge depression, because of the stigma of mental illness, mourners know they can cry and wail at a funeral without being judged, Parker said.

"What happens in the African American house stays in the house," Parker said. "There's a lot of things we don't talk about or share about."

Funerals play an important psychological role in helping mourners process their loss, Bordere said. The ritual helps mourners move from denying that a loved one is gone to accepting "a new normal in which they will continue their life in the physical absence of the cared-about person." In many cases, death from COVID comes suddenly, depriving people of a chance to mentally prepare for loss. While some families were able to talk to loved ones through FaceTime or similar technologies, many others were unable to say goodbye.

Funerals and burial rites are especially important in the Black community and others that have been marginalized, Bordere said.

"You spare no expense at a Black funeral," Bordere said. "The broader culture may have devalued this person, but the funeral validates this person's worth in a society that constantly tries to dehumanize them."

In the early days of the pandemic, funeral directors afraid of spreading the coronavirus did not allow families to provide clothing for their loved ones' burials, Parker said. So beloved parents and grandparents were buried in whatever they died in, such as undershirts or hospital gowns.

"They bag them and double-bag them and put them in the ground," Parker said. "It is an indignity."

Coping With Loss

Every day, something reminds Rollins of her losses.

April brought the first anniversary of Shalondra's death. May brought Teacher Appreciation Week.

Yet Rollins said the memory of her children keeps her going.

When she begins to cry and thinks she will never stop, one thought pulls her from the darkness: "I know they would want me to be happy. I try to live on that."

Liz Szabo: lszabo@kff.org, @LizSzabo

Mississippi had already narrowed an outsize gap in covid-19 incidence and mortality rates for its Black residents, leveraging community partnerships to promote masks and physical distancing while dispelling rumors.

This article was published on Sunday, May 30, 2021 in Kaiser Health News.

By Michaela Gibson Morris

At its first pop-up vaccination event on April 10, the Northeast Mississippi Coalition Against Covid 19 gave shots to nearly 40 people in Shannon, a town where roughly 60% of some 1,800 residents are African American.

This story also ran on NBC News. It can be republished for free.

Though a fraction of the doses typically given out at large mass vaccination sites, the event was a success, say organizers — a coalition of health care providers and elected officials. Held outdoors, it allowed for a physically distant, communal atmosphere that many have missed over the past year.

“People would get their shot, and then say, ‘I’m going to get my wife or my daughter,’” said Dr. Vernon Rayford, a Tupelo internal medicine physician and coalition member.

The group has held two more events and administered a total of 110 doses, Rayford said. More pop-ups are scheduled.

Mississippi had already narrowed an outsize gap in covid-19 incidence and mortality rates for its Black residents, leveraging community partnerships to promote masks and physical distancing while dispelling rumors. Now health advocates hope to stretch those partnerships to help ensure vaccines reach all Mississippians equally.

It appears to be working. Vaccine rates are neck and neck among Black and white residents, with available state data showing a slightly higher rate for whites and Centers for Disease Control and Prevention data showing the opposite. Mississippi is one of the few states where the Black rate isn’t lagging significantly behind the rate for whites.

And as of mid-May, African Americans, who make up 38% of the state’s population, are getting 40% of the doses given each week, said state epidemiologist Dr. Paul Byers.

“We continue to reach parity with our doses,” Byers said during a May press conference.

This is the latest phase of Mississippi’s dramatic turnaround on covid among its Black residents.

In the first four months of the pandemic, the incidence of covid was almost three times higher for African Americans than whites — 1,131 cases per 100,000 for Black Mississippians compared with 403 cases per 100,000 for whites. Mortality in those first months was almost twice as high for African Americans — 46.2 per 100,000 compared with 24.6 per 100,000 for whites, based on an analysis of weekly covid reports published by the Mississippi State Department of Health.

“Covid revealed what many already knew in the public health community: that the inequities in Black and brown communities have existed for a long time,” said Victor Sutton, who directs the state health department’s preventive health and health equity division.

That disproportionate toll on Black Mississippians started to wane, though, as covid cases began a rapid climb in the state and the rest of the country in the fall. Public health officials saw per capita rates of infection and deaths for African Americans drop below the rates of the white population. Through the peak of the holiday covid wave in mid-January, the infections and deaths rose for both groups, but the rates for African Americans remained lower than for whites.

State health department officials pointed to outreach through churches, historically black colleges and universities and community organizations that reinforced the importance of masking and physical distancing among African Americans. Efforts were also underway to reach other underserved groups, including Hispanics across the state, Native Americans in eastern Mississippi and Vietnamese communities on the Gulf Coast.

While Mississippi was among the first states to drop its mask rules, the groups hit hardest by the pandemic were more open to masking and physical distancing than the overall population, health officials said.

“It didn’t get political in the African American community,” Rayford said.

In Tupelo, the Temple of Compassion and Deliverance’s Bishop Clarence Parks was among the Mississippi clergy who used his pulpit both in his church and on Facebook. He lost his 91-year-old mother to covid on April 9, 2020. Hers was among the first cases diagnosed in Tupelo.

“It did give me a sense of urgency,” Parks said. “I saw what covid was doing.”

In addition to moving church services online and into the parking lot, Parks made a point to talk to his congregation about how to protect themselves, their parents and grandparents from covid. As small groups came back inside the church, masks were required. He talked to other pastors about safeguarding their flocks. Parks, 61, posted on Facebook when he got his covid vaccine.

In his congregation of 400, Parks estimates about 15 became infected with covid.

“My mom is the only one in our church who passed from covid,” Parks said.

Mississippi Valley State University, a historically Black school in Itta Bena, a town in the Mississippi Delta, hosted drives to distribute masks and information on protective measures, plus hosted Zoom community meetings to reach beyond its campus boundaries.

“We’re trying to focus on the Delta,” said La Shon Brooks, chief of staff and legislative liaison for the Mississippi Valley president.

Parity on vaccines, though, got off to a slow start. When supply was limited and appointments were snapped up in minutes in February, African Americans were receiving about 15% of the vaccines distributed through the state health department. As more vaccine became available, the department started sending thousands of doses to community health centers and clinics serving large minority populations, said State Health Officer Dr. Thomas Dobbs.

“We want to make sure we‘re addressing trust and access issues,” Dobbs said during a February press conference.

In southwestern Mississippi, Alcorn State University, a historically Black school, organized a vaccine clinic in partnership with the state health department and local county emergency management agency. Located in a rural county with the closest hospitals about 45 minutes away by car, the university has attracted between 160 and 200 Mississippians to each drive-in clinic session. The organizers even made walk-up appointments available to reach students and staff members on campus.

“We’re drawing a wide range of ages and races,” said Jennifer Riley Collins, Alcorn State’s covid response coordinator.

In recent weeks, the state health department has increased efforts to partner with community groups on smaller vaccination events and to reach the homebound. They are also working to direct the public to pharmacies and clinics offering the vaccine.

Health advocates remain concerned that more Mississippians of all races and ethnicities need to be vaccinated or the state risks another wave of infections that could overwhelm health care resources.

In survey results released in mid-May, the Mississippi State Health Department, which polled 11,000 state residents across all 82 counties between December and March, found that 73% were likely to take the vaccine, but as of Thursday only 33.7% of the state’s residents had rolled up their sleeves for at least one dose, according to CDC data. Nationwide, the rate was 49.9%.

Among African Americans, the survey found 56% intended to get vaccinated, compared with 80% of white Mississippians.

“We’re still at risk,” Dobbs said. “We still have a large part of the population that is still vulnerable.”

Even as racial equity in vaccine distribution has improved, closing the gap among the still hesitant and skeptical remains a significant challenge to achieving widespread immunity.

Health care workers, ranked as top vaccine influencers in the health department survey, will need to switch out of their traditional role of giving monologues and engage instead in a dialogue to understand what is preventing the unvaccinated from getting the shots, said Dr. Jeremy Blanchard, chief medical officer for Tupelo-based North Mississippi Health Services.

“We need to listen more effectively,” Blanchard said.

The number of Americans 65 and older is expected to nearly double in the next 40 years. Finding a way to provide and pay for the long-term health services they need won't be easy.

This article was published on Friday, May 28, 2021 in Kaiser Health News.

By Lydia Zuraw and Carmen Heredia Rodriguez  

Healthcare for the nation's seniors looms large as the baby-boom generation ages into retirement. President Joe Biden tacitly acknowledged those needs in March with his proposal to spend $400 billion over the next eight years to improve access to in-home and community-based care.

The swelling population of seniors will far outpace growth in other age groups. That acceleration — and the slower growth in other age groups — could leave many older Americans with less family to rely on for help in their later years. Meanwhile, federal officials estimate that more than half of people turning 65 will need long-term care services at some point. That care is expensive and can be hard to find.

Spending for paid long-term care already runs about $409 billion a year. Yet that staggering number doesn't begin to reflect the real cost. Experts estimate that 1 in 6 Americans provide billions of dollars' worth of unpaid care to a relative or friend age 50 or older in their home.

As the country weighs Biden's plan, here's a quick look at how long-term care works currently and what might lie ahead. Read the KHN coverage here.