Many Californians have relied on telehealth to connect with their healthcare providers during the COVID-19 pandemic, but the option isn't available to everyone.
This article was published on Thursday, May 27, 2021 in Kaiser Health News.
SACRAMENTO, Calif. — When his 20-month-old daughter developed a rash earlier this month, Anthony Rendon did what many other parents do when their child is sick: The speaker of the California Assembly took Vienna to her pediatrician — but he did so via video from the comfort and safety of his home.
Many Californians have relied on telehealth to connect with their healthcare providers during the COVID-19 pandemic, but the option isn't available to everyone. That imbalance is just one of the "frailties" in America's health system that Rendon says lawmakers must address.
"So many folks, when they lose their job, they're in trouble," he said.
A Democrat from Los Angeles County and grandson of Mexican immigrants, Rendon led a nonprofit organization dedicated to early childhood education before his election to the Assembly in 2012. Although he hasn't authored any sweeping bills on healthcare, as leader of the Assembly since 2016 he has influenced which measures get a vote — and which don't.
For instance, though he says he's a single-payer advocate, he angered many progressives four years ago when he blocked a bill that would have provided government-funded healthcare to all Californians. Rendon described the measure, approved by the state Senate, as "woefully incomplete." While that decision drew the ire of the powerful California Nurses Association union — its leader tweeted an illustration of California's iconic grizzly bear logo with a knife in its back inscribed with Rendon's name — some Capitol insiders say Rendon made the strategic decision to take the hit for his members on a politically charged issue that didn't have the votes to pass.
"It's never leadership acting alone," said David Panush, a healthcare policy consultant who worked in state government for 35 years. "They do it on behalf of their caucuses."
Rendon won his post as California's 70th Assembly speaker in part by pledging to allow his colleagues to set their own agendas in their policy committees. Under his leadership, the legislature has approved measures to expand Medicaid coverage to undocumented immigrants ages 19 to 26, protect patients from some surprise medical bills, ban the sale of flavored tobacco products, and require drug companies to report and explain drug price increases. But lawmakers rejected bills that would have taxed sugary drinks and given the state attorney general more authority over hospital consolidations.
After missing nine weeks of work last year when COVID shuttered the Capitol, lawmakers returned to plastic barriers on their desks, mask requirements and other safety measures.
In December, Rendon's colleagues elected him to a third term as speaker. He talked with KHN's Samantha Young about his leadership role during the pandemic and his legislative priorities for the rest of this year.
Q: What did you learn leading this legislative body through a pandemic as a lawmaker, a husband and a dad?
First of all, we're all very fragile and we're all very resilient. It doesn't take much for our various systems to be upset and to change course. At the same time, we adjust, whether it's as a society, as a state, as an institution. In the Assembly, for example, we've almost learned how to do our business in a completely different manner, in the same way that Californians up and down the state have learned to navigate their lives in a different way.
Q: How have you juggled home and work life?
On the one hand, weekends are great. A lot of district events don't happen, my wife can work on her dissertation full time, and I get to take care of the baby from sunup until around dinnertime. Having worked in early childhood education for 20 years, I realize how important the first couple years are. I've spent way more time with her than I thought I would. At the same time, there's been challenges finding safe child care.
Q: What weaknesses did the pandemic expose in the healthcare system, and what can the legislature do about it?
Telehealth is great and can be very helpful but has its limitations. The pandemic really exposed the need for effective broadband throughout the state and broadband equity as well. We used to regard lack of broadband access as a rural issue.
Once we sent schoolkids home, we realized there were more pervasive broadband problems. So, there's absolutely a need to do something big around broadband this year, and that's because of education and also because of healthcare.
Q: You say you're a single-payer advocate, but under your leadership, California's coverage gains have been piecemeal. Why not just go for it and pass single-payer for everyone?
Mostly because of the challenges. First of all, we would need a federal waiver. The Biden administration has already hinted that they won't do so. The president has said time and time again that he wants Obamacare to be expanded.
And there's the huge price tag. There are very, very serious constitutional problems relating to the development and implementation of single-payer.
Q: So, who should get coverage next?
Senior undocumented immigrants are the next big group left. It's a population that obviously has tremendous challenges with respect to access and language. They tend to have a lot of preexisting conditions, a lot of other health challenges as well. So, it's important that we make sure that we cover those folks.
Q: Is there anything you would have done differently, looking back on the past year?
I wish we could have come up with some of the ideas for social distancing and bringing the legislature back more quickly. I think there was a sense early on in March and April [of last year] that the pandemic would run its course more quickly than it did. I remember people saying, "We'll be back in two weeks, we'll be back by midsummer, the pandemic will be gone." So, in terms of developing a lot of those plans, they came to us a little later than I wish they had.
Q: How do you think vaccine distribution is going now that supply is exceeding demand?
I received a phone call from a neighboring district, the president of a community college, who called me up saying, "We have all these vaccines and people have stopped showing up."
We've reached this sort of plateau that's disappointing. We haven't reached this plateau because 90% of people have been vaccinated. It links directly to public health, education and information campaigns. We have to talk about the safety of the vaccine and have validators also talk about the need to get to herd immunity.
Q: Along those lines, local public health departments feel that they have been underfunded for years and that they haven't had the money to do the job in this pandemic. Do you support their request for additional state funding?
We need to make sure that they're adequately funded. There was a problem with respect to the pandemic. We honestly weren't ready for it. As far as these health efforts are concerned, they have to happen at the local level.
The conversation has to go hand in hand with accountability measures and accountability metrics. We're not going to give folks a blank check. We know that there are vast differences in practices that a lot of the public health agencies throughout the state want to pursue, and we want to make sure that best practices are really implemented.
Q: How do you negotiate with influential industries, such as hospitals, pharmaceutical companies and big labor, to get meaningful legislation passed that goes against their interests?
When people boil it down to a simple question of who gives the most money, that's overly simplistic. Look at the incredible amount of work we've done here in California with respect to oil. The enviros do not give as much money to politicians as the oil companies do.
But with respect to having these conversations, we take all of their input, and then the decisions, for me, are informed by what's best for the state.
Dozens of people were seriously injured during the protests last summer, leading to lawsuits, promises of reform and calls to ban the use of rubber bullets for crowd control.
This article was published on Wednesday, May 26, 2021 in Kaiser Health News.
(Editor's note: This is a follow-up to last year's joint investigation by KHN and USA Today finding that police in several citiesviolated their own crowd-control policies during protests over racial injustice and police brutality.)
As police in riot gear approached the demonstrators, Soren Stevenson raised his hands like scores of others and called out, "Hands up, don't shoot."
Suddenly, tear gas canisters and rubber bullets rained down.
The demonstrators had gathered for a sixth straight day to decry Minneapolis police officers' use-of-force practices after the slaying of an unarmed Black man named George Floyd.
On May 31, 2020, the protesters were under fire.
Stevenson, a graduate student at the University of Minnesota Humphrey School of Public Affairs, lost his left eye after an officer fired a plastic-tipped round at him — even though Minneapolis Police Department policy bans the use of those munitions against nonviolent people.
According to a federal court complaint that cites video of the incident and witness accounts, Stevenson was unarmed, had committed no crime, posed no threat and was not in a chaotic crowd.
It wasn't an isolated event. Dozens of people were seriously injured during the protests last summer, leading to lawsuits, promises of reform and calls to ban the use of rubber bullets for crowd control.
"This is a moment in time where we can totally change the way our Police Department operates," Minneapolis Mayor Jacob Frey said when the City Council banned chokeholds soon after Floyd's death. "We can quite literally lead the way in our nation enacting more police reform than any other city in the entire country, and we cannot fail."
Nearly a year later, there is scant evidence that Minneapolis has changed how its police officers use less-lethal weapons or strengthened its oversight. Instead, the city may be a study in stymied reform, unenforced policies and a lack of transparency.
The Minneapolis Police Department still has not given the public or the City Council a full accounting of how it responded to last summer's demonstrations. The department has failed to disclose basic facts such as the number of protesters arrested or wounded.
No officers have been disciplined for their actions during the protests. The only discipline related to the protests was meted out to an officer who described the department's toxic culture in a GQ story, despite not being authorized to talk to the media.
"I'm appalled by the behavior of our police during the protests," City Council President Lisa Bender said. "For this to be the department in our city with the least amount of transparency is the opposite of what it should be."
From New York to Portland, an investigation by USA Today and KHN last year found that police violated their own crowd-control policies during protests over racial injustice and police brutality.
Michelle Gross, co-founder of the nonprofit Communities United Against Police Brutality, said she's seen no reform or accountability regarding Minneapolis officers' conduct, including their use of rubber bullets. "I call it 'cop exceptionalism,'" she said. "They do what they want."
The Minneapolis City Council passed a resolution last month calling for an end to the use of rubber bullets, tear gas and other less-lethal rounds. It was merely a "statement of values" with no legal force.
Police Chief Medaria Arradondo rejected the resolution as "unhelpful and uninformed," according to the (Minneapolis) Star Tribune, saying if officers can't use less-lethal weapons they would have only guns and batons to combat demonstrators "who are here to strike harm and chaos and destroy our city."
Council Member Says Police Escalated Tensions
Floyd was killed May 25, 2020, by police during an arrest that was captured on video and seen worldwide.
In a city raw from complaints of officer abuses, outrage exploded into street demonstrations. Police responded with riot squads armed with tear gas and less-lethal firearms that launch 40-millimeter projectiles tipped with hard foam or plastic, commonly called rubber bullets.
For six days and nights, some peaceful demonstrations escalated into arson, looting and chaos, making it difficult for outsiders to sort out whether protesters or police triggered violence.
Steve Fletcher and other City Council members contended officers inflamed crowds with tear gas and rubber bullets. "The community gathered Tuesday night to mourn and express their outrage, peacefully," he tweeted May 28 amid the violence.
"It was bad choices by Minneapolis police officers that escalated the situation to the point that it turned into a prolonged week of action," he said later, according to the Star Tribune.
Officers used about 5,200 less-lethal munitions over six days, according to records provided to USA Today.
Frey told USA Today that officers faced unprecedented conditions in which violent provocateurs mixed with peaceful protesters. "Distinguishing between those two became increasingly difficult," he said.
At least 57 people were injured so severely by less-lethal projectiles that they required urgent care during protests in Minneapolis from May 26 to June 15, 2020, according to the University of Minnesota's medical school.
Of those, 23 were hit in the face or head. Ten were blinded or suffered severe eye trauma. Sixteen suffered traumatic brain injuries.
Minneapolis policy defines a less-lethal weapon as one that "does not have a reasonable likelihood of causing or creating a substantial risk of death or great bodily harm."
The policy says officers may use less-lethal weapons against individuals posing a threat but "shall not deploy 40mm launchers for crowd management purposes." It says shots to the head or neck are potentially deadly and should be avoided.
The study concluded, "Projectiles are not appropriate for crowd control." Years ago, other researchers reached a similar conclusion. But the devices have been marketed for crowd control and, last summer, that's how police across the country used them.
Frey acknowledged seeing videos of officers shooting nonviolent civilians and journalists — sometimes appearing to target the head. Though such conduct is "unacceptable," he said, efforts to enforce policies have been thwarted by procedural requirements, union resistance and litigation.
Asked whether any Minneapolis officer has been disciplined for violating use-of-force policies during the protests, Frey said in April "quite a few cases" were under investigation, but he declined to say how many.
Mychal Vlatkovich, a spokesperson for Frey, said Saturday no discipline has been finalized, and the city can't comment on open investigations.
'We're Getting Hit'
Terry Hempfling, 39, an artist who was raised by activist parents, said protesting injustice is a patriotic duty.
On May 29, she and her friend Rachel Clark joined a crowd near the 3rd Precinct police station. Around 11:30 p.m., police ordered protesters to disperse. Hempfling said she and Clark walked away and were unlocking their bikes when tear gas swirled in the darkness. They were trapped between two lines of police.
Hempfling said she was disoriented, eyes and throat stinging, as Clark blurted out, "We're getting hit." They climbed a fence to escape but not before Hempfling was shot in the back, breast and leg, leaving an expansive bruise that is still discolored.
Hempfling and Clark, who was hit by three projectiles, are among hundreds of plaintiffs in an American Civil Liberties Union of Minnesota lawsuit alleging Minneapolis and state police have "a custom or policy authorizing the deployment of crowd-control weapons and/or less-lethal munitions in an unconstitutional manner."
The ACLU complaint contends departmental restrictions on the use of rubber bullets are not enforced, so officers ignore them with impunity. At least a dozen other lawsuits contain similar allegations.
Stevenson, who seeks $55 million in damages plus court-ordered policing reforms, claims in his suit that a rubber bullet fired by a Minneapolis police officer fractured facial bones, ruptured an eye and caused brain damage. As blood streamed from the wound, at least a half-dozen officers allegedly did nothing to render aid — behavior his lawsuit says was not just a violation of policies but inhumane.
"MPD has allowed its officers to get away with policy and constitutional violations without fear of repercussion for decades," the complaint says.
Ethan Marks alleged he was at a demonstration May 28 with his mother when he was "shot in the eye with a tear gas canister from several feet away." It hit him so hard he was knocked out of his shoes.
Andrew Noel, an attorney who represents Stevenson and Marks, said police have yet to identify the officers who shot his clients, even though they tracked down suspected rioters with video and social media. "If you can locate those folks, you'd better be able to identify the officers involved," Noel said.
Hempfling said she has taken part in more than 100 demonstrations and thought she understood how to exercise her First Amendment rights safely.
"I left feeling like I had no clue what a police officer might do to me, regardless of whether I'm being peaceful," she said.
Attorneys for the city sought to dismiss the ACLU case based in part on a claim that officers faced a "rapidly evolving, violent, and dangerous situation" that required less-lethal force to repel and disperse "unruly individuals."
A federal judge rejected the motion in March, ruling that plaintiffs plausibly allege city officials tacitly authorized police abuses or were indifferent to them.
ACLU attorney Isabella Salomão Nascimento said the Police Department remains in dire need of reform.
"We really hope this litigation will serve as a vehicle for that," she said. "This was an outrageous use of force."
Limited Reforms
In early June 2020, Minnesota's Department of Human Rights filed an emergency action accusing the Minneapolis Police Department of discriminating against people of color.
The city promptly agreed to a restraining order. As part of that deal, the use of rubber bullets against demonstrators is prohibited unless authorized by the police chief or someone he designates.
Vlatkovich, the mayor's spokesperson, said Arradondo authorized use of less-lethal weapons during demonstrations in August.
The court agreement included a provision requiring timely and transparent discipline for officers who violate use-of-force policies. Despite repeated requests from USA Today, neither police nor Frey identified any officer punished for misuse of less-lethal munitions.
Citizen complaints of misconduct and abuse by Minneapolis police nearly tripled during the second quarter of 2020, when the demonstrations took place, according to the Minneapolis Office of Police Conduct Review.
Gross, the community activist, said the data is almost meaningless because residents don't believe police officers are held accountable and seldom bother to report wrongdoing. She serves on an advisory council with the Minnesota Peace Officer Standards and Training agency.
She said she witnessed an officer shoot a nonviolent protester in the face with a tear gas canister during last year's demonstrations, but there was no point in lodging a complaint.
A nurse by profession, Gross referred to the conduct review office as "the place where complaints go to die."
The city has an appointed Police Conduct Oversight Commission, described on the municipal website as an "independent body which assures police services are delivered in a lawful and nondiscriminatory manner." The commission conducts audits but has no power over citizen complaints, officer discipline or law enforcement policies.
An analysis by the Minnesota Reformer, a nonprofit news site, found that fewer than 3% of the commission's cases from 2013 to 2019 resulted in significant discipline of officers. It took an average of 18 months to resolve each case.
The news outlet concluded that the Minneapolis Police Department "is notoriously ineffective at removing bad cops from its ranks" due to a "pattern of mismanagement."
A City Council bid to reorganize the roughly 800-officer Police Department is caught in a power struggle. The council and activists are pressing to let voters decide whether the department should be replaced by a public safety agency under council control.
Frey opposes those efforts and insists he is changing police customs and rules from within.
For example, he said, one new policy says only SWAT units can use rubber bullets for crowd control. It makes an exception if no tactical squad is available.
Frey said he made "overture after overture" to City Council members, asking for suggestions on what to change without receiving any.
Bender, the council president, said she's seen no significant reforms under Frey's leadership. "There is public debate about the use of less-lethal force for crowd control," she said, "but no public decision-making. The mayor and chief make those decisions behind closed doors."
City Won't Say Whether Officers Followed Reporting Policies
The Minneapolis Police Department's policy manual requires officers to file a report each time they discharge a less-lethal projectile. If someone is injured, an officer is required to notify a supervisor, which prompts an inquiry that must be documented.
It is unclear whether officers complied with those policies during May and June 2020. In response to a public records request from USA Today, the department supplied no records other than a spreadsheet summarizing how many munitions were discharged.
Frey said Arradondo compiled "a whole lot of data" about enforcement efforts during the protests. Asked in early April where that information has been disseminated, he said, "I am trying to get it right now, and we're expediting the requests."
Attorneys for shooting victims said the city has turned over few documents in response to their lawsuits, and it has secured protective orders to keep disclosures about police behavior out of public view. Among the records that Minneapolis lawyers want sealed: bodycam videos, internal investigative reports, misconduct reviews and personnel files.
Police agencies commonly seek independent reports that evaluate performance and tactics after major events. Minneapolis did not commission an after-action review of the George Floyd demonstrations until February.
In an email, city spokesperson Casper Hill said the review was delayed because there wasn't money in the budget. The $250,000 study will not be completed until later this year.
Police Officers Nationwide Fired on Protesters
A nationwide survey by the nonprofit Physicians for Human Rights counted 115 demonstrators who suffered head wounds from less-lethal projectiles during last summer's demonstrations. That tally, based on news and social media reports, is believed to be a fraction of the total.
The organization concluded that rubber bullets "are not an appropriate weapon for crowd management" and recommended cities ban such use.
Minneapolis police were particularly aggressive, according to the study, firing more neck and head shots than officers in any other city except Los Angeles, which has roughly 10 times the population.
Though laws and regulations are important, policing experts stress that culture is crucial.
Mike Tusken, chief of police in Duluth and an executive board member with the Minnesota Chiefs of Police Association, said crowd control is difficult because civil disturbances are dynamic and there's no playbook on how to respond.
Though policies set a framework, Tusken said, proper decision-making requires a "culture of discipline" that emanates from training and leadership.
As he watched news across the country last summer, Tusken said, he saw some officers de-escalate tensions, even showing kindness to protesters. A small minority fired on nonviolent protesters.
"Why are they still in policing? Why are they not being held accountable?" Tusken asked. "I'm outraged to see it. The narrative becomes 'All cops: bad.'"
State Rep. John Thompson said the cycle never seems to end.
In 2016, a close friend, Philando Castile, was pulled over by an officer in a Minneapolis suburb and shot five times as his girlfriend's 4-year-old daughter looked on. The officer was acquitted.
At Castile's memorial viewing, Thompson said, he vowed to change things. Four years later, as an elected official, he witnessed officers firing less-lethal projectiles at protesters outside the 3rd Precinct station.
"There were peaceful people there exercising their rights," Thompson said. "There's this big bang from a canister, and rubber bullets are flying everywhere."
Viewers could be excused for thinking Robert De Niro was just being a good fella in an ad promoting safe buildings amid the COVID pandemic, along with the likes of Jennifer Lopez, Lady Gaga and Michael B. Jordan.
De Niro and the other A-list celebs are backing something called the Well Health-Safety seal, offered by the International Well Building Institute. The organization, a for-profit subsidiary of a decade-old real estate service company called Delos, is piggybacking on post-pandemic anxiety to profit by popularizing its healthy building certification program.
"Feeling safe should be a right for all, not a privilege for some," De Niro says in one spot.
What the ad doesn't tell viewers, though, is that the seal itself is something of a privilege that must be bought. Companies pay — sometimes a lot — to be judged on a range of categories. Some relate directly to COVID (such as air quality), but others are less easily measured and have little obvious link to the pandemic (community "connectivities").
And De Niro, plus Venus Williams, Wolfgang Puck and even New Age guru Deepak Chopra, is being well paid to endorse the Well seal in a carefully planned and executed campaign.
"We compensated them for their time," IWBI President and CEO Rachel Hodgdon confirmed in an interview, explaining that the effort was modeled on a green schools campaign she ran several years ago at the U.S. Green Building Council. She declined to specify how much it cost to harness all that star power, or how much the company is spending to air the ads.
A spokeswoman said the spots have run nationally since late January on more than 30 networks, including Bravo, MTV, TBS, FX, Paramount, CNBC and CNN, but said the dollars spent "are confidential."
The cost is certainly substantial. Data from the ad-tracking firm iSpot.tv shows that the institute has spent nearly $500,000 to air six ads.
"What I wanted to do with this campaign was make it very much in the style of a public service announcement," Tony Antolino, the chief marketing officer at Delos, told Ad Age.
But the effort very much services the bottom line of Delos.
Not to be confused with the diabolical corporation of the same name in the HBO series Westworld, Delos was founded in 2009 by former Goldman Sachs partner Paul Sciallawith the aim of linking real estate to the health and wellness industry.
The company has raised $237 million from investors, including Bill Gates, according to Forbes.
In interviews, Scialla describes himself as an "altruistic capitalist." He told the Los Angeles luxury lifestyle publication Dreams that he saw "a unique opportunity to merge the world's largest asset class — the $180 trillion worth of real estate — with the world's fastest growing industry — wellness."
Putting together an all-star cast for a for-profit venture took some doing.
"It wasn't a fast process, because each of these celebrities and influencers has a rigorous process through which they filter any opportunity," said Hodgdon, who also got director Spike Lee to ask questions of the famous "ambassadors."
"We went through a pretty intensive process of educating the celebrities and the teams that work with them on why there was heft and legitimacy behind what we were putting out there," she said.
She recalled Lady Gaga saying in one interview, "Look, I really believe in what you all are doing. I said yes to this because I think that this is really important."
Having clean, healthy buildings is undoubtedly important for many. It's especially so for the International Well Building Institute, which is using its seal as a gateway into its broader building certification services.
"What's been exciting for us is that a lot of our customers who are entering in through the Well Health-Safety Rating are now beginning to upsize their commitment to achieve a full-on wellness certification, which is so important," Hodgdon said.
The price for the health seal starts at $2,730 and rises to $12,600. Getting seals for multiple locations or franchises can run up to $166,000. Starter costs are cheaper if a property owner already buys the broader certification service. That starts at about $9,000 and rises to just over $100,000. Additional testing services start at $6,500.
Delos launched the certification standard in 2014 after what the institute says was a rigorous peer-reviewed process. The program is modeled on the U.S. Green Building Council's LEED program, and uses the Green Building Council to verify its work. Hodgdon worked there for a decade before moving to the IWBI, along with the Green Building Council's founder, Rick Fedrizzi.
The certification covers 10 categories, including such easily measured things as air and water quality, sound and temperature, and harder-to-pin-down items such as mental health, community "connectivities," movement and nourishment — all backed, Hodgdon said, by science and study.
Whether meeting all the standards in those categories will also lead to a building's occupants becoming healthier and fulfilled probably will take a long time to prove. The company points to case studies — some done by its own workers and clients — that suggest the holistic approach pays off.
Independent experts — scientists, doctors, engineers, mental and physical health experts, and others — who helped evaluate the initial standard described the concepts as sound.
"They asked provocative questions. They were interested in what experts had to say. I thought it was a pretty good process," said Ellen Tohn, an assistant professor of epidemiology at Brown University who runs an environmental engineering firm and is listed as a peer reviewer.
Still there's no guarantee it actually works. Even the well-regarded LEED program often doesn't live up to its hope and hype.
"It seems rather obvious: Skepticism is in order," said John Scofield, a physics professor at Oberlin College in Ohio who has extensively studied the LEED program.
Scofield noted that there is very little empirical data that can be used to verify the effects of certification programs, since landlords often refuse access to researchers.
"Owners have little to gain by allowing someone to study the performance of their building. They have already garnered the green publicity and marketing that goes with the label," he said.
"In the end, all of these programs, no matter how well-intentioned, turn into marketing and money."
While Delos' program appears to be the most ambitious attempt to create an independent arbiter of building health, there are others, including some run by nonprofits.
Another option for builders less focused on the mind-body connection and more on just air quality is the Environmental Protection Agency's Indoor airPlus certification program.
Late last year, Janet Yetenekian was one of the thousands of people in Southern California whose case of COVID-19 was serious enough to send her to the hospital. But Yetenekian's recovery was not typical: She received hospital-level care in her own home in Glendale.
"It was even better than the hospital," Yetenekian said, laughing. "They were constantly reaching out — it's time for you to do your vitals, or it's time for you to take your medications."
Yetenekian contracted the virus that causes COVID in December, after friends invited her family to an afternoon barbecue. It seemed like a safe antidote to the isolation caused by the pandemic. But the day after the gathering, the host came down with a fever. A test confirmed it was COVID. Within two weeks, Yetenekian's husband and two teenage children developed mild symptoms. She came down with a more serious case, however, and her blood oxygen plummeted to dangerously low levels.
She went to the hospital at Adventist Health in Glendale, where doctors told her she would need an intravenous infusion of the antiviral drug remdesivir and constant monitoring. And it surprised Yetenekian when her doctor offered to move all her care home to be monitored virtually.
Doctors and nurses at a command center nearly 200 miles away in the San Joaquin Valley town of Hanford, California, managed Yetenekian's care as part of a new federal effort aimed at freeing up hospital beds during public health emergencies. Under the model, about 60 illnesses — including COVID — qualify for home treatment.
"Heart failure, pneumonia, skin infections — those are all patient populations we can safely care for in the home," said Dr. Margaret Paulson, who leads the Mayo Clinic's new home-based care program in rural Wisconsin.
Hospital care at home is nothing new for patients with low-level health needs. But since the pandemic began, a growing number of health systems, including Adventist Health, the Mayo Clinic and Kaiser Permanente (which is not affiliated with KHN) are offering people with more serious health conditions hospital-level treatment in the comfort of their homes.
Paulson said that, once her patients understand home care does not mean less care, they eagerly embrace it.
"Especially for patients who have been in the hospital a lot, to know that they can actually go home and sleep in their own bed and be with their family and have their pets by their side, it's just really reassuring," Paulson said.
"This is actually a higher level of touch from physicians and advanced practitioners," said Dr. Kavita Patel, a physician and health policy fellow at the Brookings Institution.
Regular video conferencing and 24/7 monitoring is augmented by twice-daily, in-person visits by nurses and other health workers who provide basic care — such as antibiotics — that can't be given virtually.
"This isn't just sending Mom or Dad to the bedroom," Patel said.
The technology infrastructure is key, Patel said, for patients and doctors. It includes Wi-Fi phones that ring directly into a hospital's command center, iPads that allow videoconferencing with health professionals and wearable devices with emergency call buttons.
Raphael Rakowski is co-founder of Medically Home, a Boston-based technology company that supports at-home programs for Adventist Health. Mayo Clinic and Kaiser Permanente announced on May 13 a combined $100 million investment in Medically Home to help expand the service to other health systems. Rakowski said another selling point of the at-home care model is that there are no facility transfers as patients heal.
"We stay with the patient until they're fully recovered, and that averages anywhere from 20 to 30 days, sometimes longer," he said. "So, we substitute not just for the hospital, but for all the care that follows."
Still, the program is not a good fit for every patient. To be eligible for care at home, patients must live within 30 minutes of emergency care; they also need high-speed internet and, said Patel, they can't be too sick.
"This can't be something where it's so complicated that you are monitoring a patient, worried that they could crash and need to be in the ICU within minutes," she said.
But for moderate COVID and dozens of other conditions, acute hospital care at home is likely to become a more common option as more health systems adopt the program and even more diseases are included. It is offered now in 30 states.
This story is part of a reporting partnership that includes NPR and KHN.
DENVER — Tired of waiting for federal action to reduce prescription drug costs, Colorado is acting on its own — even if it must do so with one arm tied behind its back. Unable to set prices or change patent protections, the state is exploring creative legislative and administrative approaches to lower out-of-pocket costs on medications.
While none of the efforts alone would result in broad-based, deep cuts, state officials estimate the combined impact of the various measures could save Coloradans between 20% and 40% in out-of-pocket costs.
"That's why it's so important to have a variety of levers," said Kim Bimestefer, executive director of the Colorado Department of Healthcare Policy & Financing. "You start stacking all these up, and it's remarkable how much we can drive down the cost."
Like many other states, Colorado has been looking to lower drug prices for several years, issuing a report late in 2019 that explained why the state spent more than $1 billion annually on drug purchases. Although the pandemic derailed action last year, the state updated the report in January, and state agencies and the legislature are working to implement some of the proposals.
One bill would create a prescription drug affordability board, which could review prices of medications sold in the state to consumers and set payment limits. The legislation, backed by Democratic Gov. Jared Polis, has already passed the Colorado Senate and is making its way through the House. The board would be charged with ensuring those savings are passed on to consumers.
Drugs would qualify for an affordability review under various triggers, including when prices increase by more than 10% per year, or exceed either $30,000 a year for brand-name drugs or $100 a month for generics per person. Patients or consumer advocates could also nominate drugs for review.
State officials estimate those categories probably cover 100 to 125 medications, but the board would be permitted to set limits for only 12 drugs per year. The board could review affordability of more drugs and make recommendations for other types of administrative or legislative action to lower their costs.
"It is inherently limited," said Isabel Cruz, a policy manager with the Colorado Consumer Health Initiative, a nonprofit that seeks to lower health costs for state residents. "That's the political reality that we had to accept."
The bill is intended to help patients like 18-year-old Koen Lichtenbelt, of Ridgeway, who was diagnosed with a rare autoinflammatory disease in kindergarten. The condition damaged his nerves and, in December, doctors prescribed the drug Hizentra, with an out-of-pocket cost of $10,000 per month. His parents footed the bill for three months before their insurance plan agreed to cover the drug.
His mother, Cat Lichtenbelt, said, that's "$30,000, which is the price of a car, but, you know, this is our son's life."
Once on the medication, Koen, who had been missing half of his school days over the course of his education, was able to graduate this year. He's been accepted to Colorado State University but is taking a gap year to work as a first responder at a local fire department. Had he not had access to the drug, Lichtenbelt said, her son would likely be reliant on state aid now.
"There is a need for pharmaceutical companies to continue to develop medications and drugs to improve people's lives," she said. "However, what is the price point at which there is access to actually being able to use those drugs?"
In addition to opposition from the state's hospital and pharmacy groups, the pharmaceutical industry is throwing its weight against the bill, including threats not to sell in Colorado the drugs facing payment limits.
"Creating a board of unelected bureaucrats with the authority to arbitrarily decide what medicines are worth and what medicines patients can get would be a disaster for patients," said Hannah Loiacono, a spokesperson for the national Pharmaceutical Research and Manufacturers of America industry group.
The Colorado BioScience Association warned that setting payment limits could reduce the funding available for new pharmaceutical discoveries.
"If passed, this bill will create unpredictability for the startups and development-stage companies in Colorado's life sciences ecosystem, making it harder for them to raise funds," said Jennifer Jones Paton, the group's president and CEO. "Investors will look elsewhere for opportunities."
Nonetheless, the bill is expected to pass. Proponents said it's unlikely a manufacturer could carve out specific drugs or states from its supply chain and pointed out that drug companies already sell their highest-cost drugs at lower prices to Medicaid, community health clinics and charity hospitals.
The governor's office is also implementing changes on its own. On July 1, it is formally launching a tool embedded in electronic medical records allowing doctors and other prescribers to see what patients with public or private health plans would pay for a medication. Bimestefer said 80% of prescribers in the state have the tool enabled, and 37% are using it ahead of the official start date.
The state is also pursuing contracts with drug companies that would link prices to the effectiveness of the drugs, measured, for example, by whether they reduce hospitalizations or heart attacks.
The Colorado legislature had previously approved importing drugs from Canada for consumers to purchase at lower costs and, now with federal approval, the state is reviewing bids from contractors to make that happen. The state estimates Canadian imports would reduce costs for 50 common drugs by 63%. But the state found that importing drugs from Australia and France could save 78% to 84%. Colorado would need an adjustment to federal law to expand importation to those countries but could rely on the same infrastructure being built for Canadian imports.
"If we open up other countries, we could increase the supply of the drugs coming in," Bimestefer said. "This will actually help us battle pharma if we can turn on the spigot full, full, full throttle."
Colorado's efforts are part of a national trend by states that started in earnest about five years ago, said Megan Olsen, a principal in the policy practice at Avalere, a healthcare consulting firm in Washington, D.C. The lack of federal action, as well as exploding Medicaid and state employee health plan budgets, encouraged states to tackle the issue.
"Early on the focus was on transparency," she said. "Now what we're seeing is sort of a progression from those transparency bills into more of trying to regulate prices or control prices in different ways."
According to the National Academy for State Health Policy, which provides draft health policy legislation to states, nearly every single state and U.S. territory is considering some sort of prescription drug cost bill this year. There are 14 prescription drug affordability board bills, 24 foreign drug importation bills and 58 bills addressing prescription drug coupons or cost sharing. And, following a December U.S. Supreme Court ruling allowing states to regulate pharmacy benefit managers, the go-between companies that control the drug prices paid by insurance companies, states are considering 97 separate PBM measures. Colorado legislators, for example, are debating a bill that would force those companies to compete to service state health plans.
Trish Riley, executive director for the academy, said states serve as 50 health policy laboratories, experimenting with policies that can set precedent for other states, prove the viability of various approaches and put pressure on the feds to act. Some national policies, such as the Children's Health Insurance Program, started as state measures.
"We're on the front lines," Bimestefer said. "And we can see some of the solutions more readily."
While a patchwork of state regulations can add administrative burdens for drug companies, Riley said it can also spur federal action.
"I would argue chaos theory," Riley said. "The more differentiation between states, the more there's pressure on the federal government to make a more consistent system."
Almost all 15 companies surveyed — among the largest and most influential Fortune 500 companies — have strong pro-vaccine messages from their corporate leadership.
This article was published on Tuesday, May 25, 2021 in Kaiser Health News.
Many of the companies with the largest number of employees say they'll do almost anything to encourage their employees to get vaccinated. But a survey of some of them found that none would be inclined to mandate shots as a condition for holding a job.
Almost all 15 companies surveyed — among the largest and most influential Fortune 500 companies — have strong pro-vaccine messages from their corporate leadership, emphasizing that the shots can both help protect individuals and bring the pandemic to a close.
CVS Health, which administers COVID vaccines as part of the federal pharmacy distribution program, says it strongly encourages the shots for its employees "from a public health standpoint" but won't mandate them. Starbucks is also encouraging the shots "to help mitigate the spread of COVID-19," but also doesn't mandate them.
Some companies are giving employees paid time off to either get shots or stay home if they have side effects, a trend that could increase now that the Biden administration has announced tax credits for smaller companies to offer up to 80 hours of paid sick leave until Sept. 30.
Target is giving hourly employees up to four additional hours of pay if they get the vaccine (two hours per shot). Amazon is offering $40 a shot for hourly workers, and Kroger is giving employees $100 if they receive both doses.
"Vaccination, in our view, is absolutely the only way out of the pandemic, both for us to get to normalcy and also for the country," said Dr. Vin Gupta, a pulmonologist and chief medical officer for Amazon's COVID response.
Amazon, like other large retailers, has experienced COVID outbreaks at its workplaces throughout the pandemic. In October it revealed that nearly 20,000 out of the company's 1.37 million front-line employees had tested positive or were presumed to have been infected with the COVID virus.
The company, which includes Whole Foods Market, distribution warehouses and data centers, has organized vaccination events for employees such as delivery workers in at least 29 states, and is among the giant companies doing the most to bring shots to its workers. But for now, Amazon isn't making vaccines mandatory.
Target, the only company among those surveyed that is offering financial incentives, extra paid time off and vaccinations at the worksite, has no plans to mandate the vaccinations.
However, the pandemic has brought a stream of fast-changing policies and recommendations from federal health authorities, and some companies, while declining mandates for now, indicated that could change.
"I don't have a crystal ball, and I can't predict the future, but that's what our message is now," said Carrie Altieri, vice president of communications for COVID strategy at IBM.
Legal and public health experts caution against any mandates before the Food and Drug Administration fully licenses the shots, which could happen this summer. The vaccines were authorized by the FDA for "emergency use" and as such employers can't require them, some legal experts have argued. Even post-licensure, though, companies could spark a backlash if they require employees to get them, said Joanne Rosen, senior lecturer and associate director at the Center for Law and the Public's Health at Johns Hopkins University.
A mandate could anger certain employees while only marginally increasing the number of vaccinations, Rosen and others say. It would be more prudent to focus on "carrots instead of sticks," she said.
"If the purpose of a mandate is to ensure that the largest number of people get vaccinated, a backlash to a mandate, in which you have more reluctance or opposition to vaccination, is the opposite of the outcome you want to get," she said.
Post-licensure, employers would face fewer legal challenges to vaccine mandates, especially if staff members work with medically vulnerable or at-risk patients, as in nursing homes or prisons. Aside from these special sectors, employee mandates aren't necessarily a good idea from a public health perspective, said Michelle Mello, a professor of law and medicine at Stanford University.
Hard-line vaccine opponents likely wouldn't be swayed by an employment-based vaccine requirement, and it could risk alienating some in the "wait and see" contingent, she said.
About 6% of Americans not yet vaccinated against COVID said they would accept a shot if it was required, according to an April survey from KFF. An additional 15% who hadn't gotten a shot expressed a "wait and see" attitude toward vaccination. And 13% flatly refused to be vaccinated.
Gains in the small group who say they'd get a shot if it's required might not be worth the uproar a mandate could foment, Mello said.
Mandates risk further politicizing COVID vaccines in U.S. society, said Brian Castrucci, CEO of the de Beaumont Foundation, a charity focused on public health.
Polling conducted by de Beaumont and GOP pollster Frank Luntz on April 15 found that 36% of those who voted for Donald Trump in the 2020 presidential election agreed it was important for American businesses to encourage and incentivize the vaccines, versus 54% of Joe Biden voters. The survey also found that 41% of Trump voters believed that businesses should not be involved in COVID vaccinations at all, compared with 18% of Biden voters.
"Mandating vaccination will hit every button there is on the political right," Castrucci said.
Once public health tools and strategies become politicized, local governments can choose to simply take them off the table as an option. A new Florida law bans businesses and government entities from requiring proof of a COVID vaccination. The law builds on Gov. Ron DeSantis' executive order, which he signed April 2.
"Vaccine verification can be a useful tool," Castrucci said. "Now it's no longer available in Florida."
Despite the potential backlash, the financial case for COVID vaccinations is clear, said Aaron Yelowitz, an economics professor at the University of Kentucky, given how effective the shots are.
Taking into account the costs of a shortened life span, mental health conditions and lost income due to illness and shutdowns, the COVID pandemic has cost the average American family of four almost $200,000, according to an analysis by researchers at Harvard.
Some of these costs may be borne by businesses in the form of lost productivity and higher health insurance prices, said Yelowitz. Financial incentives for the shots are thus an extremely tempting trade-off, he said.
Incentives for vaccination — like a $25 gift card or free Uber ride — are "surely worth it in terms of savings," Yelowitz said. In the same vein, he also called Ohio Gov. Mike DeWine's $5 million vaccine lottery "innovative and imaginative."
But for now, employers are sensitive about what they can and can't demand of workers, said Lindsey Leininger, a clinical professor of business administration at Dartmouth College. The tight labor market and the fraught, ongoing negotiations over when and how to bring employees back to the office makes some companies wary of asking too much of their workers, said Leininger, who advises smaller businesses on COVID vaccines and other issues.
"All of the businesses I work with have a general preference for carrot versus stick types of approaches," she said. "How many things do you want to mandate of your employees right now?"
COVID-19 is opening the door for researchers to address a problem that has vexed the medical community for decades: the overtreatment and unnecessary treatment of patients.
On one hand, the pandemic caused major health setbacks for non-COVID patients who were forced to, or chose to, avoid tests and treatments for various illnesses. On the other hand, in cases in which no harm was done by delays or cancellations, medical experts can now reevaluate whether those procedures are truly necessary.
But never before, said researcher Allison Oakes, has there been such a large database to compare patients who received a particular test or treatment with those who did not.
Oakes was a principal author of an October paper in Health Affairs by the Research Consortium for Healthcare Value Assessment. The paper noted that COVID provided an important new measurement — examining outcomes for patients who received treatment before hospitals canceled care because of COVID and those who had their care canceled.
Areas ripe for study, said Oakes: colonoscopies done on patients older than age 85; hemoglobin blood work for Type 2 diabetes patients; semi-elective surgeries, such as knee arthroscopy for articular cartilage surgery; and yearly dental X-rays. All were done less often because of COVID, she said.
"There are two sides of the pie: low-value care and care that people get in trouble if they don't get," said Oakes, who expects researchers to take advantage of all the data provided from COVID on "both types of care."
One recent study looked at Veterans Affairs patients who had elective surgeries canceled because of COVID. The study found they were no more likely to visit hospital emergency departments than patients who had undergone those surgeries in 2018.
Dr. Heather Lyu of Brigham and Women's Hospital and Harvard Medical School said much testing and care was cut back by patients' fears of contracting COVID in a medical setting and because medical facilities and staffers were fighting just to keep up with COVID cases.
"There are some procedures, tests, and exams that cannot be delayed in any situation," Lyu said in an email. For example, she pointed to the screening, surveillance and treatment of cancer patients.
However, she said other tests and treatments can be delayed or canceled without negative effects. Lyu oversaw a 2017 survey of 2,000 physicians, with half the doctors saying the percentage of unnecessary medical care was higher than 20.6% and half saying it was lower.
Unnecessary treatment or overtreatment can result from several factors, the doctors in Lyu's survey said. Concerns about malpractice lead doctors to test even for unlikely problems to avoid missing something, they said. Sometimes health providers have difficulty assessing patients' prior medical records. Then there is the incentive for the health industry to boost revenue, sometimes to help pay for expensive testing equipment, the doctors said.
Leaps in technology are a major factor.
Dr. Jill Wruble, a radiologist at Johns Hopkins Medicine in Baltimore, said a CT scan that provided 30 or 40 images when she began practicing in the 1990s now provides thousands of high-resolution images.
"We now see things that we would have never seen before, like a lesion that may never become a problem," Wruble said.
Wruble said some patients still opt for aggressive medical treatment for things like that questionable lesion.
"Patients … often resist advice to 'watch and wait' and will demand surgery even when the operation itself comes with potentially dire consequences," Wruble said. The consequences are not only higher costs but potentially years of physical discomfort and pain, along with diminished physical abilities, she said.
Susan Gennaro, dean and professor at the William F. Connell School of Nursing at Boston College, said COVID provides not only opportunities to study unnecessary medical care, but also opportunities to examine areas of insufficient care. She cites a lack of mental health resources for COVID patients suffering through difficult treatment and even facing death without friends or family.
"When we are thinking of new ways to treat, we all need to think about our fascination with surgery and invasive procedures and start thinking more holistically about health," Gennaro said.
COVID's upending of scheduled non-COVID care hit hard in March and April last year, when the pandemic first began to overwhelm hospitals. Cancer surgery scheduled in April for Krista Petruzziello, for example, was postponed due to the focus on COVID care.
Instead of surgery, the 49-year-old real estate agent from Lowell, Massachusetts, received hormonal treatment usually reserved for breast cancer patients with larger tumors.
"It was concerning for sure," said Petruzziello. "Who knew a year ago how long it would be until surgery would be available for patients like me?"
It was only about six or seven weeks later when she had successful surgery to remove a tumor shrunken by the hormonal treatment. A recent follow-up scan found her clear of cancer, she said.
"Maybe there will be cases where the tumor disappears altogether [from hormonal treatment], allowing the surgery to be canceled," Petruzziello said. "Wouldn't that be a good thing?"
Dr. Harold Burstein, an oncologist at Dana-Farber Cancer Institute in Boston who treated Petruzziello, said breast cancer surgery will remain a key component of treatment for the foreseeable future. But he said hormone treatment "before surgery" can shrink the tumor and "hopefully make for less extensive surgery."
COVID, he said, forced healthcare providers to "think outside the box."
Almost all 15 companies surveyed — among the largest and most influential Fortune 500 companies — have strong pro-vaccine messages from their corporate leadership.
This article was published on Tuesday, May 25, 2021 in Kaiser Health News.
Many of the companies with the largest number of employees say they'll do almost anything to encourage their employees to get vaccinated. But a survey of some of them found that none would be inclined to mandate shots as a condition for holding a job.
Almost all 15 companies surveyed — among the largest and most influential Fortune 500 companies — have strong pro-vaccine messages from their corporate leadership, emphasizing that the shots can both help protect individuals and bring the pandemic to a close.
CVS Health, which administers COVID vaccines as part of the federal pharmacy distribution program, says it strongly encourages the shots for its employees "from a public health standpoint" but won't mandate them. Starbucks is also encouraging the shots "to help mitigate the spread of COVID-19," but also doesn't mandate them.
Some companies are giving employees paid time off to either get shots or stay home if they have side effects, a trend that could increase now that the Biden administration has announced tax credits for smaller companies to offer up to 80 hours of paid sick leave until Sept. 30.
Target is giving hourly employees up to four additional hours of pay if they get the vaccine (two hours per shot). Amazon is offering $40 a shot for hourly workers, and Kroger is giving employees $100 if they receive both doses.
"Vaccination, in our view, is absolutely the only way out of the pandemic, both for us to get to normalcy and also for the country," said Dr. Vin Gupta, a pulmonologist and chief medical officer for Amazon's COVID response.
Amazon, like other large retailers, has experienced COVID outbreaks at its workplaces throughout the pandemic. In October it revealed that nearly 20,000 out of the company's 1.37 million front-line employees had tested positive or were presumed to have been infected with the COVID virus.
The company, which includes Whole Foods Market, distribution warehouses and data centers, has organized vaccination events for employees such as delivery workers in at least 29 states, and is among the giant companies doing the most to bring shots to its workers. But for now, Amazon isn't making vaccines mandatory.
Target, the only company among those surveyed that is offering financial incentives, extra paid time off and vaccinations at the worksite, has no plans to mandate the vaccinations.
However, the pandemic has brought a stream of fast-changing policies and recommendations from federal health authorities, and some companies, while declining mandates for now, indicated that could change.
"I don't have a crystal ball, and I can't predict the future, but that's what our message is now," said Carrie Altieri, vice president of communications for COVID strategy at IBM.
Legal and public health experts caution against any mandates before the Food and Drug Administration fully licenses the shots, which could happen this summer. The vaccines were authorized by the FDA for "emergency use" and as such employers can't require them, some legal experts have argued. Even post-licensure, though, companies could spark a backlash if they require employees to get them, said Joanne Rosen, senior lecturer and associate director at the Center for Law and the Public's Health at Johns Hopkins University.
A mandate could anger certain employees while only marginally increasing the number of vaccinations, Rosen and others say. It would be more prudent to focus on "carrots instead of sticks," she said.
"If the purpose of a mandate is to ensure that the largest number of people get vaccinated, a backlash to a mandate, in which you have more reluctance or opposition to vaccination, is the opposite of the outcome you want to get," she said.
Post-licensure, employers would face fewer legal challenges to vaccine mandates, especially if staff members work with medically vulnerable or at-risk patients, as in nursing homes or prisons. Aside from these special sectors, employee mandates aren't necessarily a good idea from a public health perspective, said Michelle Mello, a professor of law and medicine at Stanford University.
Hard-line vaccine opponents likely wouldn't be swayed by an employment-based vaccine requirement, and it could risk alienating some in the "wait and see" contingent, she said.
About 6% of Americans not yet vaccinated against COVID said they would accept a shot if it was required, according to an April survey from KFF. An additional 15% who hadn't gotten a shot expressed a "wait and see" attitude toward vaccination. And 13% flatly refused to be vaccinated.
Gains in the small group who say they'd get a shot if it's required might not be worth the uproar a mandate could foment, Mello said.
Mandates risk further politicizing COVID vaccines in U.S. society, said Brian Castrucci, CEO of the de Beaumont Foundation, a charity focused on public health.
Polling conducted by de Beaumont and GOP pollster Frank Luntz on April 15 found that 36% of those who voted for Donald Trump in the 2020 presidential election agreed it was important for American businesses to encourage and incentivize the vaccines, versus 54% of Joe Biden voters. The survey also found that 41% of Trump voters believed that businesses should not be involved in COVID vaccinations at all, compared with 18% of Biden voters.
"Mandating vaccination will hit every button there is on the political right," Castrucci said.
Once public health tools and strategies become politicized, local governments can choose to simply take them off the table as an option. A new Florida law bans businesses and government entities from requiring proof of a COVID vaccination. The law builds on Gov. Ron DeSantis' executive order, which he signed April 2.
"Vaccine verification can be a useful tool," Castrucci said. "Now it's no longer available in Florida."
Despite the potential backlash, the financial case for COVID vaccinations is clear, said Aaron Yelowitz, an economics professor at the University of Kentucky, given how effective the shots are.
Taking into account the costs of a shortened life span, mental health conditions and lost income due to illness and shutdowns, the COVID pandemic has cost the average American family of four almost $200,000, according to an analysis by researchers at Harvard.
Some of these costs may be borne by businesses in the form of lost productivity and higher health insurance prices, said Yelowitz. Financial incentives for the shots are thus an extremely tempting trade-off, he said.
Incentives for vaccination — like a $25 gift card or free Uber ride — are "surely worth it in terms of savings," Yelowitz said. In the same vein, he also called Ohio Gov. Mike DeWine's $5 million vaccine lottery "innovative and imaginative."
But for now, employers are sensitive about what they can and can't demand of workers, said Lindsey Leininger, a clinical professor of business administration at Dartmouth College. The tight labor market and the fraught, ongoing negotiations over when and how to bring employees back to the office makes some companies wary of asking too much of their workers, said Leininger, who advises smaller businesses on COVID vaccines and other issues.
"All of the businesses I work with have a general preference for carrot versus stick types of approaches," she said. "How many things do you want to mandate of your employees right now?"
Alice Herb, 88, an intrepid New Yorker, is used to walking miles around Manhattan. But after this year of being shut inside, trying to avoid COVID-19, she's noticed a big difference in how she feels.
"Physically, I'm out of shape," she told me. "The other day I took the subway for the first time, and I was out of breath climbing two flights of stairs to the street. That's just not me."
Emotionally, Herb, a retired lawyer and journalist, is unusually hesitant about resuming activities even though she's fully vaccinated. "You wonder: What if something happens? Maybe I shouldn't be doing that. Maybe that's dangerous," she said.
Navigating Aging focuses on medical issues and advice associated with aging and end-of-life care, helping America's 45 million seniors and their families navigate the healthcare system.
Millions of older Americans are similarly struggling with physical, emotional and cognitive challenges following a year of being cooped up inside, stopping usual activities and seeing few, if any, people.
If they don't address issues that have arisen during the pandemic — muscle weakness, poor nutrition, disrupted sleep, anxiety, social isolation and more — these older adults face the prospect of poorer health and increased frailty, experts warn.
What should people do to address challenges of this kind? Several experts shared advice:
Reconnect with your physician. Large numbers of older adults have delayed medical care for fear of COVID. Now that most seniors have been vaccinated, they should schedule visits with primary care physicians and preventive care screenings, such as mammograms, dental cleanings, eye exams and hearing checks, said Dr. Robert MacArthur, chief medical officer of the Commonwealth Care Alliance in Massachusetts.
Have your functioning assessed. Primary care visits should include a basic assessment of how older patients are functioning physically, according to Dr. Jonathan Bean, an expert in geriatric rehabilitation and director of the New England Geriatric Research, Education and Clinical Center at the Veterans Affairs Boston Healthcare System.
At a minimum, doctors should ask, "Are you having difficulty walking a quarter-mile or climbing a flight of stairs? Have you changed the way you perform ordinary tasks such as getting dressed?" Bean suggested.
A little-discussed, long-term toll of the pandemic is that large numbers of older adults have become physically and cognitively debilitated and less able to care for themselves after sheltering in place.
Get a referral to therapy. If you're having trouble moving around or doing things you used to do, get a referral to a physical or occupational therapist.
A physical therapist can work with you on strength, balance, range of motion and stamina. An occupational therapist can help you change the way you perform various tasks, evaluate your home for safety and identify needed improvements, such as installing a second railing on a staircase.
Don't wait for your doctor to take the initiative; too often this doesn't happen. "Speak up and say: Please, can you write me a referral? I think a skilled evaluation would be helpful," said James Nussbaum, clinical and research director at ProHealth & Fitness in New York City, a therapy provider.
Start slow and build steadily. Be realistic about your current abilities. "From my experience, older adults are eager to get out of the house and do what they did a year ago. And guess what. After being inactive for more than a year, they can't," said Dr. John Batsis, associate professor of geriatrics at the University of North Carolina-Chapel Hill.
"I'm a fan of start low, go slow," Batsis continued. "Be honest with yourself as to what you feel capable of doing and what you are afraid of doing. Identify your limitations. It's probably going to take some time and adjustments along the way."
Nina DePaola, vice president of post-acute services for Northwell Health, the largest healthcare system in New York, cautioned that getting back in shape may take time. "Pace yourself. Listen to your body. Don't do anything that causes discomfort or pain. Introduce yourself to new environments in a thoughtful and a measured fashion," she said.
Be physically active. Engaging regularly in physical activity of some kind — a walk in the park, chair exercises at home, video fitness programs — is the experts' top recommendation. The Go4Life program, sponsored by the National Institute on Aging, is a valuable resource for those getting started and you can find videos of some sample exercise routines on YouTube. The YMCA has put exercise classes online, as have many senior centers. For veterans, the VA has Gerofit, a virtual group exercise program that's worth checking out.
Bienvenido Manzano, 70, of Boston, who retired from the Coast Guard after 24 years and has significant lower back pain, attends Gerofit classes three times a week. "This program, it strengthens your muscles and involves every part of your body, and it's a big help," he told me.
Have realistic expectations. If you're afraid of getting started, try a bit of activity and see how you feel. Then try a little bit more and see if that's OK. "This kind of repeated exposure is a good way to deal with residual fear and hesitation," said Rachel Botkin, a physical therapist in Columbus, Ohio.
"Understand that this has been a time of psychological trauma for many people and it's impacted the way we behave," said Dr. Thomas Cudjoe, a geriatrician and assistant professor at Johns Hopkins Medicine in Baltimore. "We're not going to go back to pre-pandemic activity and engagement like turning on a light switch. We need to respect what people's limits are."
Eat well. Make sure you're eating a well-balanced diet that includes a good amount of protein. Adequate protein consumption is even more important for older adults during times of stress or when they're sedentary and not getting much activity, noted a recent study on health aging during COVID-19. For more information, see my column about how much protein older adults should consume.
Reestablish routines. "Having a structure to the day that involves social interactions, whether virtual or in person, and various activities, including some time outside when the weather is good, is important to older adults," said Dr. Lauren Beth Gerlach, a geriatric psychiatrist and assistant professor of psychiatry at the University of Michigan.
Routines are especially true for older adults with cognitive impairment, who tend to do best when their days have a dependable structure and they know what to expect, she noted.
End-of-day routines are also useful in addressing sleep problems, which have become more common during the pandemic. According to a University of Michigan poll, administered in January, 19% of adults ages 50 to 80 report sleeping worse than they did before the pandemic.
Reconnect socially. Mental health problems have also worsened for a segment of older adults, according to the University of Michigan poll: 19% reported experiencing more sadness or depression while 28% reported being more anxious or worried.
Social isolation and loneliness may be contributing and it's a good idea to start "shoring up social support" and seeing other people in person if seniors are vaccinated, Gerlach said.
Families have an important role to play in re-engaging loved ones with the world around them, Batsis suggested. "You've had 15 months or so of only a few face-to-face interactions: Make it up now by visiting more often. Make the effort."
Laura Collins, 58, has been spending a lot of time this past month with her mother, Jane Collins, 92, since restrictions on visitation at Jane's nursing home in Black Mountain, North Carolina, eased and both women were vaccinated. Over the past year, Jane's dementia progressed rapidly and she became depressed, sobbing often to Laura on the phone.
"She loves getting outside and that has been wonderful," Laura said. "Her mood immediately shifts when she gets out of the building: She's just happy, almost childlike, like a kid going out for ice cream. And, in fact, that's what we do — go out for ice cream."
We're eager to hear from readers about questions you'd like answered, problems you've been having with your care and advice you need in dealing with the healthcare system. Visit khn.org/columnists to submit your requests or tips.
Major hospital systems are betting big money that the future of hospital care looks a lot like the inside of patients' homes.
Hospital-level care at home — some of it provided over the internet — is poised to grow after more than a decade as a niche offering, boosted both by hospitals eager to ease overcrowding during the pandemic and growing interest by insurers who want to slow healthcare spending. But a host of challenges remain, from deciding how much to pay for such services to which kinds of patients can safely benefit.
Under the model, patients with certain medical conditions, such as pneumonia or heart failure — even moderate COVID — are offered high-acuity care in their homes, with 24/7 remote monitoring and daily visits by medical providers.
In the latest sign that the idea is catching on, two big players — Kaiser Permanente and the Mayo Clinic — announced plans this month to collectively invest $100 million into Medically Home, a Boston-based company that provides such services to scale up and expand their programs. The two organizations estimate that 30% of patients currently admitted to hospitals nationally have conditions eligible for in-home care. (KHN is not affiliated with Kaiser Permanente.)
Several other well-known hospital systems launched programs last summer. They join about two dozen already offering the service, including Johns Hopkins Medicine in Baltimore, Presbyterian Healthcare Services in New Mexico and Massachusetts General Hospital.
But hospitals have other financial considerations that are also part of the calculation. Systems that have built sparkling new in-patient facilities in the past decade, floating bonds and taking out loans to finance them, need patients filling costly inpatient beds to repay lenders and recoup investments.
And "hospitals that have surplus capacity, whether because they have newly built beds or shrinking populations or are losing business to competitors, are not going to be eager about this," said Dr. Jeff Levin-Scherz, co-leader of the North American Health Management practice at consultancy Willis Towers Watson.
Medicare gave the idea a boost in November when it agreed to pay for such care, to help keep non-COVID patients out of the hospital during the pandemic. Since then, more than 100 hospitals have been approved by Medicare to participate, although not all are in place yet.
Tasting opportunity, Amazon and a coalition of industry groups in March announced plans to lobby for changes in federal and state rules to allow broader access to a wide range of in-home medical services.
"We're seeing tremendous momentum," said Dr. Bruce Leff, a Johns Hopkins Medical School geriatrician who has studied and advocated for the hospital-at-home approach since he helped establish one of the nation's first programs in the mid-1990s.
Leff and other proponents say various studiesshow in-home care is just as safe and may produce better outcomes than being in the hospital, and it saves money by limiting the need to expand hospitals, reducing hospital readmissions and helping patients avoid nursing home stays. Some estimates put the projected savings at 30% over traditional hospital care. But ongoing programs are a long way from making a dent in the nation's $1.2 trillion hospital tab.
While the goal is to shift 10% or more of hospital patients to home settings, existing programs handle far fewer cases, sometimes serving only a handful of patients.
"In a lot of ways, this remains aspirational; this is the early innings," said Dean Ungar, who follows the insurance and hospital industries as a vice president and senior credit officer at Moody's Investors Service. Still, he predicted that "hospitals will increasingly be reserved for acute care [such as surgeries and ICUs]."
Challenges to scaling up include maintaining the current good safety profile in the face of rapid growth and finding enough medical staff — especially nurses, paramedics and technicians — who travel to patients' homes.
The attraction for insurers is clear: If they can pay for care in a lower-cost setting than the hospital, with good outcomes, they save money.
For hospitals, "the financials of it are, frankly, a little tough," said Levin-Scherz.
Those most attracted to hospital-at-home programs run at or near capacity and want to free up beds.
Even so, Gerard Anderson, a health policy professor at Johns Hopkins University Bloomberg School of Public Health, said hospitals likely see the potential, long term, for "huge profit margins" through "saving a lot of capital and personnel expense by having the work done at home."
But Anderson worries that broad expansion of hospital-at-home efforts could exacerbate healthcare inequities.
"It's realistic in middle- and upper-middle-class households," Anderson said. "My concern is in impoverished areas. They may not have the infrastructure to handle it."
Suburban and rural areas — and even some lower-income urban areas — can have spotty or nonexistent internet access. How will that affect the ability of those areas to participate, to communicate with physicians and other hospital staff members miles away? Proponents outline solutions, from providing patients with "hot spot" devices that provide internet service, along with backup power and instant communication via walkie-talkie-type handsets and computer tablets.
Social factors play a big part, too. Those who live alone may find it harder to qualify if they need a lot of help, while those in crowded households may not have enough room or privacy.
Another possible wrinkle: Not all patients have the necessary human support, such as someone to help an ill patient with the bathroom, meals or even answering the door.
That's why both patients and their caregivers should get a detailed explanation of the day-to-day responsibilities before agreeing to participate, said Alexandra Drane, CEO of Archangels, a for-profit group that works with employers and provides resources for unpaid caregivers.
"I love the concept for a resourced household where someone can take this job on," said Drane. "But there's a lot of situations where that's not possible. What If I have a full-time job and two children, when am I supposed to do this?"
The programs all say they aim to reduce the burden on families. Some provide aides to help with bathing or other home care issues and provide food. None expects family members to perform medical procedures. The programs supply monitoring and communication equipment and a hospital bed, if needed.
"We see the patient in their home setting," said Morre Dean, president of Adventist Health's hospital at home program, which serves a broad area of California and part of Oregon. "What is in their refrigerator? What is their living situation? Can we impact that? We aren't reliant on the family to deliver care."
Patients are typically visited in their homes daily by various health workers. Physicians make home visits in some programs, but most employ doctors to oversee care from remote "command centers," talking with patients via various electronic gadgets.
All of that was delivered to James Clifford's home in Bakersfield, California, after he opted to participate in the Adventist program so he could leave the hospital and finish treatment for an infection at home. It required coordination — his wife had to be at their house for the set-up team even as she was scheduled to pick him up — but "once it was set up, it worked well."
At home, he needed treatment with antibiotics every eight hours for several days and "one nurse came at 2 a.m.," said Clifford, 70. "It woke up my wife, but that's OK. We had peace of mind by my being at home."
Adventist launched its program a year ago, but it hasn't achieved the scale needed to save money yet, said Dean. Ultimately, he envisions the hospital-at-home option as "our biggest hospital in Adventist Health," with 500 to 1,500 patients in the program at a time.
Medicare's payment decision gave momentum to such goals. But the natural experiment it created with its funding ends when the pandemic is declared over. Because of the emergency, Medicare paid the same as it would for in-hospital care, based on each patient's diagnosis. Will hospitals be as enthusiastic if that is not the case in the future? Commercial insurers are unlikely to pay unless they see lower rates, since there are already concerns about overuse.
"From a societal perspective, it's great if these programs replace expensive inpatient care," said Levin-Scherz at Towers. But, he said, it would be a negative if the programs sought to grow by admitting patients who otherwise would not have gone into the hospital at all and could have been treated with lower-cost outpatient services.