Obesity and weight-related illnesses have been deadly liabilities in the COVID era.

This article was published on Thursday, March 11, 2021 in Kaiser Health News.

By Sarah Varney

In January, as Mississippi health officials planned for their incoming shipments of COVID-19 vaccine, they assessed the state's most vulnerable: healthcare workers, of course, and elderly people in nursing homes. But among those who needed urgent protection from the virus ripping across the Magnolia State were 1 million Mississippians with obesity.

Obesity and weight-related illnesses have been deadly liabilities in the COVID era. A report released this month by the World Obesity Federation found that increased body weight is the second-greatest predictor of COVID-related hospitalization and death across the globe, trailing only old age as a risk factor.

As a fixture of life in the American South — home to nine of the nation's 12 heaviest states — obesity is playing a role not only in COVID outcomes, but in the calculus of the vaccination rollout. Mississippi was one of the first states to add a body mass index of 30 or more (a rough gauge of obesity tied to height and weight) to the list of qualifying medical conditions for a shot. About 40% of the state's adults meet that definition, according to federal health survey data, and combined with the risk group already eligible for vaccination — residents 65 and older — that means fully half of Mississippi's adults are entitled to vie for a restricted allotment of shots.

At least 29 states have greenlighted obesity for inclusion in the first phases of the vaccine rollout, according to KFF — a vast widening of eligibility that has the potential to overwhelm government efforts and heighten competition for scarce doses.

"We have a lifesaving intervention, and we don't have enough of it," said Jen Kates, director of global health and HIV policy for KFF. "Hard choices are being made about who should go first, and there is no right answer."

The sheer prevalence of obesity in the nation — 2 in 3 Americans exceed what is considered a healthy weight — was a public health concern well before the pandemic. But COVID-19 dramatically fast-tracked the discussion from warnings about the long-term damage excess fat tissue can pose to heart, lung and metabolic functions to far more immediate threats.

In the United Kingdom, for example, overweight COVID patients were 67% more likely to require intensive care, and obese patients three times likelier, according to the World Obesity Federation report. A Centers for Disease Control and Prevention study released Monday found a similar trend among U.S. patients and noted that the risk of COVID-related hospitalization, ventilation and death increased with patients' obesity level.

The counties that hug the southern Mississippi River are home to some of the most concentrated pockets of extreme obesity in the United States. Coronavirus infections began surging in Southern states early last summer, and hospitalizations rose in step.

Deaths in rural stretches of Mississippi, Tennessee, Louisiana and Arkansas have been overshadowed by the sheer number of deaths in metropolitan areas like New York City, Los Angeles and Essex County, New Jersey. But as a share of the population, the coronavirus has been similarly unsparing in many Southern communities. In sparsely populated Claiborne County, Mississippi, on the floodplains of the Mississippi River, 30 residents — about 1 in 300 — had died as of early March. In East Feliciana Parish, Louisiana, north of Baton Rouge, with 106 deaths, about 1 in 180 had died by then.

"It's just math. If the population is more obese and obesity clearly contributes to worse outcomes, then neighborhoods, cities, states and countries that are more obese will have a greater toll from COVID," said Dr. James de Lemos, a professor of internal medicine at UT Southwestern Medical Center in Dallas who led a study of hospitalized COVID patients published in the medical journal Circulation.

And, because in the U.S. obesity rates tend to be relatively high among African Americans and Latinos who are poor, with diminished access to healthcare, "it's a triple whammy," de Lemos said. "All these things intersect."

Poverty and limited access to medical care are common features in the South, where residents like Michelle Antonyshyn, a former registered nurse and mother of seven in Salem, Arkansas, say they are afraid of the virus. Antonyshyn, 49, has obesity and debilitating pain in her knees and back, though she does not have high blood pressure or diabetes, two underlying conditions that federal health officials have determined are added risk factors for severe cases of COVID-19.

Still, she said, she "was very concerned just knowing that being obese puts you more at risk for bad outcomes such as being on a ventilator and death." As a precaution, Antonyshyn said, she and her large brood locked down early and stopped attending church services in person, watching online instead.

"It's not the same as having fellowship, but the risk for me was enough," said Antonyshyn.

Governors throughout the South seem to recognize that weight can contribute to COVID-19 complications and have pushed for vaccine eligibility rules that prioritize obesity. But on the ground, local health officials are girding for having to tell newly eligible people who qualify as obese that there aren't enough shots to go around.

In Port Gibson, Mississippi, Dr. Mheja Williams, medical director of the Claiborne County Family Health Center, has been receiving barely enough doses to inoculate the health workers and oldest seniors in her county of 9,600. One week in early February, she received 100 doses.

Obesity and extreme obesity are endemic in Claiborne County, and health officials say the "normalization" of obesity means people often don't register their weight as a risk factor, whether for COVID or other health issues. The risks are exacerbated by a general flouting of pandemic etiquette: Williams said that middle-aged and younger residents are not especially vigilant about physical distancing and that mask use is rare.

The rise of obesity in the U.S. is well documented over the past half-century, as the nation turned from a diet of fruits, vegetables and limited meats to one laden with ultra-processed foods and rich with salt, fat, sugar and flavorings, along with copious amounts of meat, fast food and soda. The U.S. has generally led the global obesity race, setting records as even toddlers and young children grew implausibly, dangerously overweight.

Well before COVID, obesity was a leading cause of preventable death in the U.S. The National Institutes of Health declared it a disease in 1998, one that fosters heart disease, stroke, Type 2 diabetes and breast, colon and other cancers.

Researchers say it is no coincidence that nations like the U.S., the U.K. and Italy, with relatively high obesity rates, have proved particularly vulnerable to the novel coronavirus.

They believe the virus may exploit underlying metabolic and physiological impairments that often exist in concert with obesity. Extra fat can lead to a cascade of metabolic disruptions, chronic systemic inflammation and hormonal dysregulation that may thwart the body's response to infection.

Other respiratory viruses, like influenza and SARS, which appeared in China in 2002, rely on cholesterol to spread enveloped RNA virus to neighboring cells, and researchers have proposed that a similar mechanism may play a role in the spread of the novel coronavirus.

There are also practical problems for coronavirus patients with obesity admitted to the hospital. They can be more difficult to intubate due to excess central weight pressing down on the diaphragm, making breathing with infected lungs even more difficult.

Physicians who specialize in treating patients with obesity say public health officials need to be more forthright and urgent in their messaging, telegraphing the risks of this COVID era.

"It should be explicit and direct," said Dr. Fatima Stanford, an obesity medicine specialist at Massachusetts General Hospital and a Harvard Medical School instructor.

Stanford denounces the fat-shaming and bullying that people with obesity often experience. But telling patients — and the public — that obesity increases the risk of hospitalization and death is crucial, she said.

"I don't think it's stigmatizing," she said. "If you tell them in that way, it's not to scare you, it's just giving information. Sometimes people are just unaware."

Sarah Varney: svarney@kff.org, @SarahVarney4

Of the state's 1,200 nursing facilities, about 50% lost power or had burst pipes or water issues, and 23 had to be evacuated.

This article was published on Wednesday, March 10, 2021 in Kaiser Health News.

By Sandy West

HOUSTON — When the big, red and extremely loud fire alarm went off in Maria Skladzien's apartment, the 74-year-old ventured into the hallway with fellow residents of her Houston-area senior living community. The brutal winter storm that swept through Texas had knocked out power, which, in turn, disrupted water to the four-story building. The blaring alarms raised fears of fire.

The building's elevators were unusable without power. Dependent on her wheelchair, Skladzien went back inside her second-floor apartment. She watched as residents gathered in the subfreezing temperatures outside, wondering if she would have to "throw herself out the window" to survive.

"It's a very uneasy feeling," she said, sitting in the living room of her small apartment a week later, packages of water brought by friends and volunteers tucked against walls and sitting on tables. No fire had occurred, but her fears continued because the elevators were still not functioning. "So many crazy things race through your mind in a situation like this."

Winter storm Uri brought power failure and burst water pipes to millions of homes and businesses throughout Texas. But the impact, as is often the case in emergencies, was most profound on the state's most vulnerable — including residents of senior living facilities.

Of the state's 1,200 nursing facilities, about 50% lost power or had burst pipes or water issues, and 23 had to be evacuated, said Patty Ducayet, long-term care ombudsman for Texas. Of 2,000 assisted living facilities, about 25% had storm-related issues and 47 were evacuated. Some facilities reported building temperatures in the 50s.

The federal government requires nursing homes to maintain safe ambient temperatures but does not stipulate how and does not require generators or other alternative energy sources to run heating and air conditioning systems. States can implement more stringent guidelines, but, to date, Texas has not. Several bills were introduced in the Texas legislature after Uri to do just that, said Ducayet.

Uri was the latest disaster to highlight an ongoing problem. Evacuations and nursing home deaths in Hurricane Katrina in 2005 led to calls for similar protections. In 2009, Hurricane Sandy forced the evacuation of more than 4,000 nursing home residents in New York when backup power systems failed and emergency plans buckled. And calls for stricter rules were renewed when Hurricane Irma tore into Florida in 2017 and left a dozen residents dead in a nursing home that lost air conditioning. Multiple blackouts and wildfires in California also have exposed lax adherence to federal requirements for backup power at skilled nursing facilities, as well as weak state enforcement of those rules, according to a 2019 report from the U.S. Department of Health and Human Services.

"Every time we come back around with a new disaster, you see that these facilities still aren't as prepared as, maybe, they can or should be," said Lori Smetanka, executive director of the National Consumer Voice for Quality Long-Term Care, an advocacy organization based in Washington, D.C. "And many of them still aren't following the requirements that are in place. So it's like: What's it going to take to actually get the plans in place and to get enforcement of those plans?"

In November 2016, the Centers for Medicare & Medicaid Services implemented a slate of new regulations, including rules on disaster planning and emergency backup power in the nation's nursing homes.

A month later, Mark Parkinson, president and CEO of the long-term care industry's trade group, the American Healthcare Association and National Center for Assisted Living, sent a letter to then-President-elect Donald Trump requesting new rules because the regulations were burdensome and financially onerous, according to reporting by ProPublica.

In 2019, CMS published final rules with revised emergency preparedness guidance, agency spokesperson William Polglase said, after feedback from the public that those requirements were "overly burdensome and duplicative." But, he added, the rules require such facilities to have emergency and standby power systems and emergency plans. "We did not remove or modify any requirements that would endanger patient health or safety," he said.

Advocates for older adults, however, decried the changes as watering down the protections.

"The facilities push back because of the expense, but what I think recent years have shown us is that we're not talking about once-in-a-century type of disasters," said Eric Carlson, directing attorney with Justice in Aging, a national legal advocacy nonprofit.

But it's not just nursing homes at risk.

Cristina Crawford, an AHCA spokesperson, said prioritizing long-term care facilities at all levels is important in emergencies. "Nursing homes and assisted living facilities should be prioritized for power restoration and supplies for resource delivery in emergency situations," she said. "Long-term care facilities should also be included in community-based exercises to help ensure successful coordination in actual emergencies."

Although nursing homes face federal oversight, the licensing and regulatory authority for assisted and senior independent living facilities lies with the states, meaning a patchwork of definitions and guidelines for the facilities. Given that assisted and independent living communities have been the fastest-growing sector in senior living for many years, the disparate definitions and rules often leave residents and their families without a clear understanding of a facility's offerings and safety guardrails.

"There's no transparency from a consumer perspective about what are these different options, what am I getting in each of them," said David Grabowski, professor of healthcare policy at Harvard Medical School.

Years ago, Grabowski and others said, independent and assisted living facilities were filled with a generally healthier population who didn't need much medical assistance and who could afford to pay out-of-pocket for enhanced lifestyle amenities such as restaurants or outings.

But as the population ages, residents are often less healthy and may not have the financial resources to afford the higher level of care they need. And unlike nursing homes, assisted and independent living facilities do not necessarily operate under regulations that require building codes to address the needs of elderly or disabled residents, or requirements for backup power or emergency systems. It depends on where they are.

In Texas, assisted living facilities are required to have emergency plans but not generators. The legislation introduced in the wake of winter storm Uri seeks to change that. Independent living facilities like the one Skladzien lives in might not be covered, though; they already have even fewer state guidelines to follow.

"We still don't have good emergency management planning and preparation ingrained within the regulations to make sure our loved ones are safe within these facilities, because it just comes down to the money," said Brian Lee, executive director of Families for Better Care, a nonprofit in Austin, Texas, focused on the nation's long-term care facilities.

The debate is analogous to previous efforts to require sprinkler systems in nursing homes, he said. "How many more people have to be injured, maybe even have to have suffered death, because of power failure negligence?"

Lee and others said there is a distinction to be made between staff members — some of whom stayed in their facilities throughout the winter storm to keep residents safe — and industry forces resisting regulatory efforts to beef up backup safety systems.

"We can't, and shouldn't, let the industry decide how this is going to work," said Ducayet. "There needs to be involvement and organization at government levels, so that there is clarity and information about how these different settings work."

With elevators still not working at Skladzien's independent living building a week after the storm, she was trying to figure out how she would get to her weekly post-cancer medical treatment.

Skladzien, who owned her own cleaning business for 25 years and drove a school bus for 15 years, moved into senior housing in 2019 when she could no longer handle the upkeep on her home. When she was looking for a place to live, though, it never occurred to her that apartments marketed toward older adults would not have a generator or plans to help residents in an emergency. And she never thought to ask.

"I had no experience," she said.

It may not have mattered: Medical bills had depleted her savings, leaving her only the choice of what was available in low-income housing. In her building, she was told, wheelchair-accessible apartments on the first floor were beyond her financial reach.

Sandy West: sandywestwriter@gmail.com, @_SandyWest

Many long haulers have found it impossible to fulfill their professional obligations and are making the tough decision to stop working and seek disability benefits.

This article was published on Wednesday, March 10, 2021 in Kaiser Health News.

By David Tuller

Rickie Andersen took a brief break from work in March after she fell ill. Her cough, fever and chills were typical COVID-19 symptoms, but coronavirus tests were so scarce she could not obtain one to confirm the diagnosis.

After Andersen returned to her job as an information systems project manager in the San Francisco Bay Area, she struggled with profound fatigue, cognitive difficulties and other disabling complaints. For six months, she tried to keep awake during meetings and finish basic tasks that took much longer than before.

Finally, she decided to retain legal help so she could take advantage of the disability insurance coverage offered as an employee benefit. "I realized this is not going to be a short-term thing," Andersen said.

Hundreds of thousands of people around the world are experiencing what is being called "long COVID" — a pattern of prolonged symptoms following an acute bout of the disease. Many have managed to continue working through accommodations like telecommuting, cutting down on hours and delegating responsibilities.

Others have found it impossible to fulfill their professional obligations and are making the tough decision to stop working and seek disability benefits. But as they pursue the application process, they are discovering a particular set of challenges.

Given the lack of testing in the first months, many "long haulers," like Andersen, have no laboratory proof of infection. While antibody tests can provide such evidence, their accuracy varies. Moreover, many of the reported symptoms, including fatigue and cognitive impairment, are subjective and not clearly linked to specific organ damage.

Beyond that, compiling a thorough record for a disability application and navigating the bureaucratic hurdles require sustained brain power, something many long-haul patients can no longer muster. Barbara Comerford, a New Jersey disability lawyer, said she received dozens of inquiries starting last fall from long haulers seeking advice on filing for disability and often citing what is being called "brain fog" as their main complaint.

"Most are people calling to say, 'I thought I could do it. I can't. My mind doesn't function for more than really brief periods of time,'" Comerford said. She gave a presentation to the New Jersey State Bar Association in mid-February on how to develop evidence for such cases.

In the U.S., close to 30 million people have tested positive for the coronavirus, although many cases of infection are asymptomatic. What proportion might be affected by long-term illness isn't known. Scientific understanding of the phenomenon is in its infancy.

In January, The Lancet reported that around three-quarters of more than 1,700 COVID patients who had been hospitalized in Wuhan, China, reported at least one ongoing symptom six months later. More recently, investigators from the University of Washington reported in JAMA Network Open that around 30% of 177 patients who had tested positive for the coronavirus still reported symptoms when they were surveyed one to 10 months later.

The Social Security Administration provides long-term disability to American workers who qualify under its strict criteria, but applicants often get turned down on the first try. A few states, including California and New York, provide short-term disability benefits, in some cases for up to a year.

Tens of millions of Americans also have private disability coverage, most often as part of their employment benefit packages.

The maximum currently available to an individual through the Social Security Disability Insurance program is just over $3,000 a month. A typical private long-term disability plan might cover 60% of a beneficiary's base salary, with a much higher maximum amount.

Sandy Lewis, a pharmaceutical industry researcher, fell ill last March with what she assumed was COVID. She recovered but relapsed in April and again in May.

Through her employer-based insurance coverage, she received short-term disability for November and December, but the insurer, Prudential Financial, rejected her request for an extension. Soon after, she was diagnosed with myalgic encephalomyelitis/chronic fatigue syndrome, or ME/CFS, a debilitating illness that can be triggered by viral infections.

Lewis, who lives outside Philadelphia, is planning to appeal Prudential's rejection of the short-term extension and apply for long-term disability. But the matter is unlikely to be resolved before fall. The situation has left her feeling "devastated," she said, and in serious financial distress.

"This has been such an arduous journey," she said. "I have no income and I'm sick, and I'm continuing to need medical care. I am now in a position, at 49 years old, that I may have to sell my home during a pandemic and move in with family to stay afloat."

In Lewis' case, a Prudential reviewer noted that her symptoms were "subjective" and that there were "no physical exam findings to correlate with any ongoing functional limitations," according to Cassie Springer Ayeni, an Oakland disability lawyer who is representing her as well as Andersen.

Prudential would not comment on a specific case. Evan Scarponi, chief claims officer, said in a statement that "our collective understanding of COVID-19 and any associated long-term effects are still evolving" but that Prudential is "well-versed in evaluating both subjective and objective aspects of disability claims."

Lawyers and advocates in the field expect the numbers of COVID-related long-term disability applicants to rise this year. But it's still too soon to detect any such increase, said a spokesperson for the American Council of Life Insurers, a trade association. Workers typically must be unable to work for half a year before becoming eligible for long-term disability benefits, and applying can itself be a lengthy process.

Brian Vastag, a former Washington Post science and health reporter with ME/CFS, stopped working in 2014 and then sued Prudential after it rejected his long-term disability claim. Insurance companies, he said, can easily find reasons to dismiss applications from claimants with chronic illnesses characterized by symptoms like fatigue and cognitive impairment.

"The insurance companies will often say, 'There's no objective evidence, so we have nothing to support your claim,'" said Vastag, who won his case against Prudential in 2018. "I'm worried about the long-COVID patients who can't work anymore."

Claimants can appeal a rejection. If the insurer rejects the appeal, claimants have the right to sue, as Vastag did. However, most such cases fall under the Employee Retirement Income Security Act of 1974. Because this federal law requires a losing insurer to pay the unpaid claims but does not provide for punitive or compensatory damages, critics argue it incentivizes the denial of coverage.

In the event of litigation, the court's role is to assess the already existing evidentiary record. That means it is essential to present a robust case in the initial application or during the administrative appeal before any litigation begins, said Ayeni, the disability lawyer for Andersen and Lewis.

"It's the only shot to build a record for the courts, to develop a full body of evidence," she said.

However, a successful disability case ultimately depends on documenting inability to work, not on obtaining a specific diagnosis. To augment the medical evidence, Ayeni often sends clients for neuropsychological testing, investigations of lung function and other specialist assessments. She also gathers affidavits from family members, professional colleagues and friends to confirm patients' accounts.

In Rickie Andersen's case, the strategy worked. Recognizing how complicated the application process was likely to be, she sought legal help early on. The insurer contracted by her employer approved her for short-term benefits late last year and granted her application for long-term benefits in February.

"I knew all of it was completely exhausting, so it wasn't something I thought I could do on my own," Andersen said.

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

Nearly 11 million undocumented immigrants living in the U.S. without legal permission are particularly vulnerable to the economic fallout wrought by the pandemic. 

This article was published on Tuesday, March 9, 2021 in Kaiser Health News.

By LJ Dawson March 9, 2021

Ana's 9-year-old son was the first in the family to come down with symptoms that looked like COVID-19 last March. Soon after, the 37-year-old unauthorized immigrant and three of her other children, including a daughter with asthma, struggled to breathe.

For the next three weeks, the family fought the illness in isolation — Ana clutching the top of door frames to catch her breath — while friends and neighbors left food on the porch of their home in Colorado Springs, Colorado. Ana and her children never took tests to confirm they caught the coronavirus, but the pressure in her lungs, the fever, the headache and the loss of smell and taste convinced her it couldn't be anything else.

"It was horrible," said Ana, a Colorado resident for more than two decades who requested her last name not be used because of her immigration status. "We had to lay on the floor to breathe."

Nearly a year later, the effects of the virus go far beyond nagging shortness of breath for Ana. She lost her job cleaning houses when she got sick last March, so she couldn't pay rent. A local nonprofit's cash assistance funded by some federal COVID relief helped her catch up in the fall, but she still had no work and fell behind on rent again. Her landlord finally threw the family out of their home at the beginning of January with 30 hours' notice, she said.

Ana is one the nearly 11 million undocumented immigrants living in the U.S. without legal permission, who are particularly vulnerable to the economic fallout wrought by the pandemic and have no direct access to the billions of dollars in federal pandemic relief over the past year. An estimated 4 in 5 of them work essential jobs that put them at high risk to catch the COVID virus. They are also more likely to suffer the economic consequences, even with protections in place — such as the Centers for Disease Control and Prevention's eviction moratorium, extended through March — because they fear that reaching out for help or reporting landlords could lead to deportation or detention.

President Joe Biden's inauguration brought some encouraging news, as he's said he wants to create a path for citizenship for many of the nation's undocumented immigrants. He also said they should be able to be vaccinated against COVID without worrying that they will be arrested and deported.

Even though the COVID vaccines are available to everyone no matter their citizenship, a distrust of government and law enforcement in the immigrant community and a lack of culturally competent vaccination information and even misinformation have made some undocumented immigrants reluctant to come forward early in the vaccination rollout.

Even if Biden makes good on his pledge of equitable access to a vaccine, unauthorized U.S. residents continue to have no direct access to billions of dollars in federal pandemic relief. The issue was brought up again on March 6 when Republican Sen. Ted Cruz claimed Biden's new $1.9 trillion aid package would send stimulus checks to every illegal alien in America. Democratic Sen. Dick Durbin clarified that undocumented immigrants don't qualify for checks in the measure that passed the Senate. The House was set to take up the Senate's changes on Tuesday.

Advocacy groups have argued for "inclusive" aid packages that provide direct aid to as many immigrants as possible no matter citizenship status, and while a few states set up aid for the undocumented, it's not nearly enough, according to Marielena Hincapié, executive director of the National Immigration Law Center.

"Immigration status shouldn't be the gatekeeper to any of these programs. It really ultimately is about need and ensuring that families have the economic stability, to not only survive, but to get through this pandemic that all of us are impacted by," Hincapié says. "Eighty percent of undocumented immigrants are working as essential workers. We are relying on them, and yet are denying their families this basic support that everyone else is getting."

Couples with mixed immigration status — in which only one partner is a U.S. citizen — were also blocked from aid until December. They can now apply for stimulus payments retroactively but will still receive less than couples who are U.S. citizens. Though the change made millions more families eligible for some aid, couples in which both partners are undocumented immigrants also have not received stimulus payments for their children even if their children were born in the U.S. and are citizens. A group of families sued the Trump administration in May 2020 after it excluded children in the first COVID-19 aid package known as the CARES Act. The Department of Justice under the Biden administration has continued to defend the policy and has asked a federal judge to dismiss the lawsuit. A decision is pending.

Meanwhile, in February, eight Senate Democrats, including John Hickenlooper of Colorado, voted in favor of a budget amendment that continues to block both documented and undocumented immigrants who pay taxes using ITINs (individual taxpayer identification numbers) from receiving direct relief. (A Social Security number is a requirement for federal pandemic aid, which means immigrants who pay taxes with ITINs can't qualify.) After getting blowback for his vote from Colorado's immigration rights community and a letter from the Colorado ACLU accused the senator of breaking campaign promises to stand with immigrants, Hickenlooper met with community members and released a statement to a local news station: "I recognize how this vote has distorted that important fact and fed dangerous and damaging narratives about the undocumented community. … I remain committed to working together to finally achieve a comprehensive fix for our broken immigration system, including a pathway to citizenship."

Hincapié calls the vote "morally unconscionable." "The pandemic has shown how interdependent we are and that this is a time in our nation to make sure we're taking care of everyone. It's the only way we're going to get out of this," she said. "There is no recovery without including immigrants."

Nearly half of the nearly 11 million immigrants living illegally in the United States (including some 190,000 in Colorado) pay taxes, according to the American Immigration Council, a Washington, D.C.-based advocacy organization. In Colorado, they paid an estimated $272.8 million in federal taxes and $156.5 million in state and local taxes in 2018. According to the IRS, ITIN filers nationwide pay over $9 billion in annual payroll taxes.

The Migration Policy Institute, a nonprofit think tank in Washington, D.C., reported in January that 9.3 million unauthorized immigrants whose income meets the threshold for COVID aid are blocked from accessing it, and also can't apply for federal programs that provide cash and food assistance. It reported that undocumented people represent more than half of the workers in the hardest-hit industries, such as meatpacking, the restaurant business, healthcare and child care.

The Colorado nonprofit that provided Ana with rental assistance, Servicios de la Raza, received applications from 300 families for rental help. The group could assist only 51 of them, said Julissa Soto, the group's director of statewide programs. Soto, who used to be undocumented herself, said she knows of at least 30 undocumented families that are homeless because of the pandemic in El Paso County, which includes Colorado Springs. She said she is frustrated by a lack of action by Colorado's political leaders to address the problem.

"My community is starving and getting evicted, and this is because we are undocumented and we don't exist," she said. "No one wants to talk about the undocumented community."

It's unclear how many people living illegally across the nation have been evicted during the pandemic. One reason for the uncertainty is because they often leave the moment a landlord threatens to kick them out to avoid going to eviction court and risking deportation, immigration advocates say. As a result, landlords can often evict undocumented people without ever officially filing in civil court and without following the state and federal rules, so there is no paper trail to track.

"Rather than go to court and assert their rights, they just move out," said Zach Neumann, founder of the Colorado COVID-19 Eviction Defense Project. "They often do so in a way that's really disruptive to their families and their lives."

Ana's landlord evicted her at the end of her lease exploiting a loophole in the federal eviction moratorium that allows evictions when leases expire. She said her landlord threatened to call the police, so she left as quickly as possible. The short time frame her landlord set does not follow Colorado law, which allows tenants 10 days to appeal an eviction in court or leave the property after official notice is given.

A phone number listed for the landlord, AB Property Management, was disconnected, and multiple attempts to contact the owners of Ana's past rental property were unsuccessful.

Though President Joe Biden's proposed emergency pandemic aid package mentions ensuring vaccine access to Americans "regardless of their immigration status," there is no similar statement included for the $30 billion proposed in rental and critical energy and water assistance, or extended unemployment benefits or individual stimulus checks..

California and New York City developed payment programs for undocumented residents. But despite having an undocumented population of almost 200,000 — accounting for about 3% of the state's population in 2016 — Colorado has no financial aid program to address that community.

Ana and her children are now sleeping on the floor in a friend's unfurnished spare room. She recently found a cleaning job that pays $300 a week. It's not much, but she's thankful to have it after nine months of looking for work. She's still terrified of losing her kids if social-service workers find out the family is homeless.

"This is not living. This is just surviving. Let's be clear. This is just surviving, and I want to live. I want a house for my kids," she said.

LJ Dawson: @LJDawson0