In America, COVID Vaccine Eligibility Is a 'Crazy Quilt' of State Rules

KFF Health News, March 22, 2021

The federal government bought hundreds of millions of doses of COVID vaccines but it left distribution largely up to the states.

This article was published on Monday, March 22, 2021 in Kaiser Health News.

By Phil Galewitz

In North Carolina, the nation's leading tobacco producer, any adult who has smoked more than 100 cigarettes in their lifetime can now be vaccinated against COVID.

In Florida, people under 50 with underlying health conditions can get vaccinated only if they have written permission from their doctor.

In Mississippi, more than 30,000 COVID vaccine appointments were open Friday — days after the state became the first in the contiguous United States to make the shots available to all adults.

In California — along with about 30 other states — people are eligible only if they are 65 or older or have certain health conditions or work in high-risk jobs.

How does any of this make sense?

"There is no logical rationale for the system we have," said Graham Allison, a professor of government at Harvard University. "We have a crazy quilt system."

Jody Gan, a professional lecturer in the health studies department at American University in Washington, D.C., said the lack of a national eligibility system reflects how each state also makes its own rules on public health. "This hasn't been a great system for keeping, you know, the virus contained," she said.

The federal government bought hundreds of millions of doses of COVID vaccines from Pfizer, Moderna and Johnson & Johnson — as well as other vaccines still being tested — but it left distribution largely up to the states. Some states let local communities decide when to move to wider phases of eligibility.

When the first vaccines were cleared for emergency use in December, nearly all states followed guidance from the federal government's Centers for Disease Control and Prevention and restricted use to front-line health workers and nursing home staffs and residents.

But since then states have gone their own way. Some states have prioritized people age 75 and older, while others have also allowed people who held certain jobs that put them at risk of being infected or had health conditions that put them at risk to be included with seniors for eligibility. Even then, categories of jobs and medical conditions have varied across the country.

As the supply of vaccines ramped up over the past month, states expanded eligibility criteria. President Joe Biden promised that by May 1 all adults will be eligible for vaccines and at least a dozen states say they will beat that date or, as in the case of Mississippi and Alaska, already have.

But the different rules among states — and sometimes varying rules even within states — created a mishmash. This has unleashed "vaccine jealousy" as people see friends and family in other states qualify ahead of them even if they are the same age or have the same occupation. And it has raised concerns that decisions on who is eligible are being made based on politics rather than public health.

The hodgepodge mirrors states' response overall to the pandemic, including wide disparities on mask mandates and restrictions for indoor gatherings.

"It's caused a lot of confusion, and the last thing we want is confusion," said Harald Schmidt, an assistant professor of medical ethics and health policy at the University of Pennsylvania.

As a result, some Americans frantically search online every day for an open vaccine appointment, while vaccines in other states go wanting.

The assorted policies have also prompted thousands of people to drive across state lines — sometimes multiple state lines — for an open vaccine appointment. Some states have set up residency requirements, although enforcement has been uneven and those seeking vaccines are often on the honor system.

Todd Jones, an assistant professor of economics at Mississippi State University near Starkville, said the confusion signals a need for a change in how the government handles the vaccine. "The Biden administration should definitely be thinking about how it might want to change state allocations based on demand," Jones said. "If it does become clear that some states are actually not using lots of their doses, then I think it would make sense to take some appointments from these states to give to other states that have higher demand."

Jagdish Khubchandani, a professor of public health at New Mexico State University, said no one should be surprised to see 50 different eligibility systems because states opposed a uniform federal eligibility system.

"Many governors don't want to be seen as someone who listens to the federal government or the CDC for guidance," he said. Florida Gov. Ron DeSantis, a Republican, has boasted of ignoring the CDC advice when he opted to make anyone 65 and older eligible beginning in December.

"There is a lot of political posturing in deciding eligibility," Khubchandani said.

To be sure, governors also wanted the flexibility to respond to particular needs in their states, such as rushing vaccines to agricultural workers or those in large food-manufacturing plants.

Jones said the decision to open vaccines to all adults in the state may sound good, but Mississippi has one of the nation's lowest vaccination rates. Part of that is attributed to hesitancy among some minority communities and conservatives. "It's good news everybody can get it, but there doesn't seem to be a whole lot of demand for it."

Jones, 34, was able to go online for a shot on Tuesday and was vaccinated at a large church a short drive from his home on Thursday morning. "I was very happy," he said.

Phil Galewitz: pgalewitz@kff.org, @philgalewitz

The Hype Has Faded, but Don't Count Out Convalescent Plasma in COVID Battle

KFF Health News, March 22, 2021

The treatment that infuses blood plasma from recovered COVID patients into people newly infected to boost their immune response has not lived up to the hype.

This article was published on Monday, March 22, 2021 in Kaiser Health News.

By JoNel Aleccia

Six months after it was controversially hailed by Trump administration officials as a "breakthrough" therapy to fight the worst effects of COVID-19, convalescent plasma appears to be on the ropes.

The treatment that infuses blood plasma from recovered COVID patients into people newly infected in hopes of boosting their immune response has not lived up to early hype. Some high-profile clinical trials have shown disappointing results. Demand from hospitals for the antibody-rich plasma has plunged. After a year of large-scale national efforts to recruit recovered COVID patients as donors and the collection of more than 500,000 units of COVID convalescent plasma, known as CCP, some longtime advocates of the therapy say they're now pessimistic about its future.

"I fear the CCP train has left the station," said Dr. Michael Busch, director of the Vitalant Research Institute, one of the largest blood-center based transfusion medicine research programs in the U.S. "We created all this enthusiasm, and then these studies came out and they say this stuff didn't work in the first place."

But that sentiment is by no means universal. Other respected proponents say we are watching the science progress in real time, and it's simply too soon to count out convalescent plasma. They note that larger studies employing more calibrated doses of convalescent plasma and more targeted groups of patients, during a set window in their illness, have met the standards for moving forward and may show promise.

"It's just been a really interesting story to see it unfold," said Dr. Julie Katz Karp, director of transfusion medicine at Thomas Jefferson University Hospitals in Philadelphia. "People are doing a good job of reading the literature, but one week the answer is 'yes,' the next week, 'maybe not.'"

Convalescent plasma was thrust into the national conversation last August, when the Food and Drug Administration, under political pressure, made the decision to authorize the treatment for emergency use despite objections from federal government scientists cautioning that the therapy was unproven. In the months since, tens of thousands of Americans have been infused with plasma.

Enthusiasm faded in recent weeks following two serious setbacks: A large federal clinical trial, dubbed C3PO, testing the use of convalescent plasma in high-risk patients who came to an emergency room with mild to moderate COVID symptoms was halted late last month after researchers concluded that, while the infusions caused no harm, they were unlikely to benefit patients. That same week, a pooled analysis of 10 convalescent plasma studies, published in JAMA, found no clear benefit.

In January, the FDA scaled back the emergency authorization of convalescent plasma, limiting its use to hospitalized COVID patients early in the course of the disease and those with medical conditions that impair immune function. The agency also said that only plasma with high concentrations of virus-fighting antibodies could be used after May 31.

At the same time, the COVID surge that engulfed the U.S. through much of the winter eased, sending demand for convalescent plasma plummeting. Hospital infusions fell from a high of about 30,000 units a week at the start of the year to about 7,000 per week in early March.

Further complicating matters, federal contracts worth $646 million that paid U.S. blood centers to collect COVID convalescent plasma are about to expire, prompting centers nationwide to reconsider whether the complicated process of collecting the plasma is still worth the work. Given the added complexity, blood centers have been reimbursed $600 to $800 a unit for the COVID product, compared with the $100 price for a regular unit of fresh, frozen plasma.

"We're not getting orders," said Dr. Louis Katz, chief medical officer at the Mississippi Valley Regional Blood Center in Davenport, Iowa. "I don't want to collect a product that is not going to get used and will cost me more money."

Officials with the American Red Cross have paused direct collection of convalescent plasma, citing changes required by the FDA's revised emergency use authorization and an "evolving" market. People previously infected with COVID may still donate whole blood, and those units that test positive for high levels of antibodies could be used as CCP.

Even as they acknowledge the setbacks, plasma proponents say declaring its death just a few months into the research would be a foolish overreach. The idea of using plasma from recovered patients to treat the newly ill is a century-old concept that has been employed on an experimental basis during a host of plagues, including the devastating 1918 flu, the 1930s measles outbreak and, more recently, Ebola.

Rather than abandon efforts, scientists need to refine the way convalescent plasma is used and temper their expectations, said Dr. Michael Joyner, principal investigator of the Mayo Clinic-led program that supplied convalescent plasma for more than 100,000 U.S. patients last year.

"This is an unstandardized dose of an unstandardized product being given to all comer patients for a disease with variable progression," Joyner said in an email. "So it is unrealistic to expect cookie-cutter results like you get for statin/heart attack trials."

Joyner and others pointed to research that continues to show promise. In mid-February, scientists in Argentina reported that giving convalescent plasma with very high concentrations of antibodies within three days of onset of mild COVID symptoms helped slow the progression of disease in older patients. In mid-March, researchers in the U.S. and Brazil reported in a study that has not yet been peer-reviewed that plasma therapy didn't improve symptoms during hospitalization for patients with severe cases of COVID. But it was associated with a 50% reduction in death after 28 days that "may warrant further evaluation," the authors wrote.

Oversight committees this month gave the nod to two federally funded clinical trials of convalescent plasma to continue enrolling hundreds of patients. One, led by researchers at Johns Hopkins University, is testing convalescent plasma in people who were infected and developed symptoms of COVID but were not hospitalized. The other, led by scientists at Vanderbilt University, is testing high-potency plasma in hospitalized patients.

There's no question "antibodies work against the virus," said Dr. David Sullivan, a professor of molecular microbiology and immunology at Johns Hopkins University and a principal investigator for the institution's plasma trials.

"It's all dose and time," Sullivan said, adding that giving convalescent plasma with high concentrations of antibodies within the first few days of infection is crucial.

The most promising use of convalescent plasma might come from "super donors," people who were infected with COVID and then vaccinated, said Dr. Michael Knudson, co-medical director of the DeGowin Blood Center at the University of Iowa Carver College of Medicine.

Knudson said his early research shows plasma from recovered then vaccinated people can provide five to 20 times more neutralizing antibody than the plasma from those who have not been vaccinated. "This would be almost a completely different product compared to what is used to date," he wrote in a presentation to colleagues.

Joyner and others believe "boosted" plasma could be used as a potent antiviral treatment early in infection, similar to how monoclonal antibodies — laboratory-made proteins that act like human antibodies in the immune system — are used. It could be a cheaper option for low-resource countries unable to afford the monoclonal treatments at more than $1,200 per dose.

Even the National Institutes of Health scientists conducting the halted C3PO trial, Dr. Simone Glynn and Dr. Nahed El Kasser, agreed that more data about the usefulness of convalescent plasma is needed. "The answer is no, it is not the final word," they said in an emailed statement.

But overcoming skepticism about the use of any type of convalescent plasma, let alone "super" plasma, won't be easy, given the roller coaster of recent results. And broad use of convalescent plasma will depend on continued funding. If the federal contracts with blood collectors are not renewed, COVID convalescent plasma likely will be paid for by hospitals or private insurers, depending on where patients receive the treatment.

In the meantime, the federal government, along with academic centers and private donors, has continued to fund the Hopkins and Vanderbilt trials. And the federal Biomedical Advanced Research and Development Authority has allocated at least $27 million to for-profit companies that collect COVID convalescent plasma from paid donors to create hyperimmune globulin, a purified and concentrated form of plasma that may halt disease. Results from late-stage clinical trials of that therapy are expected later this spring.

"I think that it would be a mistake to stop now," said Dr. Claudia Cohn, chief medical officer of the AABB, an international nonprofit focused on transfusion medicine and cellular therapies. "We have some evidence that it works and evidence that we can produce high-titer plasma. Let's see what we can do to keep people out of the hospital."

JoNel Aleccia: jaleccia@kff.org, @JoNel_Aleccia

Blue Shield Spent Years Cultivating a Relationship with Newsom. It Got the State Vaccine Contract.

KFF Health News, March 20, 2021

Facing mounting criticism early this year over the chaotic covid-19 vaccination rollout and a growing recall effort to remove him from office, Newsom gave the insurer a $15 million, no-bid contract to take over California's life-or-death effort to quickly vaccinate its 40 million residents.

This article was published on Friday, March 19, 2021 in Kaiser Health News.

By Samantha Young and Angela Hart

SACRAMENTO — Gavin Newsom was just making a name for himself as mayor of San Francisco in 2005 when Blue Shield of California wrote him its first major check.

The young, business-friendly Democrat had exploded onto the national scene the year before by issuing same-sex marriage licenses in San Francisco, and he was pushing his next big idea, called Project Homeless Connect. The initiative would host bazaar-style events in neighborhoods across the city, linking homeless people to services like food assistance and health care.

Newsom needed financial support from businesses, and Blue Shield answered with a $25,000 contribution.

Over the next 16 years, as Newsom’s political career flourished, the health insurance behemoth became one of his most generous and trusted supporters. It contributed nearly $23 million to Newsom’s campaigns andspecial causes, according to a California Healthline analysis of political and charitable contributions. Of that, nearly 90% has funded the homelessness initiatives that critics and allies say are dearest to Newsom’s heart.

Newsom, elected governor in 2018, in turn has rewarded Blue Shield and its executives with positions of power during the coronavirus pandemic, which has claimed nearly 56,000 Californians’ lives.

Facing mounting criticism early this year over the chaotic covid-19 vaccination rollout and a growing recall effort to remove him from office, Newsom gave the insurer a $15 million, no-bid contract to take over California’s life-or-death effort to quickly vaccinate its 40 million residents. Last spring, Newsom also enlisted Blue Shield’s CEO, Paul Markovich, to help steer the state’s covid testing strategy, another component of the state’s pandemic response that had faltered.

“Blue Shield responded early and responded often,” and it was among the first to invest in Newsom’s controversial homelessness ideas, said Philip Mangano, who led homelessness policy under former President George W. Bush and now informally advises Newsom. “Gavin understood they could be depended on over the years.”

But Newsom’s decision to rely on Blue Shield is backfiring. Agrowing number of public health officials and lawmakers say Blue Shield isn’t the right choice to coordinate the state’s vaccine distribution. And California’s counties, which are implementing the state’s coronavirus response, simply refuse to sign on with the insurer.

Newsom’s political future now hinges, in part, on how quickly Blue Shield — which is still charged with leading how vaccines are allocated — can get shots into Californians’ arms. The Republican-driven recall campaign slams him for his response to the pandemic and for violating his own public health recommendations when he dined last fall at the exclusive French Laundry restaurant in Napa Valley with people from outside his household.

Recall organizers say they have submitted 2.1 million signatures, and county election officials have until April 29 to certify that at least 1.5 million are valid in order for the state to set a recall election this fall.

Newsom did not respond to interview requests.

Blue Shield, which has already contributed $269,000 to a political account that Newsom could tap to fight a recall election, also declined multiple interview requests. But in an email, spokesperson Don Campbell said the Oakland-based company regularly supports candidates who share its mission of improving health care access and affordability.

“There is no financial or other benefit being bestowed upon, or accrued by, Blue Shield,” Campbell said. “Blue Shield was asked by the state to help with vaccines. Our reward is to help save lives.”

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Blue Shield isn’t alone in donating to the governor and his projects. Other interest groups have given more, such as Silicon Valley’s Facebook and the health care giant Kaiser Permanente, which covers about one-quarter of the state’s population. (KHN is not affiliated with Kaiser Permanente.)

Kaiser Permanente is advising Blue Shield on vaccine distribution and has a special agreement with the state to vaccinate Californians — including patients outside its system. Kaiser Permanente also invested in homelessness projects in San Francisco after Newsom got them off the ground, and twice last year responded to Newsom’s pleas for corporate dollars to combat the state’s toughest crises: It gave $25 million to a state homelessness fund set up by Newsom and $9.75 million to an immigrant covid relief fund.

But unlike Blue Shield, which gave $20 million to the homelessness fund, Kaiser Permanente has never donated to Newsom as a political candidate, according to local and state campaign records. Blue Shield has given to Newsom in every elected office he has held over the past 20 years.

“That’s how the game works. It’s just about standard influence peddling,” said David McCuan, a Sonoma State University political scientist. “What’s different here is the degree, or the depth of what [Blue Shield] has done under this governor.”

Over time, the company has funded Newsom and his policy initiatives in a way it hasn’t contributed to other politicians at the local or state level, records show, helping elevate him to higher office.

Blue Shield wrote its first check to Newsom for $500 in 2002, when the company was based in San Francisco and he was a city supervisor pushing an ambitious social welfare agenda to help both poor people and businesses that were growing impatient with the explosion of homeless people sleeping in front of their establishments and crowding hospital emergency rooms. It was Blue Shield’s only donation to a local political race in California that year, according to records with the secretary of state’s office.

After he had ascended to the mayor’s office, 14 of Blue Shield’s top executives, including Markovich, contributed a combined $5,150 — on a single day, Aug. 22, 2007 — according to campaign statements filed with the San Francisco Ethics Commission. The company’s contributions continued when he served as lieutenant governor from 2011 to 2019.

But the company’s investment in Newsom soared during the 2018 gubernatorial race. Blue Shield and its executives contributed $71,550 to Newsom’s campaign, and the company partnered with powerful labor unions to form a special committee that allowed them to spend unlimited amounts of money on Newsom’s behalf. Blue Shield chipped in nearly $1 million to that effort, and also gave $1 million to a committee formed by health industry groups to defeat one of Newsom’s primary opponents, then-state treasurer John Chiang.

After Newsom won the election, Blue Shield contributed $100,000 to his inauguration celebration and cut a $50,000 check in his name to a charity supporting firefighters.

With Newsom in office, Blue Shield focused on again giving to the governor’s deepest passion: homelessness. In January 2020, the same month Newsom promised to dedicate unprecedented resources to combating homelessness, Blue Shield announced its $20 million donation to his homelessness fund, which later transformed into “Project Homekey.” That initiative is intended to finance the conversion of more than 6,000 hotel rooms across the state into housing units.

“No one sector can solve the homelessness crisis alone,” Blue Shield quoted Newsom as saying in its Jan. 17, 2020, press release announcing its donation. “It’s our collective responsibility to meet this moment with bold action and intentional leadership — and that’s exactly what Blue Shield’s leadership is doing.”

Behind the scenes in our meeting with @BlueShieldCA CEO Paul Markovich. We cannot solve our homelessness crisis alone in California, and we are so thrilled for Blue Shield's $20mm investment in our statewide homelessness fund. #CaliforniaForAll @CAgovernor @GavinNewsom pic.twitter.com/Ug6AdneFBw

— Kathleen Kelly Janus (@kkellyjanus) January 28, 2020

The donation to Project Homekey came shortly before covid derailed Newsom’s sweeping health and homelessness agenda. But Newsom’s confidants say the relationship he forged with Blue Shield assured him that the company could quickly turn around the state’s troubled vaccination program.

“Because of their early investment, there was a level of trust — I would even say camaraderie — established going forward,” Mangano said. “Blue Shield took a risk way back when Gavin was becoming mayor. There are other organizations like Kaiser Permanente who have since staked out positions in support, but they weren’t there early and they weren’t the ones taking the greatest risk.”

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When Newsom announced that Blue Shield would take over California’s vaccine distribution, he emphasized the job would be in the hands of a nonprofit with an expansive provider network equipped to quickly get vaccines into arms. While it remains a nonprofit, the state stripped Blue Shield of its tax-exempt status in 2014, alleging it operated much like a for-profit insurance company.

The insurer, which covers about 4 million Californians, took in $21 billion in revenue in 2019, the most recent year for which data is available, with net income of slightly more than $573 million. The same year, it paid Markovich $7.5 million, plus benefits.

The National Committee for Quality Assurance has given Blue Shield a poor rating for efficient patient care. And on the chief job Newsom is asking it to do — getting vaccines to patients — Blue Shield is average, ranking 3 out of 5 in the national ranking on flu shots.

No other state appears to have delegated the vaccination job to an insurer, said Dr. Georges Benjamin, executive director of the American Public Health Association. And because counties refuse to contract with Blue Shield, the Newsom administration is scrambling to give counties the option to work with the state government instead.

A growing number of state and local lawmakers are calling the deal a waste of taxpayer money.

“I don’t think having Blue Shield step in is going to get teachers vaccinated any quicker. I don’t think it’s going to get the 70-year-old Black folks vaccinated any quicker,” said state Sen. Sydney Kamlager (D-Los Angeles), adding that she has “more faith” in her local public health experts than in Blue Shield. “And they’re not doing it for free.”

Newsom has insisted that the insurer won’t be allowed to profit.

But critics of the deal argue that even though Blue Shield isn’t technically allowed to make money off vaccinating Californians, the company stands to gain enormous prestige.

Since taking over the program on March 1, Markovich has appeared in press conferences and the company has produced slick advertising urging Californians to get vaccinated. In one ad, viewers are left with the image of the company’s blue logo on a black screen.

“This is not about making money. This is about the marketing opportunity it represents. It’s huge,” said Michael Johnson, a Blue Shield whistleblower who left his post as director of public policy in 2015. “The reason Blue Shield has been selected for this is not because of its capabilities, but because of its relationship with Newsom.”

Methodology

How California Healthline compiled data about political and charitable spending by Blue Shield of California and Kaiser Permanente

Political contributions: Blue Shield of California made direct contributions to Gavin Newsom’s personal campaign accounts for every political office he has held since 2002, when he served as a San Francisco supervisor. These contributions can be found on the California secretary of state’s website or the San Francisco Ethics Commission website.

Additionally, Blue Shield has given large contributions to a ballot measure account run by the governor called “Newsom’s Ballot Measure Committee,” which can accept unlimited amounts of money. Those contributions can be found on the California secretary of state’s website. And Blue Shield made sizable contributions, known as “independent expenditures,” to two ballot measure committees that benefited Newsom’s 2018 gubernatorial bid. One, “Newsom for Governor 2018, Sponsored by Labor Organizations and Blue Shield of California,” was also supported by the Service Employees International Union and teachers, police and firefighters unions. The other, “Chiang for Governor 2018; Health Care Providers for Fiscal Accountability Opposed to John,” also received contributions from the California Medical Association and California Dental Association.

Charitable contributions: Blue Shield and Kaiser Permanente have made “behested payments,” which are donations to charities and other nonprofit organizations in elected officials’ names. Blue Shield gave in Newsom’s name to “Project Homeless Connect” while he was mayor and “Project Homekey” as governor.

Kaiser Permanente gave to Project Homekey and a state covid immigrant relief fund in Newsom’s name. Behested payments to state elected officials are disclosed on the California Fair Political Practices Commission website, and behested payments to Newsom when he was mayor are on the San Francisco Ethics Commission website.

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

The Case for Donating US COVID Vaccines Overseas

KFF Health News, March 19, 2021

Epidemiologists are urging the Biden administration to make plans for getting surplus U.S. COVID vaccine supplies overseas once Americans are vaccinated.

This article was published on Friday, March 19, 2021 in Kaiser Health News.

By Arthur Allen

A Senate committee grilled federal officials about the shortage of vaccines to protect Americans against a pandemic virus. Two months later, the U.S. public had lost interest in the virus, and millions of vaccines were sitting in warehouses — although poor countries still needed them.

This happened during the 2009-10 swine flu pandemic. One official on the hot seat was Dr. Nicole Lurie, who was in charge of preparedness and response at the Department of Health and Human Services. Today, she's a senior adviser at the Coalition for Epidemic Preparedness Innovations, which is helping to vaccinate the world against COVID. And she's worried about history repeating itself.

Lurie told Congress back then that vaccine production was unpredictable. In any case, the swine flu virus turned out to be relatively tame, but the experience holds a lesson for today, she said: Pandemics shift directions quickly, so it's best to be prepared for threats and opportunities — anywhere in the world.

In particular, Lurie and others are urging the Biden administration to make plans for getting surplus U.S. COVID vaccine supplies overseas once Americans are vaccinated. They note that the administration has secured at least 700 million doses of vaccines — more than enough to fully vaccinate every adult and child in the U.S. — by the end of July. The current focus must be the United States, which has had more COVID cases and deaths than any other country. But in the longer term, global immunization will be crucial.

"We need to take care of the problem everywhere to be able to take care of it anywhere," said Dr. Mark Feinberg, president and CEO of the International AIDS Vaccine Initiative, a remark echoed in a petition circulated by leading U.S. scholars. "Even if we get high-level vaccine coverage here, we'll still be vulnerable to imported variants that are less responsive to the first-generation vaccines. It's going to be an ongoing problem."

Vaccine experts and activists give the Biden administration high marks for reengaging with the World Health Organization and its global partners. They also understand that the United States has to take care of itself first.

"Until we have enough for Philadelphia, I don't see them wanting to give vaccine away," said Feinberg, who is 64, lives in Philadelphia and had yet to be vaccinated as of March 18. "We have a long way to go."

In the coming months, however, many believe the Biden administration should at least partially pivot to a global approach. The Trump administration wisely spread its risk on vaccine development, spending $14 billion on contracts with eight different companies. Five now have vaccines authorized for use in the United States or overseas.

"Now that there are five vaccines that work, the hedging is looking a lot more like hoarding," said Tom Hart, North American executive director of One, a global anti-poverty group. "You don't need more than one or two inoculations to become immune. As soon as you become immune, you need to share."

Biden is committed in principle to sharing vaccine doses with the world. On Day One, the administration issued a national security memorandum calling on the secretaries of state and HHS to promptly deliver Biden "a framework for donating surplus vaccines, once there is sufficient supply in the United States, to countries in need."

In a largely symbolic move, the administration on Thursday said it planned to provide 1.5 million doses of vaccine to Canada and 2.5 million to Mexico. The donation would come from a cache of vaccine produced by AstraZeneca, which has yet to apply for its use in the United States.

The administration also has promised other countries cash for vaccines. It pledged $4 billion to the COVAX facility, the coordinating group that aims to distribute 2 billion COVID vaccines to low-income and middle-income countries by the end of the year. Half of that money has been paid out.

The administration is also helping to expand vaccine manufacturing in the developing world — a key objective to protect these countries against COVID, as well as routine childhood diseases and future pandemics.

Biden and the leaders of India, Australia and Japan just signed an agreement that calls on the U.S. International Development Finance Corp., which supports projects in poorer countries, to help Biological E., an Indian pharmaceutical company, produce 1 billion COVID vaccine doses by the end of 2022. Johnson & Johnson, Novavax and AstraZeneca have partnered with several Indian manufacturers over the past year in unusually cooperative arrangements.

But donating vaccine would be the quickest way to help — and here the picture is murkier. The administration hasn't said when or how it will determine there is a "sufficient supply" of U.S. vaccine to be shared.

Federal officials are working on the framework for future donations, an HHS official said.

"Our primary focus is to vaccinate Americans first. However, the U.S. will not be completely safe until the entire world is safe," said the official, who spoke on condition of anonymity.

White House press secretary Jen Psaki said last week that Biden "wants to be overprepared and oversupplied," with extra doses that could be used for "booster shots." That's a fuzzy goal, however, since it's unclear when or whether or what type of booster shots could be needed.

It's also not clear whether vaccine donations would all go through COVAX, which decides where to send them, or would be given out bilaterally to allies like Mexico.

This is a shame, said Hart, of One, because vaccine sharing could have a big payoff in building goodwill. China and Russia, which already have donated or sold their vaccines in Africa, the Mideast and Latin America, "are increasing their spheres of influence through vaccine diplomacy," he said. "People don't soon forget when you saved their lives and the lives of their families."

Now is the time to think about these issues, Lurie said. During the swine flu pandemic, tens of millions of unused U.S. influenza vaccines were held in warehouses for months, awaiting shipment overseas, because of cumbersome rules imposed by the U.S., the World Health Organization and overseas governments.

"There were 68 steps that no one knew about," Lurie recalled. "My favorite was the fumigation certificate required for the wood pallet for exporting doses to the Philippines."

Merck faced similar problems when it tried to ship its Ebola vaccine to West Africa during the 2014-16 epidemic there. Commercial and trade rules, Food and Drug Administration regulations and other red tape make shipping an unlicensed vaccine out of the country very complex, said Feinberg, who was then a senior Merck scientist. "It took a lot of jumping through hoops to even send the vaccine to Guinea or Liberia or Sierra Leone."

The donations to Canada and Mexico would apparently come from some 30 million doses that AstraZeneca has reportedly warehoused in Ohio while the company prepares to submit data to the FDA for authorization of the vaccine. The U.S. could put those doses to good use by exporting them if they are not going to be used here, Lurie said. "That would be a fine alternative to having the vaccine just sitting in a warehouse."

However, several countries have suspended use of the AstraZeneca vaccine while European drug regulators study reports that the vaccine might cause blood clots. Exporting U.S.-made supplies of this vaccine now would be a mistake, Feinberg said, because it could undermine confidence with the perception that the U.S. was offloading a vaccine the FDA hadn't deemed worthy.

"The administration has been thoughtful in addressing the key issues," he said. "In the long term and maybe even the short term, that may be better than a one-time donation of doses."

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

Arthur Allen: ArthurA@kff.org, @ArthurAllen202

COVID-Inspired Montana Health Insurance Proposal Wouldn't Kick In for 2 Years

KFF Health News, March 19, 2021

Montana is one of six states without a mini-COBRA program, despite the estimate that around 100,000 Montanans work at businesses with 19 or fewer employees.

This article was published on Friday, March 19, 2021 in Kaiser Health News.

By Sara Reardon

For employees of small businesses in Montana suddenly laid off during the COVID-19 pandemic, maintaining health insurance coverage could be a struggle.

Employers with 20 or more workers offer a bridge insurance program made possible by a federal law known as the Consolidated Omnibus Budget Reconciliation Act, or COBRA. The law allows people who have left a job voluntarily or involuntarily to keep their former employer's health insurance plan for 18 months by paying the premium that the employer used to cover.

But smaller Montana businesses employing fewer than 20 people are not required to offer such a program, potentially leaving people without continuing coverage if they are laid off. Now, a bill moving through the Montana Legislature would create a "mini-COBRA" law that would require any small business with a group health insurance plan to offer continuing coverage for up to 18 months at the employee's expense starting in 2023.

Montana is one of only six states without a mini-COBRA program, despite the estimate that around 100,000 Montanans work at businesses with 19 or fewer employees. Rep. Mark Thane (D-Missoula), the bill's sponsor, said it was brought to his attention last year by a constituent who worked at such a business.

"The concern, I think, was exacerbated during the pandemic when people were in layoff status and lost access to group health insurance plans," Thane said.

He added that the legislation would not cost Montana taxpayers anything — the premiums are paid by individuals — and that it would bring Montana in line with most other states. The measure, House Bill 378, passed the House 84-14 on March 2 and is pending in the Senate.

Business and trade groups said they opposed the measure because of the additional paperwork it might mean for small mom-and-pop businesses.

"Why do we need to add more red tape and regulations to small businesses?" David Smith, executive director of the Montana Contractors Association, asked a Senate committee on Wednesday.

In response, Thane said he acknowledges the concerns, but added, "I don't see it as an overwhelming paperwork burden."

Mini-COBRAs are not intended to be long-term health insurance plans. For one thing, they generally are expensive. On average, employees with job-based single coverage pay less than 20% of their full insurance premiums (for family coverage, it averages 27%). Under COBRA or mini-COBRA, a former employee pays 100%, plus a 2% administrative fee that goes to their former employer. Montana's bill is modeled on North Dakota's mini-COBRA legislation and provides 18 months of coverage at 102% of the premium and an additional 11 months at 150% of the premium.

Mini-COBRAs are unlikely to be widely used for another reason. The federal exchange created by the Affordable Care Act that sells individual insurance plans is a less expensive option that is better for most people, said Louise Norris, co-owner of a health insurance brokerage in Colorado who writes about health insurance. After all, job loss is among the conditions that qualify a person to buy an ACA exchange plan outside the open enrollment period.

Norris said COBRA might be a better option for patients who are in the middle of treatment, for instance, and don't want to switch physicians. People who have already paid off most of their maximum out-of-pocket costs might also prefer to continue with the same plan rather than starting over at zero with a new plan. "That's where COBRA and mini-COBRA are really attractive," Norris said.

Thane added that people who were laid off during the pandemic but expect to be rehired within a few months might also choose a mini-COBRA to tide them over.

But because the new Montana law, if it passes, wouldn't take effect until 2023, its usefulness in that scenario is likely to be minimal. It also won't come soon enough for Montanans who work at businesses with fewer than 20 employees to take advantage of a provision in the recently passed $1.9 trillion COVID relief bill that will pay for individuals' COBRA and mini-COBRA premiums through September.

Still, Thane hoped that the plan will give more options to employees of small businesses. "Given the competitive labor market, it's become increasingly important for small entities to offer benefit plans to hire and retain folks," he said.

Doctors Found Jet Fuel in Veteran's Lungs. He Can't Get Full Benefits.

KFF Health News, March 19, 2021

A retired Army staff sergeant had suffered catastrophic lung damage from breathing incinerated waste burned in massive open-air pits and probably other irritants during his tour of duty in Iraq.

This article was published on Friday, March 19, 2021 in Kaiser Health News.

By Michael McAuliff

The lungs Bill Thompson was born with told a gruesome, harrowing and unmistakable tale to Dr. Anthony Szema when he analyzed them and found the black spots, scarring, partially combusted jet fuel and metal inside.

The retired Army staff sergeant had suffered catastrophic lung damage from breathing incinerated waste burned in massive open-air pits and probably other irritants during his tour of duty in Iraq.

"There's black spots that are burns, particles all over; there's metal. It was all scarred," said Szema, a pulmonologist and professor who studies toxic exposures and examined Thompson's preserved lung tissue. "There was no gas exchange anywhere in that lung."

Thompson is still alive, surviving on his second transplanted set of lungs. Yet the story burned into the veteran's internal organs is not one that has been entirely convincing to the U.S. government.

The military has not linked the burn pits to illness. That means many who were exposed to burn pits and are sick do not qualify for benefits under any existing program.

Retirement and health benefits for members of the military depend on factors like length of service, active or reserve status, deployments to combat zones and whether the military considers specific injuries or illnesses to be service-related. Thompson has been able to get care through the Department of Veterans Affairs for his lung disease but has not been able to secure other benefits, like early retirement pay.

"I was denied my Army retirement because if it was not a combat action, then I don't receive that retirement," Thompson said at a Senate Veterans' Affairs Committee hearing last week on service members' exposures to toxic substances.

Thompson is one of at least 3.5 million veterans since 2001 who have served in war zones where the U.S. military decided to dispose of its trash by burning it, according to VA estimates.

It's not clear how many people within that population have gotten sick from exposure. Only a small fraction — 234,000 — have enrolled in the VA's online burn pit registry. Veterans' advocacy groups have said the majority of claims to the agency stemming from toxic exposures are denied, even as most former service members report contacts with toxins in their deployments.

Soldiers returning from tours in the global war on terror have reported debilitating illnesses almost from its beginning, but got little traction with the military. This year, though, the likelihood of congressional action is high, with Democrats expressing interest and a president who suspects burn pits are to blame for his son's death.

President Joe Biden's son Beau died of brain cancer in 2015 at age 46. He had deployed to Iraq in two sites with burn pits — at Baghdad and Balad — around the same time Thompson was at Camp Striker, near the Baghdad airport.

"Because of exposure to burn pits — in my view, I can't prove it yet — he came back with stage 4 glioblastoma," Biden said in a 2019 speech.

In testimony at the March 10 hearing, Shane Liermann, who works for the group Disabled American Veterans, told the committee that 78% of burn pit claims are denied. "Part of the problem is VA is not recognizing that exposure as being toxic exposures," Liermann said.

Aleks Morosky, with the Wounded Warrior Project, said that in his group's survey of 28,000 veterans last year, 71% said they had "definitely" been exposed to toxic substances or hazardous chemicals, and 18% said they had "probably" been exposed. Half of those people rated their health as poor or fair. Only about 16% of the service members who believed they had suffered exposure said they got treatment from the VA, and 11% said they were denied treatment.

Thompson, who is 49, said care for his lung disease is often slow and sometimes denied. It took the VA three years to approve an air purifier for his home to filter out allergens, and the VA refused to help pay for the removal of dust-trapping carpets, he said.

Thompson's presence at the hearing, though, was not just meant to put the spotlight on the VA. The military's entire approach to toxic exposure is a morass that leaves ill soldiers and veterans like Thompson trying to navigate a bureaucracy more labyrinthine than the Pentagon's corridors.

After Thompson was shipped back to Fort Stewart in Georgia, his medical ordeal was at first addressed within the military system, including a year at Walter Reed National Military Medical Center in Bethesda, Maryland, where doctors found his lungs filled with titanium, magnesium, iron and silica.

Yet he said he didn't qualify for the Army's traumatic-injury insurance program, which might have helped him pay to retrofit his home in West Virginia. And he can't get his military retirement pay until he's 60.

"I may not live to be age 60. I turn 50 this year," Thompson said.

Illustrating the problem, several officials at the hearing with the Department of Defense, the Army and the National Guard were unable to explain why Thompson — with 23 years of service between the Guard and Army — might have such a hard time qualifying for retirement benefits when the evidence of his lungs and the findings of the Army's own doctors are so vivid and extreme.

For advocates who have been working on the problem for decades, it reminds them all too vividly of Agent Orange, which the military is still coming to grips with.

"It's already been, since the first Persian Gulf [War] — we're talking 30 years — and since burn pits were again active, since 2001," said Liermann. "We're way behind the curve here."

Although Congress has done relatively little to deal with burn pits, many members seem to at least be thinking along the same lines. The Senate Veterans' Affairs hearing promised to be something of a kickoff to a year when lawmakers are poised to offer a slew of bills designed to confront the military's inability to care for service members poisoned during their deployments.

"Make no mistake about it," said the committee chairman, Sen. Jon Tester (D-Mont.). "We hold these hearings for two reasons: to gather information for the committee members and to help educate the VA that they might take action before Congress does."

Republicans have also shown growing interest in the problem, offering targeted bills to ensure a handful of toxin-related diseases are covered by the VA.

At the hearing, conservative freshman Sen. Tommy Tuberville (R-Ala.) seemed especially moved.

"We got to do a better job of taking care of our young people," Tuberville said. "If we're going to go to war, we got to understand we got to pay the price for it on both ends."

There is also likely to be high-profile support and attention when revised legislation starts rolling out this spring.

The broadest bill likely to be offered was first introduced by Sen. Kirsten Gillibrand (D-N.Y.) in the Senate and Rep. Raul Ruiz (D-Calif.) in the House in late 2019, with a boost from former "Daily Show" host Jon Stewart and a cadre of 9/11 responders who are turning their attention to toxic exposures.

Indeed, Ruiz and Gillibrand's legislation is modeled in part on the 9/11 health act that passed in 2015. The burn pit bill would remove the burden of proving a service-related connection.

It would vastly simplify the lives of people like Thompson.

"I am a warrior of the United States of America. I gave my lungs for my country," Thompson said.

He was cut off before he could finish, but his prepared remarks concluded, "Hopefully, after hearing my story, it will bring awareness for not only me but others who are battling the same or similar injuries related to burn pit exposures from Iraq or Afghanistan."

Michael McAuliff: @mmcauliff ‏

Need Amid Plenty: Richest US Counties Are Overwhelmed by Surge in Child Hunger

KFF Health News, March 18, 2021

The financial fallout of covid-19 has pushed child hunger to record levels.

This article was published on Thursday, March 18, 2021 in Kaiser Health News. This story also ran on USA Today and GateHouse Media.

By Laura Ungar

Alexandra Sierra carried boxes of food to her kitchen counter, where her 7-year-old daughter, Rachell, stirred a pitcher of lemonade.

“Oh, my God, it smells so good!” Sierra, 39, said of the bounty she’d just picked up at a food pantry, pulling out a ready-made salad and a container of soup.

Sierra unpacked the donated food and planned lunch for Rachell and her siblings, ages 9 and 2, as a reporter watched through FaceTime. She said she doesn’t know what they’d do without the help.

The family lives in Bergen County, New Jersey, a dense grouping of 70 municipalities opposite Manhattan with about 950,000 people whose median household income ranks in the top 1% nationally. But Sierra and her husband, Aramon Morales, never earned a lot of money and are now out of work because of the pandemic.

The financial fallout of covid-19 has pushed child hunger to record levels. The need has been dire since the pandemic began and highlights the gaps in the nation’s safety net.

While every U.S. county has seen hunger rates rise, the steepest jumps have been in some of the wealthiest counties, where overall affluence obscures the tenuous finances of low-wage workers. Such sudden and unprecedented surges in hunger have overwhelmed many rich communities, which weren’t nearly as ready to cope as places that have long dealt with poverty and were already equipped with robust, organized charitable food networks.

Data from the anti-hunger advocacy group Feeding America and the U.S. Census Bureau shows that counties seeing the largest estimated increases in child food insecurity in 2020 compared with 2018 generally have much higher median household incomes than counties with the smallest increases. In Bergen, where the median household income is $101,144, child hunger is estimated to have risen by 136%, compared with 47% nationally.

That doesn’t mean affluent counties have the greatest portion of hungry kids. An estimated 17% of children in Bergen face hunger, compared with a national average of around 25%.

But help is often harder to find in wealthier places. Missouri’s affluent St. Charles County, north of St. Louis, population 402,000, has seen child hunger rise by 69% and has 20 sites distributing food from the St. Louis Area Foodbank. The city of St. Louis, pop. 311,000, has seen child hunger rise by 36% and has 100 sites.

“There’s a huge variation in how different places are prepared or not prepared to deal with this and how they’ve struggled to address it,” said Erica Kenney, assistant professor of public health nutrition at Harvard University. “The charitable food system has been very strained by this.”

Eleni Towns, associate director of the No Kid Hungry campaign, said the pandemic “undid a decade’s worth of progress” on reducing food insecurity, which last year threatened at least 15 million kids.

And while President Joe Biden’s covid relief plan, which he signed into law March 11, promises to help with anti-poverty measures such as monthly payments to families of up to $300 per child this year, it’s unclear how far the recently passed legislation will go toward addressing hunger.

“It’s definitely a step in the right direction,” said Marlene Schwartz, director of the Rudd Center for Food Policy and Obesity at the University of Connecticut. “But it’s hard to know what the impact is going to be.”

Need Grows in Places of Plenty

After the pandemic struck, the federal government boosted benefits from the Supplemental Nutrition Assistance Program and offered Pandemic Electronic Benefit Transfer cards to compensate for free or reduced-price school meals while children were schooled from home.

Sierra’s family saw their SNAP benefits of about $800 a month rise slightly and got two of those P-EBT payments, worth $434 each. But at the same time, they lost their main sources of income. Sierra had to leave her Amazon warehouse job when the kids’ school went remote, and Morales stopped driving for Uber when trips became scarce and he feared getting covid on top of his asthma.

Federal relief wasn’t enough for them and many others. So they flocked to food pantries.

In theory, pantries and the food banks that supply them are part of an emergency system designed for short-term crises, Schwartz said. “The problem is, they’ve actually become a standard source of food for a lot of people.”

In Bergen County, the Center for Food Action helped 40,500 households last year, up from 23,000 the year before. In Eagle County, Colorado, where the tony ski resort Vail is located, the Community Market food bank saw its client load nearly quadruple to 4,000. And outside Boston, in the affluent Massachusetts county of Norfolk — where Feeding America data shows child hunger jumped from an estimated 6% of kids to 16% — Dedham Food Pantry’s clients tripled to 1,800.

“This is just out of control compared to other times,” said Lynn Rogal, vice president of the Dedham pantry, which opened in 1990.

Pantry managers said a disproportionate number of clients are from minority groups. Many lost jobs in the eviscerated service sector that undergirds the wealthier parts of their counties. Julie Yurko, CEO of the Northern Illinois Food Bank, said up to half of her current clients have never sought help before.

“In early January, we had a white minivan pull up with three kids, 5 and younger. It ran out of gas sitting there,” Yurko said. “The mom was sobbing, and her beautiful children were sitting there watching her.”

Kelly Sirimoglu, spokesperson for New Jersey’s Center for Food Action, said the stigma around seeking help can be worse in wealthy areas. She said some people tell her, “I never thought I would be in line for food.”

Advocates said the reluctance to seek help means the need is likely even larger than it appears.

Katie Wilson of St. Charles, Missouri, said she heard about a food pantry run by the Sts. Joachim & Ann Care Service from a friend of a friend. She almost didn’t go. The single mom of two children, 11 and 9, lost her job as a hotel auditor in June and tried to squeak by without her income for two months.

“We found ourselves in a situation where it was a ‘heat or eat’ kind of thing,” said Wilson, 42, describing having to choose between heating her home or buying food. “It took me looking around and saying, ‘There is nothing to eat.’”

Struggling to Meet the Need

As hunger has become more visible, donations to food charities have risen. But they don’t address the core problem of an infrastructure that doesn’t match the new need. Some pantries are open just a few hours a week in church basements, a far cry from those that operate regularly and look like supermarkets. Many small pantries struggled to shift to outdoor food distribution during the pandemic or find new helpers when the few, often senior, volunteers felt unsafe doing the work.

“It definitely is harder in these places,” said Yurko, whose food bank distributes to Kendall County, Illinois, which has just three pantries for its population of 129,000. “The safety nets are not as robust.”

A strong safety net also requires pantries to cooperate with one another and the broader array of local social services. That’s been happening for years in Flint, Michigan, said Denise Diller, executive director of Crossover Downtown Outreach Ministry, which runs a pantry. Agencies and community leaders banded together in 2014 when lead poisoned the drinking water.

“When covid occurred, we were already kind of ready,” Diller said.

So was Atlanta. As in Flint, hunger was never hidden there; 15% of children in Fulton County, which includes Atlanta, faced hunger before the pandemic. After covid suspended volunteer shifts, the Atlanta Community Food Bank asked the Georgia National Guard to help sort, pack, warehouse and deliver food to help meet the needs of the estimated 22% of kids experiencing hunger. The food bank also partnered with seven school districts on more than 30 mobile pantries.

Such coordination and connections were lacking in Bergen County, where 80 pantries worked mostly in isolation when the pandemic hit, County Commissioner Tracy Zur said. “They weren’t collaborating. They were going along the same path they had for decades,” she said. “There was this need to break out of the old way of doing things and work together to be more impactful.”

Zur spearheaded the creation of a food security task force in July, reaching out to municipal and faith leaders. Goals include feeding people, connecting them to other services and turning some emergency food programs into full-fledged pantries. “Building an infrastructure is painstaking and ongoing,” she said.

Now, Zur said, pantries are starting to share with one another when one gets a large donation of perishable items such as eggs or milk.

With the need so widespread, residents do much the same.

During a recent pantry trip, Sierra, the New Jersey mom, opened the trunk of her 1999 Toyota and rummaged through the two big boxes volunteers had just placed there. She pointed to eggs, chicken, bread, butter, cheese and apples, observing, “I have more than I need.”

But she said it would never go to waste. Any extra would go to neighbors and their hungry children.

Landmark COVID Relief Law Pumps More Than $100B Into Public Health

KFF Health News, March 18, 2021

Public health advocates worry that momentum will wane once the pandemic abates, as it has after past crises and natural disasters.

This article was published on Thursday, March 18, 2021 in Kaiser Health News.

By Steven Findlay

Acknowledging that chronic underfunding of public health contributed significantly to the nation's fragmented response to the coronavirus pandemic, Democrats included more than $100 billion in the recently enacted relief package to address urgent needs and enhance future efforts.

"The pandemic has given us possibly the best chance we've ever had of getting on the right track to shore up our public health resources," said Jeffrey Levi, a professor of health management at the George Washington University School of Public Health. "Tens of millions of us have directly experienced what happens when our country is not prepared."

Even so, Levi and other public health advocates worry that momentum will wane once the pandemic abates, as it has after past crises and natural disasters. They also say that more sustained funding will be needed over the next decade and beyond to address long-festering problems.

"We heartily support this new law," said Dr. Georges Benjamin, executive director of the American Public Health Association. "But many of its provisions are for one-time and time-limited increases in funding for COVID-related needs and financial distress. What we hope is that this will be a down payment on a long-term commitment to enhancing public health infrastructure and hiring more public health workers at the federal, state and local levels."

He pointed to long-term public health issues that existed before the pandemic, such as high rates of obesity and uncontrolled diabetes, that compounded COVID-related hospitalization and deaths in the U.S.

The law steers $49 billion toward enhancing coronavirus testing, contact tracing and genomic sequencing, to help identify and track virus variants. Even if the number of infections declines, the money assures these efforts continue for the rest of this year and into 2022 if needed.

Another $50 billion goes to the Federal Emergency Management Agency to support vaccine distribution and logistical and social support in areas hardest hit by pandemic-related job loss and financial strain. This includes such activities as food distribution.

States and local government agencies are allotted $350 billion to make up for lost tax revenue amid the pandemic-caused recession. Some of that money is expected to be spent on pandemic response and public health programs, but it comes with a deadline. It must be spent by Dec. 31, 2024.

A series examining how the U.S. public health front lines have been left understaffed and ill-prepared to save us from the coronavirus pandemic. The project is a collaboration between KHN and the AP.

The law also set aside $7.6 billion for hiring more public health workers, but experts said that won't be enough over the long term.

The Biden administration touted this element of its pandemic plan in January, recommending that 100,000 nurses and other workers be hired as part of a new "U.S public health service corps."

The proposal, mentioned often in media coverage in January and early February, stipulated that the new corps would initially provide support for vaccine distribution, contact tracing and the nation's network of more than 1,000 public-funded community health centers. After the pandemic ended, those hired would retain their jobs and serve as an enduring upgrade to local public health services and preparedness, the administration indicated.

The concept of the corps is not in the final law, however, which instead specifies that the $7.6 billion be spent on "establishing, expanding, and sustaining a public health workforce, including by making awards to state, local, and territorial public health departments." That language, public health experts said, permits the federal government more flexibility while it determines who should be hired for what and in which states.

But the language could bog down the program in red tape.

"Some state and local public health departments will need and be better able to absorb new workers than others," said Levi of George Washington University. "The flexibility makes sense, but we will need to carefully monitor how this unfolds."

The Biden administration initially estimated that hiring 100,000 workers would triple the size of the public health workforce. But it's unclear how many people work in the field nationwide now, including public health nurses, disease intervention specialists, epidemiologists, contact tracers, community health workers, lab technicians, IT specialists and support staff.

A White House spokesperson said the new law "will allow us to build our long-term public health capacity, particularly in low-income and underserved communities," in part "by hiring workers from the communities they serve."

Dr. Umair Shah, Washington state's secretary of health, said more "boots on the ground is definitely part of what we need," but he added that "recruiting new people takes time."

Shah also noted that many public health leaders and workers are burned out after the past year, in part because they often were vilified for messaging on mask-wearing, physical distancing and restrictions. Some left their jobs because of that intimidation.

Adriane Casalotti, chief of government affairs at the National Association of County & City Health Officials, which represents the nation's nearly 3,000 local health departments, said "the backlash was harmful. I hope we can move beyond it now and that lawmakers and the public see more clearly that what we do is critical."

Determining what the U.S. spends on public health is not straightforward. Federal and state spending for emergency programs, disaster relief, preventive health and social services commonly overlap with public health funding. Also, public health programs are spread across dozens of federal and state agencies.

Trust for America's Health, a nonpartisan public health advocacy group, estimates that about 3% of all health spending in the U.S. goes to public health and disease prevention in 2020 — more than $100 billion.

Not content with the funding in the new law, public health advocates are pressing Congress for an additional $4.5 billion a year in annual funding for public health.

Sen. Patty Murray (D-Wash.), chair of the Senate Health, Education, Labor and Pensions (HELP) Committee, has introduced legislation to provide funding at that level. "It's critical we end the cycle of crisis and complacency when it comes to funding for public health," Murray said in a statement. "The simple fact is: public health saves lives."

Carolyn Mullen, senior vice president for government affairs at the Association of State and Territorial Health Officials, concurred: "The money tends to increase in times of crisis and natural disasters, then declines after the crisis abates. That's not the way to sustain preparedness."

'Super-Sized' Vaccine Clinic Offers Food Workers Some Relief

KFF Health News, March 18, 2021

At a time when millions of Californians were trolling websites for hours to find vaccination slots, Long Beach, which has its own health department separate from the rest of Los Angeles County, aimed to simplify the process.

This article was published on Thursday, March 18, 2021 in Kaiser Health News.

By Lori Basheda

LONG BEACH, Calif. — Cristina Davila wasn't used to being happy about waiting in line.

As a server at the Navy Proof Restaurant and Bar, the specter of COVID has weighed heavily on her mind for the past several months. Davila has been especially worried about the possibility of bringing the virus home to her young son and diabetic mother.

And here she was, standing outside the Long Beach Convention Center with hundreds of other Long Beach residents and workers, about to receive a coveted COVID vaccine — even though she's only 31.

"It's like a relief, I would say," she said. "I'm excited."

The occasion: a super-sized vaccine clinic just for food workers. The March 5 date offered 3,000 slots to restaurant workers, bodega and market employees, cooks or anyone else in the city's food business.

The vaccine clinic that day, which the city has followed by dedicating more shots to food and other essential workers, was an attempt to help safely reopen Long Beach restaurants while providing a giant thank-you to people who've been risking illness to keep the city fed, said Long Beach Mayor Robert Garcia.

At a time when millions of Californians were trolling websites for hours to find vaccination slots, Long Beach, which has its own health department separate from the rest of Los Angeles County, aimed to simplify the process, at least for a few vulnerable groups.

"Food workers have been working nonstop since the start of this pandemic and they deserve to feel safe when they go to work to serve their community," said Garcia, whose mother and stepfather died of COVID in July.

Jennifer Rice Epstein, a spokesperson for the city health department, encouraged Long Beach residents and workers to register at longbeach.gov/vaxLB for one of 3,000 vaccine appointments the city is offering daily to employees in these sectors: food service, healthcare, agriculture, emergency response, education, janitorial services — and anyone 65 or older.

In addition to the 3,000 appointments, the city holds an additional 500 spots open each day for city residents and workers without appointments — as long as they show a pay stub or other proof they are in a priority tier.

Long Beach's century-old health department has established relationships with schools, nonprofit partners and businesses that have built up a level of trust that makes it easier to organize such campaigns, Rice Epstein said.

The city of 466,000 was also one of the first in the state to send mobile clinics to vaccinate residents with physical and mental disabilities, she said. The city also offered to send a vaccinating team out to any qualified person who can't physically reach the convention center. As of March 15, the roughly 20% of city residents who'd gotten at least one shot was similar to the overall rate in the state.

Online registration for vaccination for the food service clinic at the convention center filled quickly. By the time the event opened at 11 a.m., a line of hundreds snaked around one side of the convention center's Terrace Theater, where the shots were administered.

"I feel lucky," said Eric Bohay, 28, who has asthma and works at the grocery pickup counter at a Target store. "I'm in close contact with customers on a daily basis. I take as many precautions as I can, but you never really know what's out there."

Food service workers have been plagued by COVID during the pandemic. One study conducted at the University of California-San Francisco found that deaths of food workers in restaurants, food production and agriculture jumped 39% from March to October 2020. Adults with COVID were twice as likely to have dined out in a restaurant in the two weeks before they showed signs of illness, according to a CDC study, suggesting that the virus lingers in the air where servers, cooks and bussers spend many hours a day.

Those in line expressed some nervousness about the vaccine. "People are saying different things about how they feel after" getting the shot, said Sydney Tripoli.

The 21-year-old photographed rock bands in Orange County and Los Angeles before the pandemic shut down live events. Then she took a job at Ahimsa Vegan Cafe on Fourth Street in Long Beach. She was hoping a vaccination would bring her a step closer to returning to photo gigs.

City officials had phoned and emailed managers and owners of food enterprises — from grocery stores to bars and restaurants — encouraging them to invite their employees to sign up.

That's how Andrew Anderson found out. Anderson, 37, owns the Spicy Kitchen, which makes hot sauces, rubs and pickles for restaurants and markets.

"I was super excited because I do work with a lot of grocery stores and vendors, so I am exposed to a lot of people," he said. He ended up chatting with an industry friend who was also in the vaccination line.

"I feel like I won the lottery," said his friend Lance Todd, a 52-year-old bartender at The Brit, an LGBTQ bar in Long Beach. "My husband can't get a shot yet, so at least this is better than neither one of us having it."

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

Role Reversal: COVID Increases Ranks of Child Caregivers

KFF Health News, March 17, 2021

More than 3 million children and teens help an ill or disabled family member.

This article was published on Wednesday, March 17, 2021 in Kaiser Health News.

By Heidi de Marco  

LONG BEACH — On a recent Thursday afternoon, Rhianna Alvarado struggled to don her protective gloves, which were too big for her petite hands. 

With her mom coaching her every move, she edged close to her father and gently removed the plastic tube from his throat that allows him to breathe. She then cautiously inserted a new one. 

"What's next?" asked her mom, Rocio Alvarado, 43. 

"I know, I know," replied Rhianna, her eyes constantly searching for her mom's approval. 

Rhianna is only 13. When she finished the delicate task of changing her father's tracheostomy tube, usually performed only by adults, she went back into her room to doodle on her sketch pad and play with her cat. 

Rhianna's father, Brian Alvarado, is an Iraq War veteran and neck and throat cancer survivor. 

Like most kids, Rhianna has been stuck at home during the COVID-19 pandemic and attends school online. But unlike most other eighth graders, Rhianna is a caregiver, tending to her dad between her virtual classes. 

Rhianna is among more than 3 million children and teens who help an ill or disabled family member, according to Caregiving in the U.S. 2020, a national survey published by the National Alliance for Caregiving and AARP. The survey also found that Hispanic and African American children are twice as likely to be youth caregivers as non-Hispanic white children. 

Carol Levine, a senior fellow at the United Hospital Fund, a nonprofit that focuses on improving healthcare in New York, said the COVID pandemic, combined with the worsening opioid epidemic, has increased the number of youth caregivers because more children are homebound and must care for ill or addicted parents. 

The pandemic has also made caregiving harder for them, since many can no longer escape to school during the day. 

"In school they have their peers, they have activities," Levine said. "Because of the contagion, they aren't allowed to do the things they might normally do, so of course there is additional stress." 

Levine was an author of a national survey in 2005 that found there were about 400,000 youth caregivers between ages 8 and 11. The survey has not been updated, she said, but that number has likely grown. 

Kaylin Jean-Louis was 10 when she started doing little things to care for her grandmother and great-grandmother, who have Alzheimer's disease and live with Kaylin and her mother in Tallahassee, Florida. 

Now 15, Kaylin has assumed a larger caregiving role. Every afternoon after her online classes end, the high school sophomore gives the women their medicine, and helps them use the bathroom, dress and take showers. 

"Sometimes they can act out and it can be challenging," she said. The hardest thing, she said, is that her grandmother can no longer remember Kaylin's name. 

COVID has added another level of stress to an already complex situation, Kaylin said, because she can't decompress outside the house. 

"Being around them so much, there has been a little tension," Kaylin acknowledged. She uses art to cope. "I like to paint," she said. "I find it very relaxing and calming." 

Kaylin's mother, Priscilla Jean-Louis, got COVID last month and had to rely on Kaylin to care for the elder women while she recovered. 

"She isn't forced to do it, but she helps me a great deal," Priscilla said. "If there are moments when I'm a little frustrated, she may pick up on it and be like 'Mommy, let me handle this.'" 

Rhianna's dad, Brian, 40, never smoked and was healthy before joining the Marine Corps. He believes he got sick from inhaling smoke from burn pits during the Iraq War. 

He was diagnosed with squamous cell carcinoma of the neck and throat in 2007. He also has PTSD, an inflammatory disease that causes muscle weakness and a rash, and hyperthyroidism from chemotherapy and radiation. 

Rhianna's mom is Brian's primary caregiver, but Rhianna helps her change her dad's trach tube and feed him through a feeding tube in his abdomen. 

"I'm still learning how to do it," Rhianna said. "I get nervous, though." 

The two look after him on and off all day. "Our care for him doesn't end," Rocio said. 

Rhianna is quiet and reserved. She has autism, struggles with communication and has trouble sleeping. She has been talking to a therapist once a week. 

The trach has had the biggest impact on Rhianna, because Brian doesn't join them for meals anymore. "I feel sad that he can't eat anything," she said. 

Despite the growing number of youth caregivers, they have little support. 

"If you look at all state and national caregiving programs and respite funding, they all begin at the age of 18," said Melinda Kavanaugh, an associate professor of social work at the University of Wisconsin-Milwaukee. 

Kavanaugh is researching Alzheimer's and caregiving in Latino and African American communities in Milwaukee. 

"We had a number of kids who were much more stressed out because they had no outlet," she said. "Now they're suddenly 24/7 care and there was absolutely no break." 

Adult and youth caregivers often suffer from anxiety, depression and isolation, but there is little data on how caregiving affects young people over the long term, Kavanaugh said.

Connie Siskowski, founder of the American Association of Caregiving Youth, helped care for her grandfather as a child. "I was not prepared," she said. "It was traumatic." 

Her Florida-based group connects young caregivers and their families with healthcare, education and community resources. The goal is to identify problems such as stress or isolation among the children, and address them so they won't harm them as adults, Siskowski said. 

But long-term care experts said caregiving can also enrich a young person's life. 

"It can help kids develop a sense of responsibility, empathy and confidence," Levine said. "The problem comes when their schoolwork, their friendships, their lives as a child are so affected by caregiving that they can't develop in those other important ways."

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

Heidi de Marco: heidid@kff.org, @Heidi_deMarco

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