The state's existing system of programs and services can be confusing for seniors who must navigate a disconnected patchwork of public and private offerings.

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

By Samantha Young

Even as the pandemic derailed some of Gov. Gavin Newsom's biggest healthcare proposals, such as lowering prescription drug costs, it crystallized another: the pressing need to address California's rapidly aging population.

Already nine months into their work when Newsom issued the nation's first statewide stay-at-home order last March, members of a state task force on aging watched as the coronavirus disproportionately sickened and killed older people, and left many isolated in nursing homes, assisted living facilities and their own homes.

"In many ways, it just accelerated and made more urgent that work," said Kim McCoy Wade, director of California's Department of Aging, who led the task force.

The group's work culminated in the release last month of a 10-year "Master Plan for Aging," a blueprint intended to guide state and local governments, the private sector and charitable organizations to improve housing, healthcare, caregiving, equity and affordability for California's older residents.

The state's existing system of programs and services can be confusing for seniors who must navigate a disconnected patchwork of public and private offerings. If they're able to find a program that fits their needs, it's often too costly for anyone other than low-income Medi-Cal recipients, whose participation is covered by public funding.

McCoy Wade hopes the state's Master Plan website will serve as a destination for Californians looking for programs or support, much as the First 5 website is for caregivers of young children.

But right now, the site mostly lists scores of ideas, such as creating a variety of affordable housing options for Californians, improving public transit, expanding geriatric care, redesigning nursing homes to be smaller and more home-like, improving broadband access and expanding telehealth.

That broad, holistic approach to healthcare is needed to help the state's aging population, said Dr. Sarita Mohanty, president and CEO of The SCAN Foundation, which advocates for older people. (Kaiser Health News, which publishes California Healthline, receives support for its coverage of aging and long-term care issues from The SCAN Foundation.)

The number of Californians age 60 and older is projected to grow to about 11 million by 2030, accounting for one-quarter of the state's population. In 2019, that group made up roughly one-fifth of the state's population, according to U.S. Census data.

"We can't be reactive. We have to be extremely proactive," said Mohanty, an internist. "It's not just about healthcare; it's about health and communities."

But will the plan end up gathering dust on a shelf, as have so many other government reports? McCoy Wade pledged that won't happen, pointing to an online dashboard that tracks the administration's progress implementing the plan's proposals through the state budget, the legislature and in communities.

There is already momentum. The administration has pledged to embark on more than 100 initiatives in the next two years, McCoy Wade said. In his proposed 2021-22 state budget, Newsom has asked for $250 million to buy and rehabilitate assisted living facilities for homeless seniors, and his administration is working with the federal government to determine how Californians can continue to use telehealth medicine after the pandemic.

McCoy Wade talked to California Healthline about why Newsom issued an executive order to create the plan, why it is so important for Californians and some ways to move it forward. The interview has been edited for length and clarity.

Q: Why does California need a Master Plan for Aging?

The executive order was really driven by the demographic change that we're living longer, we're having multiple stages of aging, and aging is diversifying.

Are you living in a single-family home that entire 30, 40, 50 years? Are you working perhaps longer, are you volunteering longer, are you living with three, four or five generations in one house? Are you living alone because your spouse, your friends and your peers may have died? That has been one of the "aha" moments but also one of the challenges: How do you plan for aging when it is so diverse?

Q: The Master Plan offers a blueprint for the next 10 years, but what are some proposals that can be tackled in the next few years?

In this pandemic, we learned a lot. It's important that people can stay in the home they choose but also have services accessible to them. For middle-class people, Medicare doesn't pay for the services people need, so you see the governor proposing a new Office of Medicare Innovation and Integration to help more Californians.

As we age, there are a couple of things that can be really helpful: taking care of housecleaning, taking care of shopping, taking care of cooking. We can retrofit houses to prevent falls. I think there's a real recognition that we have to expand the ability for middle-class folks to afford and have access to services and supports.

Home and health go together at all ages. But as you age, in particular, and for the older adults who are not homeowners, keeping up with rent, keeping up with the house itself, really becomes a risk to health. How do we make sure there are affordable housing options?

You see the governor's budget proposal for $250 million to purchase residential living facilities and dedicate them to older adults who either are at risk of homelessness or are homeless.

Q: What are some of the long-term goals?

The big issue for all of California is affordability. The governor has unveiled strategies around more housing, more housing, more housing and a range of housing in terms of families living together, caregivers living together, and affordable housing options. Older adults could either stay in the main house or move to a smaller unit. It just creates a whole lot of opportunities for those different ages and stages.

Getting healthcare costs and housing costs and care costs — the expense side of the ledger — down is incredibly helpful. But, the income has to somehow keep up to provide basic needs and basic quality of life. The SSI/SSP program is a top priority of our stakeholders, and there is a commitment to try to start walking that back up towards the federal poverty line and to begin to increase it in 2023. There's a widespread recognition it is not keeping up with the cost of living, much less the federal poverty line.

Q: You say many older Californians have a hard time paying for the help and services they need as they age. Is it just too expensive?

"Expensive" feels like not a shocking enough word. In community forums, people cry about spending down their savings and their kids' savings and they're going bankrupt. It's not hundreds of dollars. It's in the five figures a month.

Q: How did the pandemic affect what you included in the plan?

We pivoted to check-in campaigns to call people and check in at home because we knew there were challenges around isolation or gaps in services. That check-in campaign was manual, list by list. So, one of the things we want to look at is how do we create more preregistration, more automated systems. All this calling and lists should not be a one-time thing, and, sadly, in California we need it for wildfires. Now we need it for vaccines. We may need it in an earthquake.

This pandemic had just a devastating impact on Black and Latino and South Pacific Islander communities. The catch line for the Master Plan became that equity is baked in; it's not kind of the last paragraph. So, language access has become much more essential. Our department is doing a plan on diversifying our hiring and all the commission appointments. We just really need to do better.

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

Samantha Young: syoung@kff.org, @youngsamantha

Restaurant owners say it's an outrageous, unnecessary law that will make expansions and opening in new buildings impossible.

This article was published on Wednesday, February 17, 2021 in Kaiser Health News. This story also ran on U.S. News & World Report. It can be republished for free.

By Miranda Green

San Francisco restaurant owners, already simmering over covid-19 restrictions, are ready to boil over because of a city ban on natural gas stoves in new buildings that takes effect in June.

The ban, which also affects other gas appliances, is part of a statewide campaign aimed at reducing climate change-feeding carbon emissions as well as health hazards from indoor gas exposure. A similar ban went into effect in Berkeley in 2020; Oakland and San Jose recently passed similar measures, and other California cities are considering them.

Officials championing the bans say they’re responding to evidence that gas stoves emit dangerous levels of toxic gases such as nitrogen oxide, nitrogen dioxide and formaldehyde, which can cause heart and lung problems, aggravate asthma and contribute to early death, according to federally funded research.

Restaurant owners say it’s an outrageous, unnecessary law that will make expansions and opening in new buildings impossible. It puts salt in the wounds of businesses agonizing over covid restrictions, they add.

“If you get rid of the gas element, I don’t think restaurants can do it unless you’re like a coffee shop with a panini press,” said Matthew Dolan, executive chef and partner of restaurant 25 Lusk in San Francisco. “Whoever cooked up this idea should be reprimanded.”

Many are skeptical that properly vented stoves pose any health problems. Restaurants in California are required to have state-of-the-art ventilation systems that remove byproducts of burning natural gas and circulate fresh air, Dolan said. “The average employee isn’t really in contact with those issues,” he said.

The California Restaurant Association sued Berkeley in 2019 over its ban, arguing that it makes it impossible to prepare flame-seared meats, charred vegetables and wok-prepared dishes, putting steakhouses, ethnic restaurants and others out of business.

“You cannot cook with an electric wok,” said Vice Mayor Chin Ho Liao of San Gabriel, a Los Angeles suburb with 200 restaurants, mostly Asian. “You can cook with them, but it won’t taste good.”

Defenders of the law say it’s a long-delayed recognition of the harm of indoor pollution, which isn’t regulated by the Environmental Protection Agency, and is especially important since 87% of the typical person’s life is spent indoors.

Research shows clearly that gas stoves put out potentially dangerous levels of toxic fumes. Electric stoves also pollute, but at lower levels. While it’s difficult to prove gas stoves diminish health, studies have shown correlations between their use and higher rates of illness.

Buildings account for the second-largest percentage of San Francisco’s carbon footprint, next to transportation, and natural gas accounts for more than 75% of that. Roughly half of California homes use natural gas for cooking, according to the California Energy Commission. But health impacts are potentially a more immediate risk than climate change.

A study by UCLA’s Fielding School of Public Health in June found that in modeled scenarios where a gas stove and oven are used simultaneously for one hour, concentrations of nitrogen dioxide usually exceed the pollution levels dictated by national and California air quality standards. Gas appliances also release carbon monoxide and particulates.

“All of those have been shown to be detrimental to human health,” said Yifang Zhu, lead author of the UCLA study and a professor in the school’s department of environmental health sciences.

San Francisco Supervisor Rafael Mandelman, the sponsor of the city’s ban, said in a written release that building electrification is “a critical step in addressing the serious public health and safety hazards of natural gas, and of course the ever-intensifying climate crisis.” He also cited a report by the Rocky Mountain Institute, a clean energy think tank, which found high levels of harmful emissions in homes and businesses with gas stoves.

In November, California’s air regulation agency adopted a resolution to curtail emissions from gas appliances in buildings and said pollution could exacerbate covid-19. Climate activists are urging the California Energy Commission to include a ban on gas hookups in its next building regulations update, a move that would affect the entire state.

There’s been a similar push in Massachusetts. The nation’s oldest medical society last December became the first to recognize the health impacts of gas cooking — though it also noted that ventilation mitigates such effects.

When caring for children with asthma, health care practitioners should ask, “‘What kind of stove do you have?’” said Dr. T. Stephen Jones, a retired former Centers for Disease Control and Prevention official who co-sponsored a resolution on the matter passed by the Massachusetts Medical Society.

Society members were taken aback by the data on how gas stoves could make children sick.

“This is not really out in the general public. It’s not out among providers,” said Dr. Heather Alker, chair of the society’s environmental and occupational health committee.

Low-income people are at particularly high risk because they tend to live in smaller residences where gases can concentrate; may use kitchen appliances for supplemental heat; and cannot easily maintain or replace older equipment, especially if they rent, according to the UCLA study.

A government-funded 2014 study concluded that residents of 62% of the Southern California homes it measured were routinely exposed to nitrogen dioxide through hoodless appliances at levels that exceed health standards. A 2012 study done at the behest of the DOE found particulate matter from indoor gas burning could hurt lungs and reduce life expectancy.

As outdoor air gets cleaner, policymakers are focusing more on indoor air quality, which was “under the radar previously” and generally not regulated by state or federal governments, Zhu said.

Critics of the bans argue that electricity is more expensive than natural gas and will drive prices up, making it especially hard for low-income residents. And not all cities are on board with the move away from gas.

More than 100 California cities, including San Gabriel, have approved resolutions, with language put forward by the Southern California Gas Co., calling for “balanced energy solutions.”

In addition to the near impossibility of properly stir-frying food with electricity, Liao is worried about making residents rely solely on the state’s overworked electrical grid, which was hit with rolling blackouts last year. He is pushing for the development of clean gas derived from methane captured from rotting food, a process called anaerobic digestion. Riverside has such a project. But the approach needs more funding and development to be scalable, the vice mayor acknowledged.

The gas ban could pose an extra burden on restaurants struggling to survive covid strictures, owners and chefs say.

“This is the last thing in the world we need right now,” said Dolan. “It’s an added burden on an already burdened industry.”

But advocates for the change say people need to look at the issue a new way.

“When you actually stop and think about it as ‘This is a gas-guzzling device that’s in the middle of my house,’ it is sort of like a mind shift,” said Brady Seals, a senior associate at the Rocky Mountain Institute. “I don’t think it’s unrealistic to think that, in a generation or two, we’ll come to a place where our kids can’t ever imagine why we would want to burn a fossil fuel in our kitchen that emits some of the same pollutants that come from tailpipes.”

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

Staffers at St. James Parish Hospital spent hours each day in January calling larger hospitals in search of the elusive beds for covid-19 patients.

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

By Lauren Weber

Editor's note: KHN wrote about St. James Parish Hospital in April, when it was experiencing its first surge of covid-19 patients. Ten months later, we checked in to see how the hospital and its staff were faring.

The "heroes work here" sign in front of St. James Parish Hospital has been long gone, along with open intensive care unit beds in the state of Louisiana.

Staffers at the rural hospital spent hours each day in January calling larger hospitals in search of the elusive beds for covid-19 patients. They leveraged personal connections and begged nurses elsewhere to take patients they know are beyond their hospital's care level.

But as patients have waited to be transferred out of the hospital, which is about 45 minutes outside New Orleans, doctors such as Landon Roussel are forced to make unthinkable choices. As recently as Jan. 29, he had to decide between two patients: Which one should get the sole available BiPAP machine to push oxygen into their lungs?

That's like a "war situation, which is not a situation that I want to be in — in the United States," he said.

As the nation's attention shifts to the vaccine rollout, rural hospitals such as St. James Parish Hospital have struggled to handle their communities' sick following the holiday surge of covid patients.

"We knew it was coming. We saw it coming," Mary Ellen Pratt, St. James Parish Hospital's CEO, said by phone. "It really has to happen to their family for them to really go, 'OK, wow.'"

And even though the vaccines have arrived and caseloads continue to improve after the holiday surge, only about 30% of staffers have opted to get their shots. Disparities in the broader community persist: In the initial rollout, only 9% of those vaccinated were Black in a parish — the Louisiana equivalent of a county — that is nearly 49% Black.

Staff members are burned out from months of handling never-ending covid crises.

"They had been giving 150%, and they're just getting really tired," Pratt said. "It's just exhausting."

'Sometimes, Your Best Isn't Enough'

In mid-January, the closest intensive care bed the staff could find was some 600 miles away in Brownsville, Texas — so far that a plane would have been necessary to transport a patient. After three days, a closer bed was found at a Veterans Affairs hospital about 45 miles away.

Staffers have tried Mississippi and Alabama with mixed luck. One patient they tried to transfer four hours away couldn't go because the ambulance didn't have enough oxygen to make it that far. A hospital in Florida even called them looking for ICU beds at St. James Parish Hospital, which has never had any.

More than half of U.S. counties are like St. James Parish and have no intensive care beds, full or empty. Rural hospitals in those communities are designed for step-down care: They often serve as a stopping point to stabilize people before they can be sent to larger hospitals with more specialized staff and equipment.

Across the country, rural residents' mortality rate from covid has been consistently higher than that of urban residents since August, according to the Rural Policy Research Institute Center for Rural Health Policy Analysis. That has occurred even though covid incidence has been lower among rural populations than urban ones since the middle of December, said Fred Ullrich, who runs the health policy department at the University of Iowa's College of Public Health and co-authored the study.

But, he said, rural populations are typically older, sicker and poorer than urban populations. And the nation has lost at least 179 rural hospitals over the past 17 years.

"This crisis is just magnifying existing access issues in a rural context," said Alan Morgan, the head of the National Rural Health Association. "If you don't have a local hospital, that impacts the diagnosis, the initial treatment, the complex treatment. It has multiple impacts, all leading to what we're seeing: higher mortality."

And at the hospitals that remain, such as St. James Parish Hospital, the stress level is palpable, because the level of care needed for such sick patients is higher than what staffers normally handle, said Karley Babin, the hospital's acute nurse manager.

"It's just an uncomfortable spot," she said. "You know you're doing everything you can and that patient just needs more."

That's led to many sleepless nights for Pratt.

"Sometimes your best isn't enough if you don't have the right resources," she said.

'We Know All These People'

Radiology technologist Brooke Michel lives seven minutes from the hospital, where she works with her husband and five other relatives. Her grandfather, grandmother and aunt were hospitalized there in December with covid.

Her family brought folding chairs to sit outside her 83-year-old grandfather's hospital window each day, keeping vigil through the glass on Christmas Eve. He died Jan. 3 while family members stood outside, taking turns looking in and praying.

"It gave us a sense of closure," Michel said. "We were all together. We were with him. We would never have gotten that at a bigger hospital."

Seeing multiple family members hospitalized at the same time is tough on the staff, said Scott Dantonio, the hospital's pharmacy director. "We know all these people," he said.

Dozens of hospital staffers also have battled covid, and three have been hospitalized. A nurse's aide died last summer after contracting it. One staffer, who was particularly close to that aide, now has a hard time treating covid patients, said Rhonda Zeringue, chief nursing officer.

"It's a reminder: 'You took my person,'" she said.

'It's Just Exhausting'

St. James Parish Hospital has been running short-staffed, because they haven't been able to hire more nurses or pay traveling nurses — they're just too expensive. Amid the pandemic, traveling nurses can command more than double what the staff nurses make.

So Babin's kids ask often why she works all the time.

Community praise has died down, she said. People aren't thanking them in grocery stores anymore. One upside? Pratt is happy to have finally lost the "covid 19" — the weight she put on from the community bringing food to the hospital back in the spring.

Pratt and Zeringue have offered staff members counseling, massage sessions, coffee and doughnuts. But it's not enough.

Zeringue said the stress has gone through the staff in waves: First they were scared to death of being the front line in the spring. Now she sees burnout and sheer exhaustion.

The vaccines were supposed to offer hope. But when Pratt heard they would be distributed through CVS and Walgreens, she knew immediately the logistics of getting the ultra-cold Pfizer vaccine from its cooler into residents' arms would fall to them. She said the community has no chain pharmacies nearby and the local health department is overloaded.

"We get an email at, like, 4:30 on Friday which says, 'We're going to send you another 350 vaccines on Wednesday and you have to respond in the next 10 minutes,'" Pratt said. "There's not enough planning or time to do it."

Staff members, who are juggling monoclonal antibody infusions and elective surgeries to deal with the backlog from the spring on top of the surge, must also call members of the community to let them know they have the vaccine available. And then the problems begin.

"People don't answer the phone or they're not available," Dantonio said. "Or they can't come at that time or they scheduled somewhere else."

Most of the people coming in following the hospital's advertising online and on Facebook have been white. So Pratt called on the people she had relied on during the rollout of the Affordable Care Act: Black preachers and well-respected Black local leaders such as Democratic state Rep. Kendricks Brass. After word from the pulpit spread and Brass' team staffed a phone line, the vaccine distribution the next week jumped to 30% Black residents from the prior week's 9%.

Even some among the St. James Parish Hospital staff have been reluctant. Many have told Zeringue they're worried about their fertility. Others just don't want to be first. So the hospital's line of defense has many holes.

And the covid patients keep coming.

"This is a nightmare," said Kassie Roussel, the hospital's marketing director. "It's crazy because it's at the same time we marketed the beginning of the end."

Lauren Weber: LaurenW@kff.org, @LaurenWeberHP

The Biden administration is promising to spend $50 million on outreach and education to get the word out about the new special enrollment period.

This article was published on Tuesday, February 16, 2021 in Kaiser Health News. This story also ran on NPR.

By Michelle Andrews

For people who’ve been without health insurance during the pandemic, relief is in sight.

In January, President Joe Biden signed an executive order to open up the federal health insurance marketplace for three months as of Monday so uninsured people can buy a plan and those who want to change their marketplace coverage can do so.

Consumer advocates applauded the directive. Since 2016, the number of Americans without health insurance has been on the rise, reaching 30 million in 2019. The economic upheaval caused by the novel coronavirus has made a bad situation worse, throwing millions off their insurance plans.

The move is in stark contrast to the Trump administration’s approach. As covid-19 took hold last spring and the economy imploded, health experts pleaded with the Trump administration to open up the federal marketplace so people could buy insurance to protect themselves during the worst public health emergency in a century. The administration declined, noting that people who suddenly found themselves without coverage because they lost their jobs were able to sign up on the marketplace under ordinary rules. They also cited concerns that sick people who had resisted buying insurance before would buy coverage and drive up premiums.

The Biden administration is promising to spend $50 million on outreach and education to get the word out about the new special enrollment period. That’s critical, experts said. Although the number of people signing up for Affordable Care Act plans has generally remained robust, the number of new consumers enrolling in the federal marketplace has dropped every year since 2016, according to KFF, corresponding to funding cuts in marketing and outreach. (KHN is an editorially independent program of KFF.)

“There are a lot of uninsured people who even before covid were eligible for either hefty marketplace subsidies or for Medicaid and not aware of it,” said Sabrina Corlette, a research professor at Georgetown University’s Center on Health Insurance Reforms. A marketing blitz can reach a broad swath of people and hopefully draw them in, regardless of whether they’re uninsured because of covid or not, she said.

Here are answers to questions about the new enrollment option.

Q: When can consumers sign up, and in which states?

The sign-up window will be open for three months, from Monday through May 15. Uninsured residents of any of the 36 states that use the federal healthcare.gov platform can look for plans during that time and enroll.

Most of the states and the District of Columbia that operate their own marketplaces are establishing special enrollment periods similar to the new federal one, though they may have somewhat different time frames or eligibility rules. In Massachusetts, for example, the sign-up window remains open until May 23, while in Connecticut, it closes March 15. Meanwhile, Colorado has reopened enrollment in its marketplace for residents who lack insurance, but anyone already enrolled in one of the state’s marketplace plans won’t be allowed to switch to a different plan based on this special enrollment period.

At this point, only Idaho has not announced plans to open their marketplaces, said Corlette. It may still do so, however.

Q: Can people who lost their jobs and health insurance many months ago sign up during the new enrollment period?

Yes. The enrollment window is open to anyone who is uninsured and would normally be eligible to buy coverage on the exchange (people who are serving prison or jail terms and those who are in the country without legal permission aren’t allowed to enroll).

People with incomes up to 400% of the federal poverty level (about $51,500 for one person or $106,000 for a family of four) are eligible for premium tax credits that may substantially reduce their costs.

Typically, people can buy a marketplace plan only during the annual open enrollment period in the fall or if a major life event gives them another opportunity to sign up, called a special enrollment period. Losing job-based health coverage is one event that creates a special sign-up opportunity; so is getting married or having a baby. But usually people must sign up with the marketplace within 60 days of the event.

With the new special enrollment period, how long someone has been uninsured isn’t relevant, nor do people have to provide documentation that they’ve lost job-based coverage.

“The message is quite simple: Come and apply,” said Sarah Lueck, a senior policy analyst at the Center on Budget and Policy Priorities.

Q: What about people who are already enrolled in a marketplace plan? Can they switch their coverage during this new enrollment period?

Yes, as long as their coverage is through the federal marketplace. If, for example, someone is enrolled in a gold plan now but wants to switch to a cheaper bronze plan with a higher deductible, that’s allowed. As mentioned above, however, some state-operated marketplaces may not make that option available.

Q: Many people have lost significant income during the pandemic. How do they decide whether a marketplace plan with premium subsidies is a better buy for them than Medicaid?

They don’t have to decide. During the application process, the marketplace asks people for income information. If their annual income is below the Medicaid threshold (for many adults in most states, 138% of the federal poverty level, or about $18,000 for an individual), they will be directed to that program for coverage. If people are eligible for Medicaid, they can’t get subsidized coverage on the exchange.

People can sign up for Medicaid anytime; there’s no need to wait for an annual or special enrollment period.

Those already enrolled in a marketplace plan whose income changes should go back into the marketplace and update their income information as soon as possible. They may be eligible for larger premium subsidies for their marketplace plan or, if their income has dropped significantly, for Medicaid. (Likewise, if their income has increased and they don’t adjust their marketplace income estimates, they could be on the hook for overpayments of their subsidies when they file their taxes.)

Q: What about people who signed up under the federal COBRA law to continue their employer coverage after losing their job? Can they drop it and sign up for a marketplace plan?

Yes people in federal marketplace states can take that step, health experts say. Under COBRA, people can be required to pay the full amount of the premium plus a 2% administrative fee. Marketplace coverage is almost certainly cheaper.

Normally, if people have COBRA coverage and they drop it midyear, they can’t sign up for a marketplace plan until the annual fall open enrollment period. But this special enrollment period will give people that option.