KFF Health News

KFF Health News is a national health policy news service that is part of the nonpartisan Henry J. Kaiser Family Foundation.

Think Your Health Care Is Covered? Beware of the 'Junk' Insurance Plan

KFF Health News, December 4, 2020

With this year’s open enrollment period well underway, millions of people are looking for coverage on the federal and state marketplaces.

This article was published on Thursday, December 4, 2020 in Kaiser Health News.

By Michelle Andrews

Looking back, Sam Bloechl knows that when the health insurance broker who was helping him find a plan asked whether he’d ever been diagnosed with a major illness, that should have been a red flag. Preexisting medical conditions don’t matter when you buy a comprehensive individual plan that complies with the Affordable Care Act. Insurers can’t turn people down or charge them more based on their medical history.

But Bloechl, now 31, didn’t know much about health insurance. So when the broker told him a UnitedHealthcare Golden Rule plan would cover him for a year for less than his marketplace plan — “Unless you like throwing money away, this is the plan you should buy,” he recalls the agent saying — he signed up.

That was December 2016. A month later Bloechl was diagnosed with stage 4 non-Hodgkin’s lymphoma after an MRI showed tumors on his spine.

To Bloechl’s dismay, he soon learned that none of the expensive care he needed would be covered by his health plan. Instead of a comprehensive plan that complied with the ACA, he had purchased a bundle of four short-term plans with three-month terms that provided only limited benefits and didn’t cover preexisting conditions.

Because they tend to be less expensive, short-term plans continue to find buyers, and they have been championed by the Trump administration, which has loosened restrictions on them, as an alternative for consumers.

With this year’s open enrollment period well underway, millions of people are looking for coverage on the federal and state marketplaces. Sometimes it’s hard to tell the difference between comprehensive plans sold there and “junk” plans with limited benefits and coverage restrictions.

“These plans continue to proliferate,” said Cheryl Fish-Parcham, director of access initiatives at Families USA, a consumer health care advocacy organization. “People need to be careful, whether they’re buying by phone or on a website.”

Bloechl assumed he was buying a comprehensive plan that would cover him for a life-threatening illness, although at the time he had no inkling he was sick. But when doctors said Bloechl needed a stem cell transplant, Golden Rule denied the request.

The reason: He had visited a chiropractor for back pain before he bought the plan. Bloechl had blamed the pain on the heavy lifting that came with running his Chicago landscaping business. But Golden Rule argued that he had sought medical treatment for a preexisting condition — cancer — so the plan didn’t have to cover it. It didn’t matter that he hadn’t been diagnosed when he purchased it.

The insurer didn’t cover any of his other bills for chemo and radiation either. Bloechl appealed the decision, but his appeals failed. He had more than $800,000 in bills for care — and that’s before the stem cell transplant he desperately needed.

“It’s just disgusting that these companies expect Joe Schmo or a guy like me to interpret [these policies] and then get screwed in the end,” Bloechl said.

UnitedHealthcare refused to discuss this case with KHN unless Bloechl signed a statement waiving his right to privacy. But he told KHN he did not feel comfortable signing a legal document provided by the insurer.

“Our agents work with individuals to help them understand their health insurance options and select a plan that best meets their needs,” said UnitedHealthcare’s communications director, Maria Gordon Shydlo, in an email. “We inform each individual of their coverage options, including associated costs, network size and if the selected plan covers pre-existing conditions. We adhere to a stringent application process that helps ensure consumers understand the plan they are purchasing before they make a final decision.”

Consumer advocates have long sounded alarm bells about short-term and other plans that don’t comply with the Affordable Care Act rules that require plans to provide comprehensive benefits to all comers, regardless of their health, and prohibit placing annual or lifetime dollar limits on coverage. ACA-compliant plans can also be purchased outside the marketplace, however, and that’s where shoppers may run into trouble, thinking they’re buying comprehensive coverage when they’re actually buying something much more limited.

“It’s a little bit of the Wild West out there,” said Sabrina Corlette, a research professor at Georgetown University’s Center on Health Insurance Reforms. “We often get calls about these products, and sometimes it can be challenging to figure out what they even are.”

Short-term plans have garnered much attention in recent years. In 2017, the Obama administration limited their duration to less than three months to discourage people from relying on these limited plans for primary coverage rather than as a temporary coverage bridge for people switching plans, as intended. But these plans were championed by the Trump administration as a cheaper option for consumers, and it issued a rule in 2018 that permitted short-term plans with terms of up to 364 days, with an option to renew for up to 36 months. The rule requires short-term plan materials to explain that the plans are not comprehensive insurance and may not cover some medical costs.

Such plans can be appealing to healthy people who don’t expect to need medical care. But as Bloechl’s experience shows, life can throw curveballs.

“Our patients are often young and healthy,” said Ryan Holeywell, senior director of advocacy communications at the Leukemia & Lymphoma Society.

Some states restrict or even prohibit the sale of short-term plans on the individual market.

But these short-term plans are just the tip of the iceberg.

There are fixed indemnity plans that pay out a certain amount — $100 a day for a limited hospital stay or $150 for an OB-GYN visit, for example — that may not come close to covering the actual costs.

Accident and critical illness plans provide lump-sum cash benefits when people experience medical emergencies like a heart attack or stroke under certain circumstances.

Cancer-only plans may provide hospitalization coverage but not cover other services. “You may be treated with chemo and radiation but never go to the hospital,” said Anna Howard, a policy principal at the American Cancer Society’s Cancer Action Network. “So, the policy may never pay out.”

Then there are bundled plans that combine options, such as a short-term plan along with a prescription drug discount card and cancer coverage.

Unfortunately, consumers can’t always rely on insurance brokers to give them accurate information or steer them to comprehensive coverage, as Sam Bloechl discovered.

In August, the federal Government Accountability Office published a report about the experiences of “secret shoppers” who called 31 health insurance sales representatives and asked about plans, saying they had preexisting conditions such as diabetes and heart disease. In more than a quarter of cases, the sales reps “engaged in potentially deceptive marketing practices,” the report found, including falsely claiming that drugs such as insulin were covered, or offering a plan that didn’t cover preexisting conditions.

One reason brokers might encourage consumers to buy non-ACA plans: higher commissions.

“In our survey of brokers, they do report they pay higher commissions than ACA plans,” Corlette said. Some brokers reported they avoid noncompliant plans, however, because they pose risks for consumers.

The National Association of Health Underwriters, an organization for health insurance and employee benefits professionals, did not respond to a request for information and comment.

Consumers can be sure they’re getting a comprehensive, ACA-compliant plan if they buy it from marketplaces set up by that health law, Howard said.

Brokers can help people understand their options and buy a plan, including plans that comply with the ACA, but picking a broker can be challenging.

“Ideally go to someone in a brick-and-mortar building who has to bump into you in the grocery store,” Corlette said.

After his experience with Golden Rule, Sam Bloechl decided his best option was to offer a group plan to workers at his small landscaping company that he could also enroll in. He worked with a different broker, and he had lawyers look over the policies he was considering. He wanted to be sure that whatever plan he bought would cover his stem cell transplant.

The new plan did cover it. And by the time he went to work out payment on his $800,000-plus bill, his income had declined so much because of his illness that he qualified for charity care. The hospital wrote off his bill.

His cancer is in remission.

But the experience with the short-term policy still rankles. “Charity care picked up the one bill and [UnitedHealthcare Golden Rule’s] competitor paid for the transplant,” he said. “They got off the hook without paying a dime.”

What Happened When the Only ER Doctor in a Rural Town Got COVID

KFF Health News, December 4, 2020

Kurt Papenfus is the lone full-time emergency room doctor in the town of 900, not far from the Kansas line.

This article was published on Thursday, December 4, 2020 in Kaiser Health News.

By John Daley, Colorado Public Radio

Kurt Papenfus, a doctor in Cheyenne Wells, Colorado, started to feel sick around Halloween. He developed a scary cough, intestinal symptoms and a headache. In the midst of a pandemic, the news that he had COVID-19 wasn’t surprising, but Papenfus’ illness would have repercussions far beyond his own health.

Papenfus is the lone full-time emergency room doctor in the town of 900, not far from the Kansas line.

“I’m chief of staff and medical director of everything at Keefe Memorial Hospital currently in Cheyenne County, Colorado,” he said.

With Papenfus sick, the hospital scrambled to find a replacement. As coronavirus cases in rural Colorado, and the state’s Eastern Plains especially, surge to unprecedented levels, Papenfus’ illness is a test case for how the pandemic affects the fragile rural health care system.

“He is the main guy. And it is a very large challenge,” said Stella Worley, CEO of the hospital.

If she couldn’t find someone to fill in while he was sick, Worley might have to divert trauma and emergency patients nearly 40 miles north to Burlington.

“Time is life sometimes,” she said. “And that is not something you ever want to do.”

‘The ‘Rona Beast Is a Very Nasty Beast’

As deaths from the coronavirus have surpassed 250,000 in the U.S., new data show the pandemic has been particularly lethal in rural areas — it’s taking lives in those areas at a rate reportedly nearly 3.5 times higher than in metropolitan communities.

About 63 people in Cheyenne County have been diagnosed with COVID-19, most of them in the past three weeks.

Papenfus, a lively 63-year-old, was discharged after a nine-day stay at St. Joseph’s Hospital in Denver, and he was eager to sound the alarm about the disease he calls the ‘rona.

“The ‘rona beast is a very nasty beast, and it is not fun. It has a very mean temper. It loves a fight, and it loves to keep coming after you,” Papenfus said.

He isn’t sure where he picked it up but thinks it might have been on a trip east in October. He said he was meticulous on the plane, sitting in the front, last on, first off. But on landing at Denver International Airport, Papenfus boarded the crowded train to the terminal, and soon alarm bells went off in his head.

“There are people literally like inches from me, and we’re all crammed like sardines in this train,” Papenfus said. “And I’m going, ‘Oh, my God, I am in a superspreader event right now.'”

An airport spokeswoman declined to comment about Papenfus’ experience.

A week later, the symptoms hit. He tested positive and decided to drive himself the three hours to the hospital in Denver. “I’m not going to let anybody get in this car with me and get COVID, because I don’t want to give anybody the ‘rona,” he said. County sheriff’s deputies followed his car to ensure he made it.

Once in the hospital, chest X-rays revealed he’d developed pneumonia.

“Dude, I didn’t get a tap on the shoulder by ‘rona, I got a big viral load,” he texted a reporter, sending images of his chest scans that show large, opaque, white areas of his lung. Just a week earlier, his chest X-ray was normal, he said.

Back in Cheyenne Wells, Dr. Christine Connolly picked up some of Papenfus’ shifts, although she had to drive 10 hours each way from Fort Worth, Texas, to do it. She said the hospital staff is spread thin already.

“It’s not just the doctors; it’s the nurses, you know. It’s hard to get spare nurses,” she said. “There’s not a lot of spares of anything out that far.”

Besides himself, six other employees — out of a staff of 62 at Keefe Memorial — also recently got a positive test, Papenfus said.

Hospitals on the Plains often send their sickest patients to bigger hospitals in Denver and Colorado Springs. But with so many people around the region getting sick, Connolly is getting worried hospitals could be overwhelmed. Health care leaders created a new command system to transfer patients around the state to make more room, but Connolly said there is a limit.

“It’s dangerous when the hospitals in the cities fill up, and when it becomes a problem for us to send out,” she said.

‘Bank Robbers Wear Masks Out There’

The impact of Papenfus’ absence stretches across Colorado’s Eastern Plains. He usually worked shifts an hour to the northwest, at Lincoln Community Hospital in Hugo. Its CEO, Kevin Stansbury, said the town mostly dodged the spring surge and his facility could take in recovering COVID patients from Colorado’s cities. Now, Stansbury said, the virus is reaching places such as Lincoln County, population 5,700. It has had 144 cases, according to state data, and neighboring Kit Carson has had 301. Crowley County to the south, home to a privately managed state prison, has had 1,239 cases. It is far and away the No. 1 most affected county per capita in the state.

“So those numbers are huge,” Stansbury said. He said that as of mid-November about a half-dozen hospital staffers had tested positive for the virus; they think that outbreak is unrelated to Papenfus’ case.

Lincoln Community Hospital is ready once again to take recovering patients. Finances in rural health care are always tight, and accepting new patients would help.

“We have the staff to do that, so long as my staff doesn’t get ravaged with the disease,” Stansbury said.

Rural communities are particularly vulnerable. Residents tend to suffer from underlying health conditions that can make COVID-19 more severe, including high rates of cigarette smoking, high blood pressure and obesity. And Brock Slabach of the National Rural Health Association said 61% of rural hospitals do not have an intensive care unit.

“This is an unprecedented situation that we find ourselves in right now,” Slabach said. “I don’t think that in our lifetimes we’ve seen anything like what is developing in terms of surge capacity.”

A couple of hours east of Cheyenne Wells, COVID-19 recently hit Gove County, Kansas, hard.

The county’s emergency management director, the local hospital CEO and more than 50 medical staff members tested positive. In a nursing home, most of the more than 30 residents caught the virus; six have died since late September, according to The Associated Press. A county sheriff ended up in a hospital more than an hour from home, fighting to breathe, because of the lack of space at the local medical center.

Papenfus fretted about his home county and its odds of fighting off the virus.

“The western prairie isn’t mask country,” he said. “People don’t wear masks out there; bank robbers wear masks out there.” He is urging Coloradans to stay vigilant, calling the virus an existential threat. “It’s a huge wake-up call.”

Since being released from the hospital, Papenfus has had a rocky recovery. His wife, Joanne, drove him back to Cheyenne Wells, wearing an N95 mask and gloves, while he rode in the back on oxygen, coughing through the three-hour drive.

Once back at home after that initial nine-day stay, Papenfus hunkered down, with the occasional trip outside to hang out with his pet falcon.

But a week after going home, he started having nightly fevers. He had a CT scan done at Keefe Memorial, the hospital where he works. It revealed pneumonia in his lungs, so he went back to Denver, getting readmitted at St. Joseph’s Hospital. This time, Papenfus arrived via ambulance.

Finding a replacement for Papenfus at Keefe has been hard. The hospital is working with services that provide substitute physicians, but these days, with the coronavirus roaring across the country, the competition is fierce.

“They’re really scrambling to get coverage,” Papenfus texted from his hospital bed. “Whole county can’t wait for my return but this illness has really taken me down.”

He said he was now at Day 35 from his first symptoms, lying in his hospital bed in Denver, “wondering when I’ll ever get back.” Papenfus noted that COVID-19 has affected his critical thinking and that he will need to be cleared cognitively to return to work. He said he knows he won’t have the physical stamina to get back to full duty “for a while, if ever.”

This story is from a reporting partnership that includes Colorado Public Radio, NPR and KHN.

After a Deadly COVID Outbreak, Maryland County Takes Steps to Protect Health Workers

KFF Health News, December 4, 2020

Union officials say the county has also made personal protective equipment, such as masks and gloves, more available in recent months and put a greater emphasis on social distancing.

This article was published on Thursday, December 4, 2020 in Kaiser Health News.

By Laura Ungar

A Maryland health department is taking new steps to protect its workers six months after a COVID-19 outbreak killed a veteran employee who was twice denied permission to work from home.

Chantee Mack, 44, died in May. More than 20 colleagues also caught the coronavirus, and some are suffering lasting problems.

Now, after a KHN and Associated Press story in July spurred an investigation, Prince George’s County officials say they have added an appeals process to their work-at-home policy and hired a consultant to identify “operational and management needs for improvement” in the department. Union officials say the county has also made personal protective equipment, such as masks and gloves, more available in recent months and put a greater emphasis on social distancing.

“We’re getting somewhere,” said Rhonda Wallace, leader of a local branch of the American Federation of State, County and Municipal Employees. “But we’re not there yet.”

In an email to KHN, health department spokesperson George Lettis said officials can’t release results of the county investigation because of personnel and medical information. But a county official’s letter to Wallace shares the inquiry’s main conclusions: that the health department tried to get PPE in early March and advised employees about social distancing and proper hygiene via a newsletter.

“It must not be overlooked that this was a rapidly evolving situation,” said the letter from Dr. George Askew, deputy chief administrative officer for health, human services and education. “Best efforts were made to keep the community and Health Department employees safe and informed during this unprecedented time.” The letter does not acknowledge any lapses made by the county.

Some employees argue the investigation didn’t delve into the circumstances around Mack’s death and say the county should publicly acknowledge its role in what happened. At a news conference in July, County Executive Angela Alsobrooks said Mack’s death “deserves an investigation” and the county would “spare no time or expense.”

Mack, who worked in the department’s sexually transmitted diseases program, was denied permission to work from home in March even though she had health problems that put her at high risk for COVID-19 complications.

At least three other employees whose requests to work from home were denied around that time also got sick. Revonda Watts, a nurse and program manager, said she was allowed to work from home for one day before being called back to the office. Some of these employees worked face-to-face with the public at least part of the time.

A union document obtained by KHN detailed a conference call by department managers in which Diane Young, an associate director, laid out criteria for working from home, such as being 65 or older or having small children. She said decisions would be made case by case.

Meanwhile, protective masks, gowns and other safety equipment were in short supply nationally and at the health department, which distributed them only to certain workers. In early April, when Young asked Watts about PPE needs, Watts wrote in an email obtained by KHN: “N-95 masks are needed for all staff. We were given 1 mask to reuse. We have no face shields for the clinicians nor do we have gowns.”

Young responded that even though goggles were available, “face shields and gowns are in limited supply and will be used for those who are testing patients for COVID-19.”

Several employees described meetings and “morning huddles” in the office in March and April held without social distancing and during which few, if any, participants wore masks.

One employee after another got sick.

Watts, who is 58 and has asthma, developed bronchitis on top of COVID-19, then chest pain from spasms in her blood vessels. She spread the virus to her adult daughter.

Administrative aide Natania Bowen also spread the virus to her family, including her husband and 7-year-old daughter, who have since recovered. Bowen, a 47-year-old with asthma, experienced a bacterial lung infection along with COVID-19.

Receptionist Yolanda Potter, 53, had severe headaches for a month from her coronavirus infection. She developed a blood clot in her right leg and had to inject blood thinners into her stomach for 45 days to prevent it from breaking off and traveling to her lungs or brain. She and Carolyn Ferguson, an X-ray tech now on desk duty, suffer ongoing memory problems, while Bowen continues to have lung issues.

While Bowen now works from home, Watts, Potter and Ferguson are back at the office. As of mid-November, Lettis said, 141 health department employees were working fully on-site, 68 partly on-site and 196 at home.

Employees said they are pleased that social distancing is now the norm in the health department, that more places to sanitize hands exist and that PPE is easier to get. They’re also hopeful about the new policy on remote work.

The countywide rules include two levels of review for work-at-home requests: one by a supervisor and another by a higher-up boss who must give a reason if a worker’s request is denied. The employee can then ask the Office for Human Resource Management to review the denial.

Despite such measures, some employees still worry about contracting COVID-19 at work, especially as the state’s COVID dashboard puts the county’s cumulative caseload over 42,000.

Several employees are seeking long-term disability leave or talking to lawyers about getting workers’ compensation. Watts said she is awaiting a workers’ comp hearing and has asked again for permission to work from home as she deals with crushing fatigue and numbness in her legs and hands. Since returning to the office, she said, she has had to bring her own mask from home.

“I get frustrated with not being able to just bounce back,” she said. The health department officials “really let us down and didn’t do their due diligence to make sure the staff was protected.”

This story is a collaboration between The Associated Press and KHN.

As LA County Sets New Infection Record, State Leaders' Behavior Sends Mixed Messages

KFF Health News, December 3, 2020

But even as the restrictions began in Los Angeles, leaders across California took heat for their do-as-I-say-not-as-I-do pandemic behavior.

This article was published on Thursday, December 3, 2020 in Kaiser Health News.

By Jackie Fortiér, KPCC

California, like the rest of the nation, is seeing a dramatic rise in COVID infections and deaths — and Los Angeles County has some of the most dire statistics.

Health officials reported more than 7,500 new cases in the county on Tuesday, shattering the old record, set last week. Hospitalizations tripled in the past month, and on average 30 people are dying of COVID-19 in the county every day.

The most populous county in the country, Los Angeles leads all U.S. counties in raw numbers of both infections and deaths, according to statistics compiled by Johns Hopkins University.

On Monday, the county started a three-week stay-at-home order, and Gov. Gavin Newsom said a similar order for the whole state could prove necessary.

“If these trends continue, we’re going to have to take much more dramatic — arguably drastic — action,” Newsom said.

But even as the restrictions began in Los Angeles, leaders across California took heat for their do-as-I-say-not-as-I-do pandemic behavior.

Los Angeles County Supervisor Sheila Kuehl dined outdoors at a favorite restaurant shortly after she voted to ban outdoor dining, a local TV station reported.

San Jose Mayor Sam Liccardo apologized for spending Thanksgiving with eight people from five households in his extended family.

And the San Francisco Chronicle reported that San Francisco Mayor London Breed joined a party of seven to dine at the famed French Laundry restaurant the day after Newsom did, angering many.

The questionable behavior threatens to overshadow alarming news about pandemic trends. Tuesday, California reported 20,759 new cases, a few hundred less than the record number of the day before. The state is in its worst situation since the pandemic started. Yet despite the record case numbers, California is so populous that it’s far from the top of the list of states with the most new cases per capita. (That spot was held by Montana on Wednesday.)

Newsom said Monday that Southern California is forecast to run out of intensive care unit capacity by mid-December if trends continue. By Christmas Eve, ICU beds are forecast to be at 107% of capacity across the region. There’s no clear plan in place for what to do when hospital demand outstrips capacity.

All races and ethnicities are seeing increases in cases, but disparities are widening. In Los Angeles County, Hispanics’ infection rate is more than twice that of whites.

“Death rates among people in high rates of poverty are three times the death rate of people in more affluent areas,” county public health director Barbara Ferrer said Wednesday.

Health officials estimate that one in every 200 people in the county has the virus and is infectious.

The hope is that the new restrictions of the stay-at-home order in Los Angeles County will slow that spread.

The order is designed to keep people in their homes as much as possible. It prohibits gatherings with anyone outside of a household and reduces capacity at stores. K-12 schools will continue to operate but at 20% capacity. Outdoor areas like beaches, parks and trails will remain open, but people are not allowed to gather.

Officials say they are trying to find a sweet spot where they can keep people from gathering and spreading the virus, but still allow some stores to remain open. Thus far the rules are less stringent than those imposed in the spring, because businesses owners have pushed back hard against more restrictions. They are losing money and, unlike in the spring, have no federal aid to offset their losses.

This story is from a reporting partnership that includes KPCC, NPR and KHN.

Come for Your Eye Exam, Leave With a Band-Aid on Your Arm

KFF Health News, December 3, 2020

Dentists and optometrists say their help will be needed to distribute the vaccines to millions of Americans — and they already have the know-how.

This article was published on Thursday, December 3, 2020 in Kaiser Health News.

By Rachel Bluth

With multiple COVID-19 vaccines rapidly heading toward approval, optometrists and dentists are pushing for the authority to immunize patients during routine eye exams and dental cleanings.

Across the country, these medical professionals say their help will be needed to distribute the vaccines to millions of Americans — and they already have the know-how.

"When you look at what dentists do, and how many injections they give day in and day out, I think they're more than qualified," said Jim Wood, a California state assembly member and dentist. "It's kind of a no-brainer."

In California, the professional organizations representing dentists and optometrists are in talks with state officials to expand their job descriptions to include administering vaccines. Oregon has already begun training and certifying dentists to give vaccines. And at least half the states have considered allowing dentists to administer COVID vaccines once they're available, according to the American Association of Dental Boards.

That list is likely to grow, because the U.S. Centers for Medicare & Medicaid Services recommended in October that states consider expanding their list of vaccine providers.

The dentists and optometrists seeking permission to vaccinate patients against COVID-19 and other diseases argue that their help will take some of the pressure off hospitals and doctors' offices. It could also bring some extra money into their practices.

"Everyone in our specialized healthcare system should also play a preventive role," said Dr. William Sage, a professor of law and medicine at the University of Texas-Austin. "Pandemic or not, being alert to preventive health in any setting is a good thing."

In November, Pfizer, Moderna and AstraZeneca announced that their COVID vaccine candidates delivered promising results in clinical trials, and that millions of doses could be ready before the end of the year. Pfizer's has to be stored at ultracold temperatures, while Moderna's and AstraZeneca's can be kept at standard refrigerator temperatures.

This wouldn't be the first time health professionals other than doctors administered vaccines during a pandemic. Nursing students, EMTs and midwives in a handful of states were granted temporary and limited authority to administer flu vaccines during the H1N1 swine flu pandemic of 2009-10. Dentists in Massachusetts, Illinois, New York and Minnesota also were temporarily deputized as vaccinators.

Since then, Minnesota and Illinois have adopted laws to allow dentists to give flu shots to adults. And last year, Oregon became the first state to allow dentists to give any vaccine to any patient, whether a child or an adult.

So far, more than 200 dentists and dental students in Oregon have completed the training course offered by the Oregon Health & Science University's School of Dentistry, with 60 others expected to finish by the end of December, said Mary Pat Califano, an instructor who helped develop the hands-on part of the training.

Students spend around 10 hours in online classes. They then undergo hands-on training during which they practice injections on a shoulder pad before practicing injecting a partner with saline. They're taught how to counsel patients about vaccines and avoid injuring patients' shoulders when giving the shots.

Once dentists pass an exam, they can register with the Oregon Health Authority and begin getting their staff trained to handle vaccines and procuring a fridge to store them.

The goal, Califano said, is not to replace family doctors or primary care physicians, but to supplement them. The federal Agency for Health Research and Quality found that, in 2017, 31.1 million Americans saw a dentist but not a physician.

"We just need as many people as possible to give flu shots and COVID-19 vaccines when they're available," Califano said. "If it happens that they're in a dental office, and that provider is educated and capable of giving a vaccine, why not?"

In California, the state dental association is exploring options for gaining vaccine authority, which would likely require the legislature to step in. This year, California passed a law allowing pharmacists to administer COVID vaccines approved by the U.S. Food and Drug Administration.

Wood, who carried that measure, hasn't yet committed to sponsoring a bill that would let dentists give vaccines, but says he supports the idea.

"We give injections in the mouth all day long, and these are very precise kinds of injections," Wood said. "I think the learning curve for a dentist would be small."

Dr. Bill Schaffner, a professor of preventive medicine and infectious disease at Vanderbilt University, said these proposals for expanding the vaccine workforce are promising. Flu vaccines, which are relatively low-risk and simple to administer, would be the perfect candidate to stock in dental and optometric fridges to start.

But Schaffner doesn't believe dentists and optometrists will play a major role in the COVID immunization effort. It would take too long to pass legislation to expand the scope of practice for every professional who wants it in every state, he said. And since some COVID vaccines have specific shipping and subzero storing requirements, they will probably be distributed only to specially trained personnel at a small number of locations, he said.

There's also the question of payment. It's hard — but not impossible — to make a profit administering vaccines, Schaffner said.

Providers have to decide each season how many doses to buy, and any that go bad or remain in the fridge at the end of their shelf life equal monetary losses.

"Unless you're very assiduous about moving the vaccine from the fridge into arms, you're not going to make money," Schaffner said. "People who do that can augment their income, but nobody is going to drive a Porsche because of vaccines."

Jeff McCombs, an associate professor of health economics at the University of Southern California School of Pharmacy, agreed it might not make business sense for most dentists to start vaccinating. He said it would be hard to keep a well-stocked vaccine fridge with enough variety to meet patients' needs without wasting doses. Generally, adults who choose not to get vaccinated do so because they're uneducated about vaccines or afraid, he said, not because they can't access them.

"I don't think it's going to harm people," McCombs said. "I just don't think they'll make any money at it."

While the California Department of Public Health said the state's current vaccine infrastructure is sufficient for flu shots and routine immunizations, it is "carefully considering the need to include additional types of immunizers" to get Californians vaccinated against COVID-19, according to a statement from the department.

The California Optometric Association said it is in talks with Gov. Gavin Newsom's vaccine task force about how to get optometrists into the mix, and is exploring legislative options as well.

"We can serve the dual role of assisting with vision needs and protecting from COVID," said David Ardaya, an optometrist in Whittier who chairs an association committee that is looking into the issue. "Our whole hope is to assist our nation in regaining its health and in returning to a sense of normal."

But three years after AB-443 was signed, the regulations implementing it have yet to be finalized.

That didn't stop Frank Giardina, an optometrist in Nipomo, from going through a certification program anyway.

The 20-hour course, which includes online lectures, hands-on lessons and an exam, is the same course pharmacists take when learning how to give all vaccines to people of all ages.

Giardina pointed to the shingles, or herpes zoster, virus as an example of why optometrists are well suited to give vaccines. The virus can infect the eyes, and even though he's allowed to treat shingles, he can't give a vaccine to prevent it.

For now, he's holding out hope he will get permission to administer vaccines, including for COVID-19. He envisions a world in which a patient comes in for contact lenses and he can offer them a flu or COVID vaccine while they're there.

"We're another member of the healthcare team. It's a waste of manpower not to," Giardina said. "If you're trying to vaccinate all these people, especially in rural areas, you need whoever you can find."

Feds Look to Pharmacists to Boost Childhood Immunization Rates

KFF Health News, December 3, 2020

Federal officials are banking on pharmacists to undergo additional training and help reverse the slump in child immunization rates caused by the coronavirus pandemic.

This article was published on Thursday, December 3, 2020 in Kaiser Health News.

By Carmen Heredia Rodriguez

Torey Watson is trained as a pharmacist but aims to do more than simply fill prescriptions.

Pharmax Pharmacy — a small drugstore chain where Watson works as a clinical services coordinator, about an hour and 30 minutes southwest of St. Louis — will soon allow him to offer childhood vaccines to patients without a doctor's prescription. This change came after the federal government expanded pharmacists' ability to administer routine immunizations to children as young as 3.

As a father of two young boys, Watson, 30, understands how difficult it can be to give a child a shot. Many pharmacists are accustomed to administering vaccines to adults, he said. Doing the same for children requires extra skill.

"We're going to have parents asking questions," he said. His other thought: "Holy cow, I don't think I can give a shot to a 3-year-old."

Federal officials are banking on pharmacists like Watson to undergo additional training and help reverse the slump in child immunization rates caused by the coronavirus pandemic. Fears over COVID-19 have led parents to avoid the doctor's office and pediatricians to curtail in-person care. As a result, many children are missing routine vaccinations.

Children who fall behind on vaccinations usually don't pose a health risk if kids around them are immunized, said Dr. Sean O'Leary, vice chair of the American Academy of Pediatrics committee for infectious diseases. However, large groups of children are now behind, and highly contagious vaccine-preventable diseases circulating in other parts of the world are only a plane ride away, he said.

"That's a big deal," he said in an email.

In August, the Department of Health and Human Services took steps to override restrictions in many states that kept state-licensed pharmacists from immunizing children.

"Today's action means easier access to lifesaving vaccines for our children, as we seek to ensure immunization rates remain high during the COVID-19 pandemic," HHS Secretary Alex Azar said in announcing the policy change.

However, challenges remain in getting pharmacists fully integrated into the nation's framework of childhood vaccinations, immunization experts said.

A key issue is that few pharmacists participate in the Vaccines for Children program, a federal initiative that purchases vaccines for the nation's neediest kids. Half of children in the U.S. receive immunizations through the program, which purchases government-recommended vaccines for kids ages 0 to 18 who are low-income, uninsured or belong to an indigenous group. Compared with last year, VFC-funded orders for vaccines overall are down 9.6 million doses as of Nov. 9, said a spokesperson from the Centers for Disease Control and Prevention. Measles-containing vaccines are down an estimated 1.3 million doses.

Weekly orders of non-flu vaccines and measles-containing vaccines have begun to rebound to levels seen last year, though the volume could again be affected if current COVID surges have a chilling effect on doctors' visits.

Without solving the issues that keep pharmacists from participating in the Vaccines for Children program, said Claire Hannan, executive director of the Association of Immunization Managers, the steps to give parents more access to immunizations through drugstores may ultimately help only Americans wealthy enough to use it.

"Yes, we have a situation with the pandemic that has caused a drop in routine vaccinations," Hannan said. "But I don't want to see us go to a solution that is only serving those who can pay."

Drugstores serve as a convenient access point. Nearly 90% of Americans in 2018 lived within 5 miles of a community pharmacy. In contrast, about 5% of rural counties in 2019 had no family physicians, according to a report from researchers at the University of Washington. Thirty-five percent of rural counties had no pediatricians. Additionally, KFF found over 51% of children in 2017 did not have a medical home, meaning they do not have a primary care doctor that manages their care. (KHN is an editorially independent program of KFF.)

"We need our pharmacists to be vaccinators" in order to catch children up on their immunizations, said L.J Tan, chief strategy officer at the Immunization Action Coalition, a national organization of physicians and health experts focused on vaccine education.

Congress established the Vaccines for Children program to remedy the immunization disparities uncovered by a measles epidemic in the early 1990s that killed hundreds of people. While doctors jumped on board, pharmacist engagement lags far behind.

This pattern continues. As of Oct. 6, out of nearly 38,000 participating providers, a CDC spokesperson said, about two-thirds work in private practices. Seventy-one are pharmacies.

Stephanie Wasserman, executive director of Immunize Colorado, an Aurora-based nonprofit organization, said boosting the number of pharmacists in VFC will be "a really critical piece" to the success of the federal authorization. However, "just because they can participate doesn't mean they necessarily will jump on it" unless pharmacists think the program is well-supported and will help their business, she said.

Enrollees must adhere to strict storage and handling requirements that involve expensive thermometers and refrigerators used only for products delivered under the government program. And if there isn't enough demand, said vaccine experts, the investment may not be worth it.

For rural pharmacies, said Michaela Newell, president of the Community Pharmacy Enhanced Services Network of Missouri, the cost of paying for the equipment and personnel needed to handle the administrative work may price them out before they apply.

"I guess it hasn't been worth the squeeze," said Hannan.

Added Newell: "I just think that the barriers right now are too high for the pharmacists to enter into it."

On the flip side, state administrators have trouble keeping up with the demands of the program, too. One study from 2019 showed limited success in getting Michigan pharmacies to administer the human papillomavirus vaccine through the Vaccines for Children program because the state's health department didn't have the personnel to conduct on-site inspections.

The strain on state resources has only grown worse during the pandemic, said Hannan.

"You can't call them out for not having the bandwidth," said Rebecca Snead, executive vice president and chief executive officer of the National Alliance of State Pharmacy Associations. "They've been compromised."

Payment also poses a challenge to recruit and maintain providers in the program, immunization experts said.

Medicaid, the government-sponsored health insurance program that offers health coverage for many of the children supported by the vaccine initiative, does not pay providers enough to cover expenses. Participating clinicians lose an average of $5 to $15 for every vaccine they administer through Vaccines for Children, according to a report from Immunize Colorado.

Pharmacists cannot deny a vaccine to eligible children if the family is unable to pay.

Some states run their Medicaid programs using a managed-care model, which may make it harder for pharmacists to get paid, the report said. Children enrolled in these programs are often required to obtain care from designated providers. If their local pharmacist is not on the list of approved providers, they may not get paid.

The possibility of little to no pay hasn't stopped pharmacist and drugstore owner Tim Mitchell from offering vaccines at his three pharmacies in Neosho, Missouri, about 30 minutes from the Oklahoma state line. He said he's been immunizing patients since the late 1990s after he realized children coming into his pharmacies were missing routine vaccinations.

"I saw it as a way to help my community," he said, "but I also saw it as a business opportunity."

Mitchell, 53, views offering vaccines as a way to stand out from his competitors and bring more customers to his pharmacies. He said he submitted the paperwork to enroll in Vaccines for Children.

Although he welcomes the federal authorization, he acknowledged that not all his peers can afford to offer the service.

"We can't work for free," said Mitchell.

Carmen Heredia Rodriguez: CarmenH@kff.org, @ByCHRodriguez

During ACA Open Enrollment, Picking a Plan Invites New COVID Complications

KFF Health News, December 3, 2020

What type of plan is best for someone with an unpredictable, ongoing medical concern?

This article was published on Thursday, December 3, 2020 in Kaiser Health News.

By Julie Appleby

People buying their own health insurance have even more to think about this year, particularly those post-COVID-19 patients with lingering health concerns, the "long haulers," who join the club of Americans with preexisting conditions.

What type of plan is best for someone with an unpredictable, ongoing medical concern? That question is popping up on online chat sites dedicated to long haulers and among people reaching out for assistance in selecting insurance coverage.

"We are hearing from a lot of people who have had COVID and want to be able to deal with the long-term effects they are still suffering," said Mark Van Arnam, director of the North Carolina Navigator Consortium, a group of organizations that offer free help to state residents enrolling in insurance.

The good news for those shopping for their own coverage is that the Affordable Care Act bars insurers from discriminating against people with medical conditions or charging them more than healthier policyholders. Former COVID patients could face a range of physical or mental effects, including lung damage, heart or neurological concerns, anxiety and depression. Although some of these issues will dissipate with time, others may turn out to be long-standing problems.

So sign up, said Van Arnam and others to whom KHN reached out for tips on what people with post-COVID-19 should consider when selecting coverage. There's no one-size-fits-all answer, but they all emphasized the need to consider a wide range of factors.

But don't delay. Open enrollment in ACA plans is ongoing until Dec. 15 in most states — longer in some of the 14 states and the District of Columbia that run their own marketplaces.

Here are tips if you are shopping for health insurance, especially if you are a COVID long hauler or have other health issues:

Make sure to select an ACA-qualified plan.

It may be tempting to consider other, often far less expensive types of coverage offered by insurers, brokers, organizations and private websites. But those non-ACA plans offer less comprehensive coverage — and are not eligible for federal subsidies to help people who qualify cover the cost of the premiums. These are key factors for patients experiencing medical problems after battling the coronavirus.

Short-term, limited-duration plans, for example, are cheaper, but the insurers offering them don't have to accept people with preexisting conditions — or, if they do enroll those people, the plans don't cover the members' medical conditions. Many short-term plans don't cover benefits such as prescription drugs or mental healthcare.

Another type of plan that doesn't meet ACA requirements are "sharing ministries," in which members agree to pay one another's medical bills. But such payments aren't guaranteed — and many don't cover anything considered preexisting.

Shop around to consider all the ACA plans available in your region.

This will help you meet your post-COVID medical needs while also getting the best buy.

Comparison-shopping also lets consumers adjust their income information, which may have changed from last year, especially after being sick, and could affect subsidy levels for those eligible for assistance in purchasing a plan.

Under the ACA, subsidies to offset premium costs are available on a sliding scale for people who earn between 100% and 400% of the federal poverty level. That range next year is $12,760 to $51,040 for an individual and $26,200 to $104,800 for a family of four.

Networks matter. Look for your doctor or hospital in the plan.

One of the first things to do once you've narrowed down your choices of plans is to dig deeper to see if the doctors, specialists and hospitals you use are included in those plans' networks. Also, check plan formularies to see if the prescription medications you take are covered.

Many insurance plans don't have out-of-network benefits, except for emergency care. That means if a doctor or hospital doesn't participate in the network, consumers must switch medical providers or risk huge bills by receiving out-of-network care. This should be a concern for long haulers.

This subset of COVID patients who report lingering health concerns may need to see a range of specialists, including pulmonologists, cardiologists, neurologists, rheumatologists and mental health professionals.

"So, you are already talking about five or six," said Erika Sward, assistant vice president for national advocacy at the American Lung Association.

To check the network status of medical providers, go to the healthcare.gov website, which will direct you to your state site if you are in one of the 14 states or the District of Columbia, which run their own. Enter a ZIP code and some other information to start looking for available plans.

Narrow the search using the "add your medical providers" button on healthcare.gov, or access each plan's "provider directory" under plan documents to see which specific doctors and hospitals are included. To be safe, Sward said, call each office to make sure they are participating with that insurer next year.

Don't just look at premium costs: Deductibles also matter.

Consumers must pay deductible amounts before the bulk of financial assistance kicks in. That can be a big hit, especially for those who need complex care all at once or very expensive prescription drugs. Long haulers, as well as others with chronic health conditions, often fall into this category.

Median deductibles — the mark at which half cost more and half cost less — vary across the different "tiers" of ACA plans, hitting $6,992 for bronze plans; $4,879 for silver plans and $1,533 for gold plans, according to an analysis by the Centers for Medicare & Medicaid Services.

Generally, plans with higher deductibles have lower monthly premiums. But getting past the deductible is a challenge for many.

What's best for those with ongoing health conditions depends on individual circumstances.

"Balancing the deductibles and premiums is a really important consideration for consumers," said Laurie Whitsel, vice president of policy research and translation at the American Heart Association.

Those with ongoing health conditions need to carefully weigh the expected annual out-of-pocket costs for various health plans, given that they may well be moderate to high users of health services. Healthcare.gov has a financial estimator tool that can help with the decision. Consumers can select whether they think they will have low, medium or high medical use next year to see the estimated total annual costs of each plan.

Frequent users of health services may discover that plans that initially seem least expensive, based solely on the premium or the deductible, may be costlier once all out-of-pocket factors are considered.

Finally, insurers in some markets are touting zero-deductible plans.

Instead of an annual deductible, such policies have higher copayment or coinsurance amounts each time a patient sees a doctor, gets a test or has surgery. Those can range from $50 to more than $1,000, depending on the visit, test or service provided. Still, for some costly services, those payments may amount to less than paying a deductible.

Broker John Dodd in Columbus, Ohio, said such plans appeal to some people who don't want to have to shell out thousands of dollars in deductible payments before their insurance picks up the bulk of medical costs.

Still, he cautioned that many of the zero-deductible plans do have what can be a sizable deductible — hundreds or even thousands of dollars — for brand-name prescription drugs.

Long haulers should weigh those factors carefully, as such zero-deductible plans may be more suited to those who don't expect to use a lot of medical care.

Read the fine print, because there are other costs.

While plans may tout similar premiums, their dissimilar structures could affect how much a consumer will shell out in flat-dollar copayments or percentage coinsurance to see a doctor, pick up a prescription, get a blood test or spend the night in the hospital. This is, again, something long haulers should focus on.

These details are spelled out in the plan's "summary of benefits," a required document under the ACA, which can be found on healthcare.gov or insurers' websites.

Still, ACA plans limit how much a consumer must pay out-of-pocket for the year. Next year, the maximum is $8,550 for an individual or $17,100 for a family plan.

Ask for help.

While services such as Van Arman's navigator program have seen stiff budget cuts during the past few years, consumers there and in many states still have access to online or phone help. Healthcare.gov has a "find local help" button that can refer people by ZIP code to navigators, assisters and brokers.

Finally, those affected by COVID who miss the open enrollment deadline can request an extension under rules that allow special enrollment for emergencies or disasters.

"It's not a guarantee and you have to telephone the call center and ask for it," said Karen Pollitz, a senior fellow at KFF.

Still, she said, it's best to sign up before Dec. 15.

"Just get it done," Pollitz said.

Julie Appleby: jappleby@kff.org, @Julie_Appleby

NYC Hospital Workers, Knowing How Bad It Can Get, Brace for COVID 2nd Wave

KFF Health News, December 3, 2020

Around the New York metropolitan area, public health leaders and healthcare workers say they're watching the trend lines.

This article was published on Thursday, December 3, 2020 in Kaiser Health News.

By Fred Mogul, WNYC

No single municipality in the country suffered more in the first wave of the pandemic than New York City, which saw more than 24,000 deaths, mainly in the spring. Medical staff in New York know precisely how difficult and dangerous overwhelmed hospitals can be and are braced warily as infections begin to rise again.

Around the New York metropolitan area, public health leaders and healthcare workers say they're watching the trend lines, as intensive care units fill up in other parts of the United States and around the world. They say it gives them flashbacks to last spring, when ambulance sirens were omnipresent and the region was the country's coronavirus epicenter.

There is wide agreement that hospitals and care providers are in much better shape now than then, because there is much more knowledge about the disease and how to handle it; much larger stockpiles of personal protective equipment; and much, much more widespread testing.

But at the same time, many front-line workers are nervous about hospital preparedness, and many observers are less bullish about the effectiveness of the coronavirus testing and tracing infrastructure.

"I think there's a lot of anxiety about doing this a second time," said Dr. Laura Iavicoli, head of emergency preparedness for NYC Health + Hospitals, the country's largest municipal hospital system. Iavicoli is also an active emergency room physician at Elmhurst Hospital, in Queens, which came to be called "the epicenter of the epicenter" back in April. Still, she has enormous confidence in the staff of the municipal hospital system.

"They will rally, because I know them," she said. "I've worked with them for 20 years, and they're the most amazing people I can possibly speak of, but there's anxiety and there's COVID fatigue."

Iavicoli said some of the city's hospitals are at capacity, but she hastened to add that she's not talking about "COVID capacity" — meaning not all the beds and recently reconfigured spillover spaces for COVID patients are full. Rather, she said, two of the network's 11 hospitals have had to transfer ICU patients to others to make room for incoming patients.

"We are doing a little bit of redistributing around the system to give them COVID capacity, but it's very manageable within the system," Iavicoli said. "The increase is definitely typical in flu season, but knowing that we have just entered upon the second wave [of COVID-19] and predicting what is to come, we're a little even more cognizant than normal to make sure we leave capacity in all of our facilities."

Many nurses, however, say hospital administrators have not learned enough from the experience in March and April.

"We're scared because we're afraid we're going to have to go through this again," said Michelle Gonzalez, a critical care nurse at Montefiore Medical Center, in the Bronx, and a union representative for NYSNA, the New York State Nurses Association.

She said that in her unit nurses typically handle one or two intensive care unit patients at a time — but now have to handle three, with the number of COVID patients creeping up once again. Tending to four patients or more was common at the peak of the pandemic surge. Gonzalez said that's overwhelming. If one patient crashes, several nurses need to converge at once, leaving other patients unmonitored.

"When we start to get triples with the frequency we're seeing right now, we know it's because we're short-staffed, and they're not getting ICU nurses into the building," she said at a demonstration that featured a phalanx of nurses marching from Montefiore to a nearby cemetery, bearing floral wreaths for fallen comrades, while a band and bagpiper played "When the Saints Go Marching In" and "Amazing Grace."

A spokesperson for the union said Montefiore, by its own reckoning, has 476 vacant nursing positions — a number that has climbed by nearly 100 since 2019.

"Management is not living up to their promise to fill vacancies and hire nurses," said Kristi Barnes, from NYSNA. "As of last week, they have 188 full-time nursing jobs they have not even posted, so there is no way they can be filled."

The Montefiore administration disagrees.

"We have a contractual agreement with the union, and we meet the contractual obligations of that agreement," said Peter Semczuk, senior vice president of operations. "We tailor our staffing in such a flexible way to meet the needs of the patient."

Like many hospital systems, Montefiore relied heavily on temporary staffing agencies for "traveling nurses" from around the country earlier this year. Hospitals are preparing to do so again — but there is demand all over the country.

"They got us travelers in April, but that was four or six weeks in, and until that we were on our own," said Kathy Santoiemma, who's been a nurse at Montefiore New Rochelle for 43 years. "I don't even know where they're going to get travelers now — everyone around the whole country needs travelers."

NYSNA led a two-day strike at Montifiore New Rochelle on Tuesday, after contract negotiations in the works for two years stalled on Monday.

Iavicoli said each of her network's facilities has submitted requests, so that NYC Health + Hospitals could place a preliminary order now.

Health planners are hoping New Yorkers won't flood into emergency rooms this time. They point to the modest climb in COVID hospitalizations over the past two months compared with other areas, including New Jersey and Connecticut. One thing they hope will keep the curve relatively flat is testing, which is more pervasive in New York than almost anywhere else in the country. About 200,000 people across New York state are getting tested each day, roughly one-third of them in New York City.

"It's the first step to actually interrupting further spread," said Dr. Dave Chokshi, the city health commissioner.

He said mass testing works on two levels — by highlighting which areas are hot zones, so health workers can target residents with "hyper-local" messages about COVID-19 spread, to get them to change their behavior, and also by allowing contact tracers to communicate individually with newly infected people.

"Once someone tests positive, we very quickly help them isolate," Chokshi said. "We do an interview with them to know who their close contacts are, and then we call those contacts and make sure they're quarantining as well."

However, the city's contact-tracing program has had a mixed record. The people it reaches say they're staying put — but fewer than half of them share names of people they might have exposed. Denis Nash, an epidemiologist who previously worked for the city's Department of Health and Mental Hygiene and the Centers for Disease Control and Prevention, said the city hasn't successfully drilled down into how the coronavirus actually spreads, because contact tracers aren't asking people enough questions about their behaviors and possible exposures.

"During the summer and early fall, when things were slowly ramping up, there were missed opportunities to use contact tracing to talk to 80 or 90% of all newly diagnosed people, to understand what their risk factors were and what kinds of things … were they exposed to that could have potentially resulted in them getting the virus," he said. "You can never know with 100% certainty [where they contracted the virus], but if you ask these questions, you could begin to understand what some likely patterns were — for example, of public transportation use, or working in office buildings that didn't have rigorous safety protocols, or indoor dining."

This knowledge, though imperfect, could lead to better informed public policy decisions, Nash said, about whether to close indoor restaurants, beauty salons or fitness centers. Without that data, leaders are just making guesses.

Others fault the city's testing and tracing program for not reaching out enough to poor communities of color — which suffered disproportionately during the first COVID wave. Chokshi, the health commissioner, said getting testing sites to these neighborhoods has been a priority — but a recent analysis suggested it's not working as well as the city intended.

"There's clearly a disparity in providing widespread testing across New York City," said Wil Lieberman-Cribbin, a graduate student and environmental health researcher at Columbia University.

He looked at how many people are getting tested, by neighborhood, and correlated those figures with race, income level and COVID positivity. In wealthier areas, people are getting many more tests and have much less illness. In poorer ones, people are getting many fewer tests and are much sicker. More testing in those areas would pick up cases sooner, before people develop symptoms.

"Testing is really, really needed, not only to protect the most vulnerable, but to collectively try and get a handle on COVID and reopen New York City," Lieberman-Cribbin said.

Personal protective equipment, or PPE, is also much more ample than it was last spring but, similarly, remains a source of contention.

New York state health authorities are requiring hospitals to stockpile a 90-day supply of PPE; for nursing homes, it's 60 days' worth. Many facilities have complied with September and October deadlines, but others have not.

Montefiore, NYC Health + Hospitals, and other large hospital networks say they have at least that much, if not more.

Nurses, though, say they should be able to get fresh N95 masks each time they see a new patient, to limit the risk of contamination. Many administrators counter that isn't feasible, given the precariousness of the supply chain. They note that CDC guidelines permit "extended use" of some PPE.

"[Nurses and other caregivers] change their gloves between every patient, but they might wear the same N95 mask for one shift and put a surgical mask over it just to preserve it and only switch it out if there's some integrity issue or it gets contaminated," said Iavicoli, of the city hospital system. "But definitely at the next shift, they're getting a new one."

Iavicoli acknowledged the challenges as the pandemic rolls on and said there are four kinds of days: "blue skies, or normal," "busier than normal," "a little stretched" and "extremely stretched."

"I think we're at the top end of 'busy normal' bordering on 'a little more than overstretched,'" said Iavicoli.

This story is from a reporting partnership that includes WNYC, NPR and KHN.

Fred Mogul, WNYC: @fredmogul

As Hospitals Fill With COVID Patients, Medical Reinforcements Are Hard to Find

KFF Health News, December 2, 2020

The typical workaround for staffing shortages — hiring clinicians from out of town — isn't the solution anymore.

This article was published on Wednesday, December 2, 2020 in Kaiser Health News.

By Blake Farmer, Nashville Public Radio and Carrie Feibel

Hospitals in much of the country are trying to cope with unprecedented numbers of COVID-19 patients. As of Monday, 96,039 were hospitalized, an alarming record that far exceeds the two previous peaks in April and July of just under 60,000 inpatients.

But beds and space aren't the main concern. It's the workforce. Hospitals are worried staffing levels won't be able to keep up with demand as doctors, nurses and specialists such as respiratory therapists become exhausted or, worse, infected and sick themselves.

The typical workaround for staffing shortages — hiring clinicians from out of town — isn't the solution anymore, even though it helped ease the strain early in the pandemic, when the first surge of cases was concentrated in a handful of "hot spot" cities such as New York, Detroit, Seattle and New Orleans.

Recruiting those temporary reinforcements was also easier in the spring because hospitals outside of the initial hot spots were seeing fewer patients than normal, which led to mass layoffs. That meant many nurses were able — and excited — to catch a flight to another city and help with treatment on the front lines.

In many cases, hospitals competed for traveling nurses, and the payment rates for temporary nurses spiked. In April, Vanderbilt University Medical Center in Nashville, Tennessee, had to increase the pay of some staff nurses, who were making less than newly arrived temporary nurses.

In the spring, nurses who answered the call from beleaguered "hot spot" hospitals weren't merely able to command higher pay. Some also spoke about how meaningful and gratifying the work felt, trying to save lives in a historic pandemic, or the importance of being present for family members who could not visit loved ones who were sick or dying.

"It was really a hot zone, and we were always in full PPE and everyone who was admitted was COVID-positive," said Laura Williams of Knoxville, Tennessee, who helped launch the Ryan Larkin Field Hospital in New York City.

"I was working six or seven days a week, but I felt very invigorated."

After two taxing months, Williams returned in June to her nursing job at the University of Tennessee Medical Center. For a while, the COVID front remained relatively quiet in Knoxville. Then the fall surge hit. There have been record hospitalizations in Tennessee nearly every day, increasing by 60% in the past month.

Health officials report that backup clinicians are becoming much harder to find.

Tennessee has built its own field hospitals to handle patient overflows — one is inside the old Commercial Appeal newspaper offices in Memphis, and another occupies two unused floors in Nashville General Hospital. But if they were needed right now, the state would have trouble finding the doctors and nurses to run them because hospitals are already struggling to staff the beds they have.

"Hospital capacity is almost exclusively about staffing," said Dr. Lisa Piercey, who heads the Tennessee Department of Health. "Physical space, physical beds, not the issue."

When it comes to staffing, the coronavirus creates a compounding challenge.

As patient caseloads reach new highs, record numbers of hospital employees are themselves out sick with COVID-19 or temporarily forced to stop working because they have to quarantine after a possible exposure.

"But here's the kicker," said Dr. Alex Jahangir, who chairs Nashville's coronavirus task force. "They're not getting infected in the hospitals. In fact, hospitals for the most part are fairly safe. They're getting infected in the community."

Some states, like North Dakota, have already decided to allow COVID-positive nurses to keep working as long as they feel OK, a move that has generated backlash. The nursing shortage is so acute there that some traveling nurse positions posted pay of $8,000 a week. Some retired nurses and doctors were asked to consider returning to the workforce early in the pandemic, and at least 338 who were 65 or older have died of COVID-19.

In Tennessee, Gov. Bill Lee issued an emergency order loosening some regulatory restrictions on who can do what within a hospital, giving them more staffing flexibility.

For months, staffing in much of the country had been a concern behind the scenes. But it's becoming palpable to any patient.

Dr. Jessica Rosen is an emergency physician at St. Thomas Health in Nashville, where having to divert patients to other hospitals has been rare over the past decade. She said it's a common occurrence now.

"We have been frequently on diversion, meaning we don't take transfers from other hospitals," she said. "We try to send ambulances to other hospitals because we have no beds available."

Even the region's largest hospitals are filling up. This week, Vanderbilt University Medical Center made space in its children's hospital for non-COVID patients. Its adult hospital has more than 700 beds. And like many other hospitals, it has had the challenge of staffing two intensive care units — one exclusively for COVID patients and another for everyone else.

And patients are coming from as far away as Arkansas and southwestern Virginia.

"The vast majority of our patients now in the intensive care unit are not coming in through our emergency department," said Dr. Matthew Semler, a pulmonary specialist at VUMC who works with COVID patients.

"They're being sent hours away to be at our hospital because all of the hospitals between here and where they present to the emergency department are on diversion."

Semler said his hospital would typically bring in nurses from out of town to help. But there is nowhere to pull them from right now.

National provider groups are still moving personnel around, though increasingly it means leaving somewhere else short-staffed. Dr. James Johnson with the Nashville-based physician services company Envision has deployed reinforcements to Lubbock and El Paso, Texas, this month.

He said the country hasn't hit it yet, but there's a limit to hospital capacity.

"I honestly don't know where that limit is," he said.

At this point, the limitation won't be ventilators or protective gear, he said. In most cases, it will be the medical workforce. People power.

Johnson, an Air Force veteran who treated wounded soldiers in Afghanistan, said he's more focused than ever on trying to boost doctors' morale and stave off burnout. He's generally optimistic, especially after serving four weeks in New York City early in the pandemic.

"What we experienced in New York and happened in every episode since is that humanity rises to the occasion," he said.

But Johnson said the sacrifices shouldn't come just from the country's healthcare workers. Everyone bears a responsibility, he said, to try to keep themselves and others from getting sick in the first place.

This story is from a reporting partnership that includes Nashville Public Radio, NPR and Kaiser Health News.

Blake Farmer, Nashville Public Radio: bfarmer@wpln.org, @flakebarmer

Carrie Feibel: @carriefeibel

Amid COVID and Racial Unrest, Black Churches Put Faith in Mental Healthcare

KFF Health News, December 1, 2020

As Black people face an onslaught of grief, stress and isolation triggered by a devastating pandemic and repeated instances of racial injustice, churches play a crucial role in addressing the mental health of their members and the greater community.

This article was published on Tuesday, December 1, 2020 in Kaiser Health News.

By Aneri Pattani

Wilma Mayfield used to visit a senior center in Durham, North Carolina, four days a week and attend Lincoln Memorial Baptist Church on Sundays, a ritual she's maintained for nearly half a century. But over the past 10 months, she's seen only the inside of her home, the grocery store and the pharmacy. Most of her days are spent worrying about COVID-19 and watching TV.

It's isolating, but she doesn't talk about it much.

When Mayfield's church invited a psychologist to give a virtual presentation on mental health during the pandemic, she decided to tune in.

The hourlong discussion covered COVID's disproportionate toll on communities of color, rising rates of depression and anxiety, and the trauma caused by police killings of Black Americans. What stuck with Mayfield were the tools to improve her own mental health.

"They said to get up and get out," she said. "So I did."

The next morning, Mayfield, 67, got into her car and drove around town, listening to 103.9 gospel radio and noting new businesses that had opened and old ones that had closed. She felt so energized that she bought chicken, squash and greens, and began her Thanksgiving cooking early.

"It was wonderful," she said. "The stuff that lady talked about [in the presentation], it opened up doors for me."

As Black people face an onslaught of grief, stress and isolation triggered by a devastating pandemic and repeated instances of racial injustice, churches play a crucial role in addressing the mental health of their members and the greater community. Religious institutions have long been havens for emotional support. But faith leaders say the challenges of this year have catapulted mental health efforts to the forefront of their mission.

Some are preaching about mental health from the pulpit for the first time. Others are inviting mental health professionals to speak to their congregations, undergoing mental health training themselves or adding more therapists to the church staff.

"COVID undoubtedly has escalated this conversation in great ways," said Keon Gerow, senior pastor at Catalyst Church in West Philadelphia. "It has forced Black churches — some of which have been older, traditional and did not want to have this conversation — to actually now have this conversation in a very real way."

At Lincoln Memorial Baptist, leaders who organized the virtual presentation with the psychologist knew that people like Mayfield were struggling but might be reluctant to seek help. They thought members might be more open to sensitive discussions if they took place in a safe, comfortable setting like church.

It's a trend that psychologist Alfiee Breland-Noble, who gave the presentation, has noticed for years.

Through her nonprofit organization, the AAKOMA Project, Breland-Noble and her colleagues often speak to church groups about depression, recognizing it as one of the best ways to reach a diverse segment of the Black community and raise mental health awareness.

This year, the AAKOMA Project has received clergy requests that are increasingly urgent, asking to focus on coping skills and tools people can use immediately, Breland-Noble said.

"After George Floyd's death, it became: 'Please talk to us about exposure to racial trauma and how we can help congregations deal with this,'" she said. "'Because this is a lot.'"

Across the country, mental health needs are soaring. And Black Americans are experiencing significant strain: A study from the Centers for Disease Control and Prevention this summer found 15% of non-Hispanic Black adults had seriously considered suicide in the past 30 days and 18% had started or increased their use of substances to cope with pandemic-related stress.

Yet national data shows Blacks are less likely to receive mental health treatment than the overall population. A memo released by the Substance Abuse and Mental Health Services Administration this spring lists engaging faith leaders as one way to close this gap.

The Potter's House in Dallas has been trying to do that for years. A megachurch with more than 30,000 members, it runs a counseling center with eight licensed clinicians, open to congregants and the local community to receive counseling at no cost, though donations are accepted.

Since the pandemic began, the center has seen a 30% increase in monthly appointments compared with previous years, said center director Natasha Stewart. During the summer, when protests over race and policing were at their height, more Black men came to therapy for the first time, she said.

Recently, there's been a surge in families seeking services. Staying home together has brought up conflicts previously ignored, Stewart said.

"Before, people had ways to escape," she said, referring to work or school. "With some of those escapes not available anymore, counseling has become a more viable option."

To meet the growing demand, Stewart is adding a new counselor position for the first time in eight years.

At smaller churches, where funding a counseling center is unrealistic, clergy are instead turning to members of the congregation to address growing mental health needs.

At Catalyst Church, a member with a background in crisis management has begun leading monthly COVID conversations online. A deacon has been sharing his own experience getting therapy to encourage others to do the same. And Gerow, the senior pastor, talks openly about mental health.

Recognizing his power as a pastor, Gerow hopes his words on Sunday morning and in one-on-one conversations will help congregants seek the help they need. Doing so could reduce substance use and gun violence in the community, he said. Perhaps it would even lower the number of mental health crises that lead to police involvement, like the October death of Walter Wallace Jr., whose family said he was struggling with mental health issues when Philadelphia police shot him.

"If folks had the proper tools, they'd be able to deal with their grief and stress in different ways," Gerow said. "Prayer alone is not always enough."

Laverne Williams recognized that back in the '90s. She believed prayer was powerful, but as an employee of the Mental Health Association in New Jersey, she knew there was a need for treatment too.

When she heard pastors tell people they could pray away mental illness or use blessed oil to cure what seemed like symptoms of schizophrenia, she worried. And she knew many people of color were not seeing professionals, often due to barriers of cost, transportation, stigma and distrust of the medical system.

To address this disconnect, Williams created a video and PowerPoint presentation and tried to educate faith leaders.

At first, many clergy turned her away. People thought seeking mental health treatment meant your faith wasn't strong enough, Williams said.

But over time, some members of the clergy have come to realize the two can coexist, said Williams, adding that being a deacon herself has helped her gain their trust. This year alone, she's trained 20 faith leaders in mental health topics.

A program run by the Behavioral Health Network of Greater St. Louis is taking a similar approach. The Bridges to Care and Recovery program trains faith leaders in "mental health first aid," suicide prevention, substance use and more, through a 20-hour course.

The training builds on the work faith leaders are already doing to support their communities, said senior program manager Rose Jackson-Beavers. In addition to the tools of faith and prayer, clergy can now offer resources, education and awareness, and refer people to professional therapists in the network.

Since 2015, the program has trained 261 people from 78 churches, Jackson-Beavers said.

Among them is Carl Lucas, pastor of God First Church in northern St. Louis County who graduated this July — just in time, by his account.

Since the start of the pandemic, he has encountered two congregants who expressed suicidal thoughts. In one case, church leaders referred the person to counseling and followed up to ensure they attended therapy sessions. In the other, the root concern was isolation, so the person was paired with church members who could touch base regularly, Lucas said.

"The pandemic has definitely put us in a place where we're looking for answers and looking for other avenues to help our members," he said. "It has opened our eyes to the reality of mental health needs."

Aneri Pattani: apattani@kff.org, @aneripattani

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