In New York, at least 237 kids appear to have Multisystem Inflammatory Syndrome in Children, or MIS-C.

By Fred Mogul, WNYC and Maria Godoy, NPR News

Israel Shippy doesn't remember much about having COVID-19 — or the unusual auto-immune disease it triggered — other than being groggy and uncomfortable for a bunch of days. He's a 5-year-old, and would much rather talk about cartoons, or the ideas for inventions that constantly pop into his head.

"Hold your horses, I think I know what I'm gonna make," he said, holding up a finger in the middle of a conversation. "I'm gonna make something that lights up and attaches to things with glue, so if you don't have a flashlight, you can just use it!"

In New York, at least 237 kids, including Israel, appear to have Multisystem Inflammatory Syndrome in Children, or MIS-C. And state officials continue to track the syndrome, but the Centers for Disease Control and Prevention did not respond to repeated requests for information on how many children nationwide have been diagnosed so far with MIS-C.

A study published June 29 in the New England Journal of Medicine reported on 186 patients in 26 states who had been diagnosed with MIS-C. A researcher writing in the same issue added reports from other countries, finding that about 1,000 children worldwide have been diagnosed with MIS-C.

Tracking the Long-Term Health Effects of MIS-C

Israel is friendly and energetic, but he's also really good at sitting still. During a recent checkup at Children's Hospital at Montefiore, in the Bronx, he had no complaints about all the stickers and wires a health aide attached to him for an EKG. And when Dr. Marc Foca, an infectious disease specialist, came by to listen to his heart and lungs, and prod his abdomen, Israel barely seemed to notice.

There were still some tests pending, but overall, Foca said, "Israel looks like a totally healthy 5-year-old."

"Stay safe!" Israel called out, as Foca left. It's his new signoff, instead of goodbye. His mother, Janelle Moholland, explained Israel came up with it himself.

And she's also hoping that after a harrowing couple of weeks in early May, Israel himself will "stay safe."

That's why they've been returning to Montefiore for the periodic checkups, even though Israel seems to have recovered fully from both COVID-19 and MIS-C.

MIS-C is relatively rare, and it apparently responds well to treatment, but it is new enough — and mysterious enough — that doctors here want to make sure the children who recover don't experience any related health complications in the future.

"We've seen these kids get really sick, and get better and recover and go home, yet we don't know what the long-term outcomes are," said Dr. Nadine Choueiter, a pediatric cardiologist at Montefiore. "So that's why we will be seeing them."

When Israel first got sick at the end of April, his illness didn't exactly look like COVID-19. He had persistent high fevers, with his temperature reaching 104 degrees — but no problems breathing. He wasn't eating. He was barely drinking. He wasn't using the bathroom. He had abdominal pains. His eyes were red.

They went to the emergency room a couple of times and visited an urgent care center, but the doctors sent them home without testing him for the coronavirus. Moholland, 29, said she felt powerless.

"There was nothing I could do but make him comfortable," she said. "I literally had to just trust in a higher power and just hope that He would come through for us. It taught me a lot about patience and faith."

As Israel grew sicker, and they still had no answers, Moholland grew frustrated. "I wish his pediatrician and [the emergency room and urgent care staff] had done what they were supposed to do and given him a test" when Israel first got sick, Moholland said. "What harm would it have done? He suffered for about 10 or 11 days that could have been avoided."

In a later interview, she talked with NPR about how COVID-19 has disproportionately affected the African American community, due to a combination of underlying health conditions and lack of access to good healthcare. She said she felt she, too, had fallen victim to those disparities.

"It affects me, personally, because I am African American, but you just never know," she said. "It's hard. We're living in uncertain times — very uncertain times."

Finally, Children's Hospital at Montefiore admitted Israel — and the test she'd been trying to get for days confirmed he had the virus.

"I was literally in tears, like begging them not to discharge me because I knew he was not fine," she recalled.

Israel was in shock, and by the time he got to the hospital, doctors were on the lookout for MIS-C, so they recognized his symptoms — which were distinct from most people with COVID-19.

Doctors gave Israel fluids and intravenous immune globulin, a substance obtained from donated human plasma, which is used to treat deficiencies in the immune system.

Immune globulin has been effective in children like Israel because MIS-C appears to be caused by an immune overreaction to the initial coronavirus infection, according to Choueiter, the Montefiore pediatric cardiologist.

"The immune system starts attacking the body itself, including the arteries of the heart," she said.

In some MIS-C cases — though not Israel's — the attack occurs in the coronary arteries, inflaming and dilating them. That also happens in a different syndrome affecting children, Kawasaki disease. About 5% of Kawasaki patients experience aneurysms — which can fatally rupture blood vessels — after the initial condition subsides.

Choueiter and her colleagues want to make sure MIS-C patients don't face similar risks. So far, they're cautiously optimistic.

"We have not seen any new decrease in heart function or any new coronary artery dilations," she said. "When we check their blood, their inflammatory markers are back to normal. For the parents, the child is back to baseline, and it's as if this illness is a nightmare that's long gone."

For a Pennsylvania Teen, the MIS-C Diagnosis Came Much Later

Not every child who develops MIS-C tests positive for the coronavirus, though many will test positive for antibodies to the coronavirus, indicating they had been infected previously. That was the case with Andrew Lis, a boy from Pennsylvania who was the first MIS-C patient seen at the Nemours/Alfred I. duPont Hospital for Children in Wilmington, Delaware.

Andrew had been a healthy 14-year-old before he got sick. He and his twin brother love sports and video games. He said the first symptom was a bad headache. He developed a fever the next day, then constipation and intense stomach pain.

"It was terrible," Andrew said. "It was unbearable. I couldn't really move a lot."

His mother, Ingrid Lis, said they were thinking appendicitis, not coronavirus, at first. In fact, she hesitated to take Andrew to the hospital, for fear of exposing him to the virus. But after Andrew stopped eating because of his headache and stomach discomfort, "I knew I couldn't keep him home anymore," Lis said.

Andrew was admitted to the hospital April 12, but that was before reports of the mysterious syndrome had started trickling out of Europe.

Over about five days in the pediatric intensive care unit, Andrew's condition deteriorated rapidly, as doctors struggled to figure out what was wrong. Puzzled, they tried treatments for scarlet fever, strep throat and toxic shock syndrome. Andrew's body broke out in rashes, then his heart began failing and he was put on a ventilator. Andrew's father, Ed Lis, said doctors told the family to brace for the worst: "We've got a healthy kid who a few days ago was just having these sort of strange symptoms. And now they're telling us that we could lose him."

Though Andrew's symptoms were atypical for Kawasaki disease, doctors decided to give him the standard treatment for that condition — administering intravenous immune globulin, the same treatment Israel Shippy received.

"Within the 24 hours of the infusion, he was a different person," Ingrid Lis said. Andrew was removed from the ventilator, and his appetite eventually returned. "That's when we knew that we had turned that corner."

It wasn't until after Andrew's discharge that his doctors learned about MIS-C from colleagues in Europe. They recommended the whole family be tested for antibodies to the coronavirus. Although Andrew tested positive, the rest of the family — both parents, Andrew's twin brother and two older siblings — all tested negative. Andrew's mother is still not sure how he was exposed since the family had been observing a strict lockdown since mid-March. Both she and her husband were working remotely from home, and she says they all wore masks and were conscientious about hand-washing when they ventured out for groceries. She thinks Andrew must have been exposed at least a month before his illness began.

And she's puzzled why the rest of her close-knit family wasn't infected as well. "We are a Latino family," Ingrid Lis said. "We are very used to being together, clustering in the same room." Even when Andrew was sick, she says, all six of them huddled in his bedroom to comfort him.

Meanwhile, Andrew has made a quick recovery. Not long after his discharge in April, he turned 15 and resumed an exercise routine involving running, pushups and situps. A few weeks later, an echocardiogram showed Andrew's heart was "perfect," Ed Lis said. Still, doctors have asked Andrew to follow up with a cardiologist every three months.

An Eye on the Long-Term Effects

The medical team at Montefiore is tracking the 40 children they have already treated and discharged. With kids showing few symptoms in the immediate aftermath, Chouetier hopes the long-term trajectory after MIS-C will be similar to what happens after Kawasaki disease.

"Usually children who have had coronary artery dilations [from Kawasaki disease] that have resolved within the first six weeks of the illness do well long-term," said Choueiter, who runs the Kawasaki disease program at Montefiore.

The Montefiore team is asking patients affected by MIS-C to return for a checkup one week after discharge, then after one month, three months, six months and a year. They will be evaluated by pediatric cardiologists, hematologists, rheumatologists and infectious disease specialists.

Montefiore and other children's hospitals around the country are sharing information. Choueiter wants to establish an even longer-term monitoring program for MIS-C, comparable to registries that exist for other diseases.

Moholland is glad the hospital is being vigilant.

"The uncertainty of not knowing whether it could come back in his future is a little unsettling," she said. "But I am hopeful."

This story is part of a partnership that includes WNYC, NPR and Kaiser Health News.

Fred Mogul, WNYC: @fredmogul

Misinformation abounds, from tales that people who talk to contact tracers will be sent to nonexistent "FEMA camps"

This article was first published on Wednesday, July 15, 2020 in Kaiser Health News.

By Julie Appleby July 15, 2020

In the midst of the COVID-19 epidemic, contact tracing is downright buzzy, and not always in a good way.

Contact tracing is the public health practice of informing people when they've been exposed to a contagious disease. As it has become more widely employed across the country, it has also become mired in modern political polarization and conspiracy theories.

Misinformation abounds, from tales that people who talk to contact tracers will be sent to nonexistent "FEMA camps" — a rumor so prevalent that health officials in Washington state had to put out a statement in May debunking it — to elaborate theories that the efforts are somehow part of a plot by global elites, such as the Clinton Foundation, Bill Gates or George Soros.

At the very least, such misinformation could hinder efforts to contain the virus, and at worst has sparked threats against tracers, say some observers, including the Institute for Strategic Dialogue (ISD), a London-based organization that studies polarization.

The dynamic, ISD notes in a June report, "is being generated both by individual social media users and by key influencers in conspiratorial communities" and plays on fears that Big Brother is watching us.

According to that report, social media posts, mainly videos, have been associated with "widespread sharing of petitions and other efforts to galvanise political action against contact tracing." The videos, steeped in disinformation and conspiracy think — whether alleging tracers' ties to the deep state or casting them as part of a Democratic effort to interfere in the 2020 election — "are receiving more than 300,000 views each on YouTube and are being shared tens of thousands of times across public Facebook pages and groups."

Of course, the real story behind tracing is nothing like these colorful conspiracy theories. It's an age-old infection control strategy, and it's a bit tedious, actually.

"We've been doing it in public health for decades," said Marcus Plescia, chief medical officer for the Association of State and Territorial Health Officials.

Part old-fashioned shoe-leather detective work, part social work, the goal is to interrupt the spread of the illness by reaching out to people who test positive — and people they have been in close contact with — and provide needed support for them to isolate. It has to be done quickly, and it takes a lot of people. Recent case count surges in some parts of the country are making the task more difficult.

So let's take a look at what it is and isn't.

What's the Process?

When a person tests positive for certain communicable diseases, health care providers must report their contact information to public health departments. Contact tracers then try to reach out quickly, generally by phone.

The tracer will ask for the patient's address. Some social media sites have decried this as nefarious, but it's not. The tracer does not want to provide private medical information — "Mr. Smith, I see you tested positive for COVID" — to the wrong person. Those contacted should also feel free to confirm it really is the public health department calling, experts note, as there have been reports of fraudulent calls.

During the initial call, the tracer makes sure the patient is OK and understands the disease and what to expect. Ideally, the contract tracer builds a relationship with the patient. Some can link the patient with local resources or services, such as food delivery or needed medical supplies, that can make it easier to stay isolated until they have recovered from the virus.

What's a Close Contact?

Contact tracers ask where the infected person traveled and with whom they came in close contact — generally defined as being within 6 feet for 15 minutes or more — from about two days before they started showing symptoms until they isolated themselves.

That does not include such things as simply passing people on the street or opening the door to pick up a package dropped off by a FedEx driver.

Providing the information is voluntary, but it is the only way the programs will work. Most patients happily comply, but a few are reluctant, said Plescia.

"That was a little surprising," he said. "You would think if you might cause another person to become ill, you would have an interest in that person being notified. But some worry they are snitching on other people."

Tracers do not disclose the name of the infected person. Contacts simply "receive a call saying 'You have had a significant exposure,'" said Crystal Watson, senior scholar at the Johns Hopkins Center for Health Security and co-author of a report on contact tracing.

To assist with tracing, some restaurants, stores, salons and other businesses are keeping daily logs of customers. Some voices on social media have raised concerns about those logs, saying they are intrusive and suggest that Big Brother is watching. Their purpose, though, is to make it easier for health officials to notify other employees and patrons in the event that someone tests positive.

Close contacts are urged to quarantine for 14 days, check their temperature regularly and avoid contact with other household members, if possible.

For each infected patient, tracers need to contact an average of 10 other people, said Watson — noting, however, that the number could be far higher. "If contact tracing is done in a place where there's a big epidemic and no one is under social distancing restrictions, you'll have to contact more," she said.

Speed is of the essence in finding close contacts. Infected people start showing symptoms within two to seven days of exposure — although it can take up to 14 — and they may be contagious before symptoms appear.

Who Asks All of These Questions?

In the early days of the COVID pandemic in the U.S., tracing was limited because testing for the virus was also limited. The two really go together. That meant the nation used the other tool at its disposal, the blunt instrument of stay-at-home orders. Now, with testing more available, and with many states in the fits and starts of reopening, the more targeted effort of contact tracing becomes important.

Used effectively, it can sharply slow outbreaks, as seen in countries that have employed comprehensive tracing programs, such as Japan, New Zealand and China.

So far, though, the U.S. has a more limited effort, and it varies by state.

An estimated 37,000 contact tracers are now employed by public health departments nationwide, triple the number just a few weeks ago, according to an NPR state survey and tracking effort. Still, those numbers are far below estimates of what many say is necessary. Indeed, Watson and other Johns Hopkins researchers say the U.S. needs to add a minimum of 100,000 contract tracers.

Can They Force Me Into Quarantine?

Although health officials do have the authority to isolate people who pose a danger to others, that power is almost never used.

"Mandatory quarantine hasn't really been used since the days of smallpox in this country, although the president used it in the beginning of the pandemic for some people repatriating back to the county," said Watson.

Public health officials avoid such aggressive tactics because they don't want to discourage people from getting tested. As for hauling people away from their homes by force, that also doesn't happen here, although it does in some authoritarian countries. Instead, a number of cities and regions have set up special hotels or other facilities where infected or exposed people who live in homes where they can't isolate themselves from other family members can voluntarily spend their convalescence.

Is It Working?

It has certainly worked in other countries, said Howard Koh, professor at the Harvard T.H. Chan School of Public Health and former assistant secretary for health in the Obama administration.

"Italy, Spain, China, Taiwan, Hong Kong and New Zealand have all gotten to the other side of the curve," said Koh. "When they have outbreaks, they are relatively small and they jump on them right away."

One difference, he said, is those places have a national strategy.

"In our country, we have a 50-state strategy, a patchwork response including contact tracing, with some states having embraced it and some have barely started."

Massachusetts and New York have reported success with tracing, said Watson.

But there are many areas of the country, especially the Sun Belt, where cases are spiking, complicating efforts to control the virus. With more interest in getting tested, turnaround time for results grows. And large numbers of new cases mean contact tracers have far more people to track down, making it challenging to do so in the short time frame needed to be effective.

"I'm discouraged that a lot of the states where we are seeing a big surge right now have not put a lot of effort into developing their contact tracing workforce," Watson said, echoing Koh's call for a national plan. "We need an initiative by the federal government focused on contract tracing."

Julie Appleby: jappleby@kff.org, @Julie_Appleby

HHS secretary says preexisting conditions have the protections originally offered under HIPAA.

This article was first published on Tuesday, July 14, 2020 in Kaiser Health News.

By Julie Rovner July 14, 2020

One of the most popular features of the Affordable Care Act is its guarantee of insurance coverage — at no greater cost — for people with preexisting health conditions.

Thus, even as the Trump administration argues before the Supreme Court that the entire Affordable Care Act should be declared invalid, the president and his administration officials maintain that regardless of what happens to the ACA, they will protect people who have had health problems in the past.

Speaking to a "virtual health summit" sponsored by the political newspaper The Hill, Health and Human Services Secretary Alex Azar answered a question about the case, Texas v. Azar, by pointing out "it's in statute already in HIPAA that preexisting conditions are covered," implying that if the ACA were declared unconstitutional, those protections would remain in place for everyone.

Umm … not so much.

When we checked with HHS for more information about Azar's comment, a spokesperson reiterated the secretary's statement, adding that Azar was "clear that the story on preexisting conditions doesn't end with HIPAA" and that affordability is a critical component.

So we investigated.

A Little About HIPAA

The Health Insurance Portability and Accountability Act, a law we have examined before, was passed by a Republican-led Congress and signed by Democratic President Bill Clinton in 1996. It is best known for safeguarding medical privacy and patient access to medical records, even though the privacy provisions were added toward the end of congressional deliberations.

HIPAA's original purpose was to end what was known as "job lock," a situation in which people with preexisting conditions were reluctant to leave jobs with health insurance even for other positions with health insurance for fear their conditions would not be covered or they would be subject to long waiting periods for coverage. Both scenarios were common at the time.

HIPAA addressed that problem — as long as people maintained "continuous" coverage, defined as having health insurance for at least 12 months without a break of more than 63 days. People who met that requirement could not have waiting periods or denials of coverage imposed upon their own or a family member's preexisting condition. HIPAA included protections for people with coverage in the small-group insurance market, which primarily comprises small businesses, by requiring insurers who sold policies in that market to sell to all small groups, regardless of health status, and to cover every eligible member of the groups — again, regardless of health status.

But HIPAA was not designed to comprehensively address the problem of people with preexisting conditions getting and keeping affordable health insurance.

For starters, the protections were only for people who already had job-based insurance, to make it easier for them to move to other job-based insurance. It did nothing for those in the individual insurance market who needed to purchase their own coverage — such as self-employed people and those working for companies that did not offer health insurance.

HIPAA attempted to create a pathway for people transitioning from employer-sponsored to individual coverage. It ensured that, after leaving a job, people who secured insurance through another law, the 1986 Consolidated Omnibus Budget Reconciliation Act, or COBRA, would be eligible to buy a "conversion" plan from their insurer once their previous job-based benefits were exhausted.

However, two giant problems arose. First, COBRA, which allows individuals to continue their employer-provided coverage for up to 18 months if they pay the entire premium themselves (plus a small administrative fee), is prohibitively expensive for most people. In 2019, the average premium for a single worker was $599 per month.

The other problem was that even if a former worker did manage to pay for COBRA coverage until that 18-month period ended, there was no limit on how much insurers could charge for the conversion policies. So, even if they were technically available, they were frequently unaffordable.

There were other problems. COBRA coverage was not available to people who worked for small businesses, or for those who became unemployed because the business they worked for failed and no longer offered insurance to anyone. HIPAA also did not stipulate which benefits had to be offered.

Next, the ACA

Sources

Health Insurance Portability and Accountability Act of 1996 

Affordable Care Act of 2010 

Email exchange with a Department of Health and Human Services spokesperson, July 10, 2020

Email exchange with Timothy Jost, emeritus professor at Washington and Lee University School of Law in Virginia, July 10, 2020

Email exchange with Karen Pollitz, a senior fellow at KFF (the Kaiser Family Foundation; KHN is an editorially independent program of the foundation), July 10, 2020

"Trump Administration Asks Supreme Court to Strike Down Obamacare," The Washington Post, June 26, 2020

"Did The ACA Create Preexisting Condition Protections For People In Employer Plans?" May 21, 2019

The HIPAA Privacy Rule, Department of Health and Human Services, April 16, 2015

"Average Annual Single Premium per Enrolled Employee for Employer-Based Health Insurance," Kaiser Family Foundation, time frame 2018

The ACA sought to deal with HIPAA's shortcomings. It required most employers to offer coverage and, for those purchasing their own, it required insurers to provide a comprehensive package of benefits at the same price to all purchasers, regardless of health status.

However, the ACA rewrote the HIPAA provisions regarding preexisting conditions, so if the ACA is struck down by the Supreme Court, it's not clear whether even HIPAA's lesser provisions would remain. Experts disagree about this, but there is a possibility that HIPAA's protections could be swept away along with the ACA.

Later in his answer to the question posed at The Hill's summit, Azar pointed out that there are significant affordability problems with coverage under the ACA, as well. "So we will work with Congress if the time ever comes, to get real affordable solutions," he said. That's true. ACA plans, even with subsidies, can be too expensive for some people, and prohibitive for those who earn just slightly too much to qualify for government help. Earlier this month, Democrats in the House passed a bill to make ACA plans more affordable.

Our Ruling

Azar's statement suggested that if the Supreme Court rules against the ACA and that sweeping law is nullified, Americans with preexisting conditions would continue to have the protections originally offered under HIPAA.

Though it contains an element of truth, it leaves out critical pieces of information. For instance, the HIPAA protections are not equivalent to those provided by the ACA. First, they are geared toward people who have work-based insurance coverage — as long as that coverage is continuous for at least 12 months with lapses no longer than 63 days. One expert we consulted pointed out that this window could be especially problematic now, during a time of "enormous economic dislocation."

Additionally, the ACA rewrote the HIPAA provisions regarding preexisting conditions — bringing into question what might become of them, too.

We rate Azar's claim Mostly False.

Julie Rovner: jrovner@kff.org, @jrovner

Across the country, the recession has cut state revenues at the same time the pandemic has increased costs, forcing lawmakers into painful decisions about how to balance their budgets.

This article was first published on Friday, July 10, 2020 in Kaiser Health News.

By Markian Hawryluk

As a teenager, Paulina Castle struggled for years with suicidal thoughts. When her mental health was at its most fragile, she would isolate herself, spending days in her room alone.

“That’s the exact thing that makes you feel significantly worse,” the 26-year-old Denver woman said. “It creates a cycle where you’re constantly getting dug into a deeper hole.”

Part of her recovery involved forcing herself to leave her room to socialize or to exercise outside. But the COVID-19 pandemic has made all of that much harder. Instead of interacting with people on the street in her job as a political canvasser, she is working at home on the phone. And with social distancing rules in place, she has fewer opportunities to meet with friends.

“Since the virus started,” she said, “it’s been a lot easier to fall back into that cycle.”

Between the challenges of the pandemic, the social unrest and the economic crisis, mental health providers are warning that the need for behavioral health services is growing. Yet faced with budgetary shortfalls, Colorado is cutting spending on a number of mental health and substance use treatment programs.

Across the country, the recession has cut state revenues at the same time the pandemic has increased costs, forcing lawmakers into painful decisions about how to balance their budgets. State legislatures have been forced to consider health care cuts and delay new health programs even in the midst of a health care crisis. But many lawmakers and health experts are concerned the cuts needed to balance state budgets now could exacerbate the pandemic and the recession down the line.

“Health care cuts tend to be on the table, and of course, it’s counterproductive,” said Edwin Park, a health policy professor at Georgetown University. When there’s a recession, people lose their jobs and health insurance, he noted, the very moment when people need those health programs the most.

‘Everything Has To Be On The Table’

In Colorado, for example, lawmakers had to fill a $3.3 billion hole in the budget for fiscal year 2020, which started July 1. That included cuts to a handful of mental health programs, with small overall savings but potentially significant impact on those who relied on them.

They cut $1 million from a program designed to keep people with mental illness out of the hospital and another million from mental health services for juvenile and adult offenders. Lawmakers reduced funding for substance abuse treatment in county jails by $735,000 and eliminated $5 million earmarked for addiction treatment programs in underserved communities. And that’s all on top of a 1% cut to Medicaid community providers who offer health care to the state’s poorest residents.

Some of those cuts were offset by $15.2 million in federal CARES Act funding allocated to behavioral health care programs. But some programs were completely defunded. Cuts were targeted primarily at programs that hadn’t started yet or hadn’t been fully implemented. The rationale: Those cuts wouldn’t have as deep an impact.

Doyle Forrestal, CEO of the Colorado Behavioral Healthcare Council, which represents 23 behavioral health care providers, worries that resources won’t be there for an emerging wave of people who have developed mental health or addiction issues during the pandemic.

“People who are isolated at home are drinking a lot more, maybe having other problems — isolation, economic despair,” she said. “There’s going to be a whole new influx once all of this takes hold.”

State legislators said they tried to avoid cutting programs that would hamper the response to the pandemic or the economic recovery.

“There was a desire on both sides to do everything we could to protect health care spending in Colorado,” said Democratic Rep. Dylan Roberts. “But when you’re looking at across-the-board cuts, everything has to be on the table.”

Every state is facing a similar conundrum. With tax filing deadlines pushed back to July 15, states are unsure how much income tax revenue they will collect.

So in addition to cutting back where possible, states are raiding discretionary funds — Colorado repurposed money from the tobacco settlement and marijuana taxes — to shore up their budgets. States are also tapping rainy day funds, which, according to the National Association of State Budget Officers, grew to record levels after the 2008 recession.

New Policies Delayed

Overall, at least 43 states have made some changes to facilitate access to Medicaid or the Children’s Health Insurance Program as many people have lost their job-based health insurance in the COVID crisis. And in late June, voters in Oklahoma approved expanding Medicaid to more residents. But since the start of the pandemic, states including Kansas and California have put off plans to expand eligibility for Medicaid, which provides health care to low-income people.

“These are symptoms of states that can’t deficit-spend, despite this great need for more coverage,” said Sara Collins, vice president for health care coverage and access at the Commonwealth Fund, an independent health policy research foundation based in New York. “If they spend more in one area, that means cuts in another.”

Colorado has had an aggressive health agenda in recent years but had to defer plans for a public health insurance option that could have provided a more affordable plan for people buying insurance on their own.

The legislature killed a proposal to create an annual mental health checkup. The measure would have cost the state only $13,000, but Democratic Gov. Jared Polis signaled he wouldn’t sign any bills that included new mandates for insurance companies.

Democratic Rep. Dafna Michaelson Jenet, who sponsored the checkup measure, was disappointed.

“Not every one of us is going to catch COVID, but every single one of us will have a mental health impact,” she said.

Long-Term Implications

Once the economic crisis eases, Roberts said, lawmakers will look to restore funding to some of the programs they cut.

But cuts are often easier to make than to restore — as illustrated by cutbacks made during the 2008 recession, according to Georgetown’s Park.

“Many cuts were never fully restored, even though we were in one of the longer economic expansion periods in our country’s history,” Park said.

He also worries many of the smaller primary care and behavioral health providers, who saw fewer patients come through their doors because of stay-at-home orders during the pandemic, might not survive.

“That means less access to care, including routine care like vaccinations,” he said. “If kids aren’t vaccinated, they may be more vulnerable to flu and measles, making them more vulnerable to COVID-19. That makes it more difficult for a stressed health care system to try to deal with a potential second wave of infections.”

The longer-term mental health toll may be harder to catalog.

Castle, for one, has focused on establishing routines to help her manage her mental health during the pandemic. Every Wednesday night, she plays games online with her friends. And every Friday night, she and her boyfriend build a fire in the backyard.

“If I know people are expecting me to be somewhere at 6 o’clock, that obligation encourages me to go out,” she explained. “There are days it’s a struggle. I have to focus on baby steps.”

Still, Castle worries about others who may be struggling during the pandemic. She has signed on to work with the Colorado chapter of Young Invincibles, which lobbies for health care, higher education and workforce policies to help young adults. Even as states and the federal government have found the money to help hospitals and doctors treat the physical effects of the COVID pandemic, she doesn’t see the same commitment to treating its mental health toll.

“We need to start treating mental health the same as we do physical health,” she said. This is an issue we need to stop keeping in the dark.”

If you or someone you know is thinking about suicide, call the National Suicide Prevention Lifeline at 1-800-273-8255, or use the online Lifeline Chat, both available 24 hours a day, seven days a week.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.