In Super-Vaxxed Vermont, COVID Strikes — But Packs Far Less Punch

KFF Health News, January 28, 2022

In a state with the motto "Freedom and Unity," freedom has largely yielded to unity, and the state's pandemic response has been met with eager compliance.

This article was published on Friday, January 28, 2022 in Kaiser Health News.

By Sarah Varney   

Even Eden, a snow-covered paradise in northern Vermont, is poisoned by omicron.

The nearly vertical ascent of new coronavirus cases in recent weeks, before peaking in mid-January, affected nearly every mountain hamlet, every shuttered factory town, every frozen bucolic college campus in this state despite its near-perfect vaccination record.

Of all the states, Vermont appeared best prepared for the omicron battle: It is the nation's most vaccinated state against COVID, with nearly 80% of residents fully vaccinated — and 95% of residents age 65 and up, the age group considered most vulnerable to serious risk of COVID.

Yet, even this super-vaxxed state has not proved impenetrable. The state in mid-January hit record highs for residents hospitalized with COVID-19; elective surgeries in some Vermont hospitals are on hold; and schools and day care centers are in a tailspin from the numbers of staff and teacher absences and students quarantined at home. Hospitals are leaning on Federal Emergency Management Agency paramedics and EMTs.

And, in a troubling sign of what lies ahead for the remaining winter months: about 1 in 10 COVID tests in Vermont are positive, a startling rise from the summer months when the delta variant on the loose elsewhere in the country barely registered here.

"It shows how transmissible omicron is," said Dr. Trey Dobson, chief medical officer at Southwestern Vermont Medical Center, a nonprofit hospital in Bennington. "Even if someone is vaccinated, you're going to breathe it in, it's going to replicate, and if you test, you're going to be positive."

But experts are quick to note that Vermont also serves as a window into what's possible as the U.S. learns to live with COVID. Although nearly universal vaccination could not keep the highly mutated omicron variant from sweeping through the state, Vermont's collective measures do appear to be protecting residents from the worst of the contagion's damage. Vermont's COVID-related hospitalization rates, while higher than last winter's peak, still rank last in the nation. And overall death rates also rank comparatively low.

Children in Vermont are testing positive for COVID, and pediatric hospitalizations have increased. But an accompanying decrease in other seasonal pediatric illnesses, like influenza and respiratory syncytial virus, and the vaccinated status of the majority of the state's eligible children has eased the strain on hospitals that many other states are facing.

"I have to remind people that cases don't mean disease, and I think we're seeing that in Vermont," said Dr. Rebecca Bell, a pediatric critical care specialist at the University of Vermont Health Network in Burlington, the only pediatric intensive care hospital in the state. "We have a lot of cases, but we're not seeing a lot of severe disease and hospitalization."

She added, "I have not admitted a vaccinated child to the hospital with COVID."

Vermont in many ways embodies the future the Biden administration and public health officials aim to usher in: high vaccination rates across all races and ethnicities; adherence to evolving public health guidelines; and a stick-to-itiveness and social cohesion when the virus is swarming. There is no "good enough" in Vermont, a state of just 645,000 residents. While vaccination efforts among adults and children have stalled elsewhere, Vermont is pressing hard to better its near-perfect score.

"We have a high percentage of kids vaccinated, but we could do better," said Dobson.

He continues to urge unvaccinated patients to attend his weekly vaccination clinic. The "first-timers" showing up seem to have held off due to schedules or indifference rather than major reservations about the vaccines. "They are nonchalant about it," he said. "I ask, 'Why now?' And they say, 'My job required it.'"

Replicating Vermont's success may prove difficult.

"There is a New England small-town dynamic," said Dr. Tim Lahey, director of clinical ethics at the University of Vermont Medical Center in Burlington. "It's easy to imagine how your behavior impacts your neighbor and an expectation that we take care of each other."

While other rural states in the Midwest and South have struggled to boost vaccination rates, New England, in general, is outpacing the pack. Behind Vermont, Rhode Island, Maine, and Connecticut have the highest percentage of fully vaccinated residents in the country.

"It's something beyond just the size," said Dr. Ben Lee, an associate professor at the Robert Larner, M.D. College of Medicine at the University of Vermont. "There is a sense of communal responsibility here that is a bit unique."

In a state with the motto "Freedom and Unity," freedom has largely yielded to unity, and the state's pandemic response has been met with eager compliance. "The general attitude here has been enthusiasm to be safer," said Lahey.

Lahey credits the state's Republican governor, Phil Scott, who has been "unambivalent about pro-vax messaging." Combined with a "tendency to trust the vaccine, you get a different outcome than in places where political leaders are exploiting that minority voice and whipping people up in anger."

Vermont's medical leaders are advising state leaders to shift from a COVID war footing — surveillance testing, contact tracing, quarantines, and lockdowns — to rapprochement: testing for COVID only if the outcome will change how doctors treat a patient; ceasing school-based surveillance testing and contact tracing; and recommending that students with symptoms simply recuperate at home.

Once the omicron wave passes and less virus is circulating, Dobson said, a highly vaccinated state like Vermont "could really drop nearly all mitigation measures and society would function well." Vermonters will become accustomed to taking appropriate measures to protect themselves, he said, not unlike wearing seat belts and driving cautiously to mitigate the risk of a car accident. "And yet," he added, "it's never zero risk."

Spared the acrimony and bitterness that has alienated neighbor from neighbor in other states, Vermont may have something else in short supply elsewhere: stamina.

"All of us are just exhausted," said Lahey, the ethics director. But "we're exhausted with friends."

Sarah Varney: svarney@kff.org, @SarahVarney4

Resistance to a Boston Hospital's Expansion Centers on Rising Prices

KFF Health News, January 27, 2022

Mass General Brigham's plans to build three ambulatory care centers in three suburbs west of Boston is stirring controversy.

This article was published on Thursday, January 27, 2022 in Kaiser Health News.

By Harris Meyer

A boisterous political battle over a proposed expansion by the largest and most expensive hospital system in Massachusetts is spotlighting questions about whether similar expansions by big health systems around the country drive up healthcare costs.

Mass General Brigham, which owns 11 hospitals in the state, has proposed a $2.3 billion expansion including a new 482-bed tower at its flagship Massachusetts General Hospital in Boston and a 78-bed addition to Brigham and Women's Faulkner Hospital. The most controversial element, however, is a plan to build three comprehensive ambulatory care centers, offering physician services, surgery, and diagnostic imaging, in three suburbs west of Boston.

On Jan. 25, the state's 11-member Health Policy Commission unanimously concluded that these expansions would drive up spending for commercially insured residents by as much as $90 million a year and boost health insurance premiums.

The commission also ordered Mass General Brigham to develop an 18-month "performance improvement plan" to slow its cost growth. The action, believed to be the first time in the country a hospital has been ordered to develop a plan to control costs, reflects concern about giant hospitals' role in rising healthcare costs.

Other states, including California, Delaware, Oregon, Rhode Island, and Washington, have created or are considering commissions on healthcare costs with the authority to analyze the market impact of mergers and expansions. That's happening because the traditional "determination of need" process for approving health facility expansions, which nearly three dozen states still have in place, has not been effective in the current era of health system giants, said Maureen Hensley-Quinn, a senior program director at the National Academy for State Health Policy.

The Mass General Brigham health system, which generates $15.7 billion in annual operating revenue, announced that the massive expansion would better serve its existing patients, including 227,000 who live outside Boston. Its leaders said the new facilities would not raise health spending in the state, where policymakers are alarmed that cost growth in 2019 hit 4.3%, exceeding the state's target of 3.1%.

The hospitals' cost-analysis report, submitted to the state last month, concluded that the system's existing patients would pay lower prices at the new suburban sites than at its downtown locations. John Fernandez, president of Mass General Brigham Integrated Care, projected that prices at the new centers would be 25% less, and he said patients will not have to pay extra hospital "facility fees" at the new outpatient sites.

"We're all going to have a tsunami of patients over the next 20 years given the aging population, and everyone has to step up to meet that demand," he said in explaining the expansion.

But a well-funded coalition of competing hospitals, labor unions, and chambers of commerce argues that Mass General Brigham's invasion of the Boston suburbs would spike total spending by drawing in patients from lower-priced physicians and hospitals. They cite the health system's own planning projection, unearthed by the attorney general's office in a November report, that the expansion would boost annual profits by $385 million.

"How could you be fooled?" said Dr. Eric Dickson, CEO of UMass Memorial Healthcare, a safety-net health system serving the towns west of Boston that is part of the coalition of expansion opponents. "If you let the state's most expensive system grow wildly, it will drive up the cost of care."

The controversy signals a shift in the concerns about the cause of rapidly escalating healthcare costs. Up to now, state and federal policymakers examining how hospital system growth affects costs have largely focused on hospital mergers and purchases of physician practices. Studies have found that these deals significantly boost prices to consumers, employers, and insurers. State and federal regulators have stepped up antitrust scrutiny of mergers and acquisitions.

Deep-pocketed hospital systems increasingly are turning to solo expansion to gain a bigger share of the market. These expansions fall outside the legal authority of antitrust enforcers.

Health systems are building satellite ambulatory care centers to attract more well-insured patients and steer them to their own hospitals and other facilities, said Glenn Melnick, a health economist at the University of Southern California.

"The outcome is the same as a merger — capturing patients and keeping them," he said. "That's not necessarily good for consumers in terms of access to care or cost efficiency."

Critics of Mass General Brigham's plans also warn that the expansion would financially destabilize providers that heavily serve lower-income and minority residents because some of their more affluent patients would move to the new facilities. Those patients' commercial insurance plans pay nearly three times what the state's Medicaid program pays.

"It's a very, very good business move for MGB," said Dickson, whose system serves a large percentage of Medicaid patients. "But they know quite well this will impact our ability to care for vulnerable populations."

The Health Policy Commission agreed with those opposing the expansion and said it would advise the state Public Health Council — which will decide on the three expansion applications by April — that the proposals are not consistent with the state's goals for cost containment.

"Our strong assessment is this would substantially increase spending," said Stuart Altman, a health policy professor at Brandeis University who chairs the commission. In addition, "there is a clear indication it would reduce revenues to those institutions we count on to provide services to lower-income and historically marginalized communities."

In a written statement, Mass General Brigham ripped the commission's findings as flawed. It also disagreed with the commission's decision to require a cost-improvement plan but said it would work with the agency to address the challenge.

Under Massachusetts' determination of need process, Mass General Brigham must show the Public Health Council that its expansion proposals would contribute to the state's goals for cost containment, improved public health outcomes, and delivery system transformation.

The council has never blocked a project on cost grounds in its nearly 50-year history, said Dr. Paul Hattis, a former member of the Health Policy Commission. He argues that Massachusetts needs more explicit statutory power to decide whether health system expansions are good for the public, because he doesn't think the council understands its own regulation.

A bill passed by the Massachusetts House of Representatives last fall would give the commission, which was created in 2012, greater authority to investigate the cost and market impact of such expansions. Its legislative fate is uncertain.

Upping the stakes in the Massachusetts expansion fight: Massachusetts General Hospital charges by far the highest prices in the state, and Brigham and Women's Hospital isn't far behind.

Patients with a Mass General Brigham primary care physician had the highest total per-member spending in 2019, nearly $700 per month, according to the Health Policy Commission. That was 45% higher than spending for patients served by doctors at Reliant, which is owned by UnitedHealth Group's Optum unit. Average payments for major outpatient surgery at Massachusetts General and Brigham and Women's were nearly twice as high as at the state's lowest-paid high-volume hospital.

After Miscarriages, Workers Have Few Guarantees for Time Off or Job-Based Help

KFF Health News, January 26, 2022

There are no national laws that protect people when they need time off from work to deal with the loss.

This article was published on Wednesday, January 26, 2022 in Kaiser Health News.

By Bryce Covert January 26, 2022

For three years, Rachel Makkar said, she thrived in her job as a broker and asset manager at J&B Building Co. in Colorado. She excelled at her work — she said her performance reviews noted that — and she thought it was "the best place I've ever worked."

That changed in August. After trying for "a really long time" to conceive a second child, she suffered an early miscarriage at home one weekend. She couldn't go to work that Monday. "I was really traumatized," she said. "That entire first week was like a heightened level of emotion that I hadn't really been through before." She also had a doctor's appointment to ensure she wasn't experiencing an ectopic pregnancy, which would have required immediate surgery.

She had emailed her bosses, informing them of the miscarriage and her need to take Monday off, which she had enough paid leave to cover. Because of the pandemic, she had been working from home several days a week and opted to do that again Tuesday because she was still bleeding and her face was "so puffy from crying," she said. She returned to the office, as scheduled, on Wednesday, she said, and then, given that her managers were out of the office, worked from home the rest of the week.

The following week, 10 days after her miscarriage, one of the company owners called her and fired her, allegedly for working from home repeatedly, even though others at the firm had similar hybrid schedules, according to Makkar. She was "shocked."

When Makkar reminded him that she had worked from home because of her miscarriage, she said he responded, "When my wife had a miscarriage in the beginning of our marriage, she only took a half a day off work."

Getting fired right after her miscarriage "was really, really awful," she said through tears. "You're already so devastated, and it's just another blow."

Makker filed a complaint based on her allegations against J&B with the Colorado Civil Rights Division, accusing the company of gender and pregnancy discrimination for her firing, in violation of Colorado state laws. "This shouldn't have to happen to other women," she said.

A lawyer for J&B said its policy is not to comment on ongoing litigation and declined to provide any responses the company may have filed with the state. "We're just confident that once the facts are reviewed the company will be vindicated," he said.

Miscarriage, which occurs in about a quarter of all pregnancies, is the most common form of loss of a pregnancy. And yet there are no national laws that protect people when they need time off from work to deal with the loss.

The physical needs of someone who experiences a miscarriage vary greatly. Within the first week or two, symptoms may resemble a heavy menstrual period with cramping and some pain. The later in the pregnancy that a miscarriage occurs, the more likely there will be significant bleeding, "to the point where it leads to anemia in some cases," said Dr. Wael Salem, a reproductive endocrinologist and fertility specialist with CCRM San Francisco. Some people have such heavy contractions that they need pain management, he added. Miscarriages in the second trimester or later may require procedures needing hospital admission. The aftereffects are often unpredictable and can last for weeks or months.

"Miscarriage is not a one-and-done thing at all," Salem said. "It drags on physically, mentally, and emotionally."

The emotional aspect "can be a very traumatic experience," noted Maria Brann, a professor of communications studies at Indiana University who has studied miscarriage for a decade. Some people blame themselves even though the vast majority of early miscarriages are due to chromosomal abnormalities beyond people's control. Compounding the grief is the lack of established rituals that accompany other losses, as well as a stigma some people attach to miscarriage.

In the wake of such trauma, "it's very difficult to focus," Brann said. "An individual is probably not going to be as productive."

"It is really important that we encourage women to take care of themselves," Brann said. Otherwise, the grief won't be processed and it can "cause even greater mental anguish later on."

More people are speaking out about the experience of miscarriage, including high-profile women like Michelle Obama, Meghan Markle, and actress Gabrielle Union.

But many workers find it difficult to get time off from work. The federal Pregnancy Discrimination Act prohibits employers from treating workers who are pregnant, give birth, or have related medical conditions — including miscarriage — worse than comparable co-workers. Courts, however, have interpreted that law differently, even after a 2015 Supreme Court decision decided in favor of a plaintiff who claimed pregnancy discrimination. Judges have dismissed two-thirds of cases in the aftermath, according to a review by A Better Balance, a national legal nonprofit promoting workplace rights.

Thirty states and five localities — including Colorado — have enacted laws that require employers to offer workers accommodations related to pregnancy, which can include time off to recover from a miscarriage. But outside those states, workers are protected only by the pregnancy act or the Americans with Disabilities Act, if a miscarriage is severe enough to substantially limit a "life activity."

Currently, 13 states, 20 cities, and four counties, also including Colorado, have enacted laws requiring some employers to provide paid sick leave to workers for medical needs, such as for the physical and mental health impacts of miscarriage. They don't require employees to say why they need the time off, other than perhaps producing a doctor's note.

"It's not putting the onus on the worker to have to reveal something that might be very personal and very sensitive," said Sarah Brafman, a senior policy counsel at A Better Balance.

Nine states and the District of Columbia have paid family leave programs, which can be used for more serious complications resulting from miscarriage. Elsewhere workers can take unpaid leave through the Family and Medical Leave Act if they qualify.

To fill the gaps, Sen. Tammy Duckworth (D-Ill.) and Rep. Ayanna Pressley (D-Mass.) introduced legislation that would ensure three days of paid leave for miscarriage and other fertility challenges. Democrats have also put forward federal legislation to guarantee paid sick leave, and they've included paid family leave in President Joe Biden's social spending plan, although that provision is meeting stiff opposition from some lawmakers and the bill is languishing in Congress.

Makkar is living with the repercussions of her miscarriage. "It's all so traumatizing still," she said. She's trying to find a new job, but the search is complicated. She's "terrified of getting myself in this situation again," she said, because she wants to have more children. "I don't want to be somewhere that that's not going to be supported."

What the Federal 'No Surprises Act' Means in California

KFF Health News, January 26, 2022

The federal law that took effect Jan. 1 protects more than 100 million people enrolled in self-funded health plans across the nation.

This article was published on Wednesday, January 26, 2022 in Kaiser Health News.

By Bernard J. Wolfson

Betty Chow, a Los Angeles resident, had a cervical disc replaced in August 2020 at a surgery center that was part of her Anthem Blue Cross PPO network.

Thirteen months later, she was blindsided by a bill for nearly $2,000 from the anesthesiologist who was on her surgical team but was not contracted with her PPO, or preferred provider organization.

Chow, a 35-year-old veterinarian, says she discussed the bill with her boyfriend, a registered nurse. He told her about a California law that took effect in 2017 and prohibits such "surprise bills" from out-of-network medical providers who work at in-network facilities.

Unfortunately, that law does not protect Chow or nearly 6 million other Californians who get health coverage through employers that pay employee medical bills out of their own treasuries. These "self-funded" plans are regulated by the U.S. Department of Labor — and thus are beyond the reach of state law.

But a federal law that took effect Jan. 1 bridges that gap for the more than 100 million people enrolled in such health plans across the United States, including those nearly 6 million Californians. And it covers millions more in the 32 states that have no laws against surprise bills or have laws offering only partial protection.

The new federal law, the No Surprises Act, also protects nearly 1 million Californians not covered by a 2009 California Supreme Court ruling that prohibits emergency room doctors and other providers of emergency services from billing HMO patients for out-of-network charges not paid by their insurers — a practice known as balance billing.

"Millions more Californians will now be protected against these bills that are not just unfair but put families' economic security at risk," says Anthony Wright, executive director of Health Access California, a consumer advocacy group.

It's high time. Surprise bills have inflicted financial pain on millions of Americans for far too long.

When patients are seen by out-of-network providers they didn't choose, it is often a double whammy: They pay more out-of-pocket — even if their health plan covers some out-of-network care — and they may later receive balance bills from providers that can total thousands of dollars.

Research shows that surprise bills are common among the nearly 200 million U.S. residents enrolled in private health plans.

A 2020 study found that 20% of privately insured patients who had elective surgery at a hospital that was in their insurance network received surprise bills from providers who were not. Bills from anesthesiologists averaged $1,219. Bills from surgical assistants averaged more than twice that amount.

"When patients pay their insurance premiums, they presume — and I believe fairly presume — that they will be covered financially," says Katie Berge, director of federal government affairs at the Leukemia & Lymphoma Society.

The No Surprises Act covers all privately insured people in employer-sponsored and individual/family health plans. Medicare and Medicaid already protect their enrollees against nasty billing surprises.

The new federal law, which is largely in sync with California's, bans balance billing for nonemergency care by out-of-network providers at in-network facilities and for most emergency room care at any facility. Insurers must cover those services at in-network rates, and providers may not bill patients for any amounts beyond that. Providers and health plans must negotiate how much the plan will pay, leaving patients out of the fray.

The federal law also protects against outlandish bills from out-of-network air ambulance services. A California law that took effect in January 2020 does the same thing. But it doesn't cover the millions of people in federally regulated health plans and has been vulnerable to a possible legal challenge because it may conflict with the 1978 deregulation of airlines, which included air ambulances.

In cases where its provisions are stronger, the federal law will trump state laws.

What about enforcement? The federal government will defer to states in cases that involve state-regulated plans, and in those that involve federally regulated ones if the target of the complaint is a provider, says Loren Adler, associate director of the USC-Brookings Schaeffer Initiative for Health Policy. But the federal government will step in if states refuse or cannot enforce the law, he says.

Federal health officials are sending letters about enforcement to the governors of every state.

California, with its strong laws against surprise billing, certainly has the means and experience for enforcement, though it has not seen a huge number of cases. In the past four years, the Department of Managed Healthcare has resolved 1,006 consumer complaints about balance billing, and 467 of them yielded total reimbursements of nearly $1 million to enrollees, says Rachel Arrezola, a department spokesperson.

Of course, not all bills that surprise patients are regulated by state or federal law. Sometimes people owe more than they thought on their deductible, or their cost sharing was higher than they realized, or their procedure wasn't covered by their health plan, or the facility they chose wasn't in their network.

So, bone up on your insurance policy. Know what and who it covers, which facilities are in the network, how much your out-of-pocket costs are, and how much of your deductible remains to be paid.

That will help you determine whether a bill is illegitimate. And there still will be illegitimate bills — because people make mistakes. And some medical professionals act in bad faith.

When you get a bill, don't pay it right away. Ask questions. Compare it with the explanation of benefits you receive from your insurer — and if that hasn't arrived yet, wait for it. If there's a discrepancy between what your provider and your health plan say, call them both, and try to iron it out.

If that doesn't work, don't get discouraged. You can file a grievance with your health plan. And if that doesn't resolve your problem, contact the Department of Managed Healthcare to open an appeal, either on its website (www.healthhelp.ca.gov) or by calling 1-888-466-2219. The department also has a fact sheet that may answer some of your questions about California's surprise billing law.

The federal government has launched a website (www.cms.gov/nosurprises) that may answer many of your questions about the No Surprises Act and will enable you to lodge a complaint or dispute a bill. You can also contact a federal "no surprises" help desk at 1-800-985-3059.

If you are simply befuddled by medical bills or lack the confidence to contest one on your own, the Health Consumer Alliance is a great resource. Find an office near you by going to www.healthconsumer.org or calling 1-888-804-3536.

Chow, a native of Hong Kong who has been a patient in the single-payer system there and in the United Kingdom, says she is baffled by the U.S. system, "where you pay for medical insurance, but then you have to pay more."

Although California's law does not protect her from the anesthesiologist's $2,000 bill and the new federal law is not retroactive, she nonetheless appears to be headed toward a happy ending.

After three collection attempts by the anesthesiologist and several phone calls by Chow, Anthem agreed to knock the bill down to $83 and to update the anesthesiologist's billing office. That still hasn't happened, but Chow is hopeful.

"I don't really understand what I'm responsible for," she says, "except $83 is a lot less than $2,000."

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

Bernard J. Wolfson: bwolfson@kff.org, @bjwolfson

With a Vaccine Mandate Looming, Nursing Homes Face More Staffing Problems

KFF Health News, January 25, 2022

Healthcare sites in states that challenged the federal requirement have until March 15 for their staffs to be fully vaccinated.

This article was published on Tuesday, January 25, 2022 in Kaiser Health News.

By Eric Berger

ST. CHARLES, Mo. — Jamie Smith, a staffing agency nurse who loves end-of-life care, said she has been warmly welcomed by staffers and residents at Frontier Health & Rehabilitation in this conservative St. Louis suburb.  

That's even though she has not been vaccinated against COVID-19.

But leaders of the nursing home, where 22 residents died from COVID before vaccines were available, likely won't be able to employ unvaccinated people like Smith for much longer. The U.S. Supreme Court on Jan. 13 upheld a federal mandate requiring healthcare workers at facilities that receive Medicaid or Medicare funding to be fully vaccinated. If all staffers — excluding those with approved religious or medical exemptions — aren't fully vaccinated, the facility will lose that money.

Healthcare sites in Missouri and other states that challenged the federal requirement have until March 15 for their staffs to be fully vaccinated, according to the Centers for Medicare & Medicaid Services, while facilities in states that didn't sue to block the mandate have a Feb. 28 deadline.

That poses a challenge for Frontier and its residents because the nursing home already doesn't have enough staffers. And it is in the state with the lowest rate of fully vaccinated nursing home healthcare workers, 67% as of Jan. 9, according to CMS data. Frontier's reported staff vaccination rate was just 30% at the start of the year.

That compares with a national rate of 81%, according to the federal data.

Although the mandate ensures that unvaccinated staff members are not caring for some of the people most vulnerable to the virus, not enough workers are willing to take the low-paying, challenging jobs. If they quit to avoid getting shots or are fired because they won't get them, nursing home residents might not be any safer — because of lack of care.

"Obviously we need good staff members to take care of residents, but the residents need to be safe as well," said Marjorie Moore, who supports the mandate and is executive director of Voyce, a St. Louis nonprofit that advocates for nursing home residents and their families.

"A person who lives in their own home has the chance to say, 'I don't want somebody in my home who isn't vaccinated,'" she added. "In a nursing home, they don't have the opportunity to say, 'I don't want somebody who is unvaccinated coming up and feeding me.'"

The problem of inadequate staffing at nursing homes predates the pandemic, and it's gotten worse.

In March 2020, 3.3 million people were employed at U.S. nursing homes and residential care facilities, according to the Bureau of Labor Statistics. In December 2021, that number had dropped to 2.9 million, a loss of 400,000 workers.

Nursing home operators can't find enough staffers because they often don't pay much. The mean hourly wage for nursing assistants in Missouri was $13.33 in 2020, according to the statistics bureau. And the homes require employees to take on a slew of responsibilities, including feeding residents, changing adult diapers, and caring for residents who have dementia and may become combative.

Nursing assistants "can typically find a job with better pay that is less physically and emotionally demanding," said Brian McGarry, a University of Rochester professor who studies long-term care. "Somebody's life and dignity is in your hands, and it's a huge responsibility, and you are not getting paid commensurate with that responsibility."

Those downsides of the job often lead to significant turnover. In 2017-18, the turnover rate among nursing home employees in Missouri was 138%, the fourth-highest in the country, according to a study in the journal Health Affairs. Frontier had a rate of more than 300%, according to Huizi Yu, one of the study's authors.

The nursing home's management declined to comment.

Smith, the nurse who works for a healthcare staffing agency, said she has not been vaccinated against COVID because she had a rare cancer in 2017 and is "very particular about what I put in my body."

She said, "I'm not sure if I would be able to get it just to keep a job."

But, she noted in a text message, "I still practice safely."

And, indeed, no Frontier residents have died from COVID since the outbreak at the start of the pandemic, according to the federal data. But the center reported having seven new confirmed cases among its residents and 10 new cases among its staff as of Jan. 9. At the beginning of the year, 89% of residents were fully vaccinated against COVID.

Low vaccination levels among staffers place residents at greater risk, according to a recent analysis in The New England Journal of Medicine. Facilities in high-COVID counties with an average staff vaccination rate of approximately 30% had nearly three times as many COVID deaths among residents as facilities where about 82% of employees were vaccinated, the analysis found.

"An unvaccinated or low-vaccinated staff, I think, pretty clearly puts residents at risk — even if they are vaccinated," said McGarry, one of the analysis's authors.

The vaccination rate has increased from fewer than half of Missouri nursing home staff members when President Joe Biden announced the mandate for nursing homes Aug. 18 to about two-thirds of staffers now, according to the federal data.

Like Frontier, Northview Village does not have enough staffers, and most people who work there have not been vaccinated. The facility — a nursing home in a predominantly Black, low-income north St. Louis neighborhood — held a vaccination drive in December to increase its roughly 20% staff vaccination rate, but the numbers did not rise, according to the federal data. And only half of residents were fully vaccinated.

The Northview management declined to comment.

Kimberly Watkins, a technician who works to keep Northview residents active, was reluctant to get any of the shots, in part because she heard the conspiracy theory that they contained a tracking chip. But she said she decided to go ahead and get vaccinated because she has asthma and high blood pressure. Co-workers told her their doctors said that they didn't need the vaccine or that they may be allergic to it.

Now with the mandate taking effect, Moore, of the nonprofit Voyce, thinks most local nursing home staffers will comply.

She highlighted Mary, Queen and Mother Center, a Catholic nonprofit nursing home in St. Louis County, that announced its own mandate in August. Before its Sept. 30 deadline, the nursing home saw its staff vaccination rate increase from 67% to 92%, with the remainder being those with a medical or religious exemption, according to the organization. The facility retained almost all its staff.

Not everyone is worried about nursing home staffers being vaccinated, in part reflecting the community around them. Just 55% of Missourians are fully vaccinated.

"I'm not into forcing stuff on people," said Antuan Diltz, a St. Louis firefighter whose mother is a 64-year-old retired nurse with dementia and diabetes living at Frontier. She received the vaccine; Diltz had not.

But others, like Bill Talton, who have family at Frontier hope more staffers will get the shots. Talton, a 77-year-old retired computer programmer, said he is happy with the care his younger brother, who has dementia, has received, although he sometimes couldn't visit him during COVID-related lockdowns.

"It's kind of late in the game," said Talton, who is fully vaccinated and received a booster. "They'll get it done — I hope."

KHN data editor Holly K. Hacker contributed to this report.

Pharmacies Are Turning Away Immunocompromised Patients Seeking 4th COVID Shot

KFF Health News, January 25, 2022

Many pharmacists are unaware that the CDC's vaccine guidance has changed.

This article was published on Tuesday, January 25, 2022 in Kaiser Health News.

By Liz Szabo    

Patients with weakened immune systems — who are at high risk from COVID-19 — say pharmacies are turning them away when they seek additional vaccine doses recommended by federal health officials.

Alyson Smith became eligible this month for a fourth vaccine dose because her medications leave her immunocompromised.

Although the Centers for Disease Control and Prevention encourages most adults to receive a total of three mRNA vaccines — two "primary" vaccinations and a booster — the agency now advises people with weak immune systems to receive three primary shots plus a booster, for a total of four doses.

Many people are confused about the difference between a primary vaccine series and a booster. A primary vaccine series helps people build antibodies to a new pathogen, while a booster combats waning immunity.

As Smith learned, many pharmacists are unaware that the CDC's vaccine guidance has changed.

Smith booked her vaccine appointment online. But when she showed up at a Chicago-area Walgreens for the appointment Jan. 19, an employee told her the pharmacy chain wasn't administering fourth doses to anyone.

Smith said she's frustrated that vulnerable people are being forced to make multiple visits to crowded pharmacies and supermarkets, where many customers are unmasked.

"I feel for the pharmacists, because they're overwhelmed like everyone else," said Smith, 52. "But two years into the pandemic, there is a corporate responsibility to take action when the guidance comes down."

In a written statement, Walgreens said it has administered thousands of fourth doses to immunocompromised people. "As vaccination guidelines continue to evolve, we make every effort to continuously update our pharmacy teams."

The confusion stems from recent updates in vaccine advice for immunocompromised people, as well as a change in the interval between the end of a primary vaccine series and a booster.

  • In August, the CDC began allowing immunocompromised people to receive a third dose of mRNA vaccine as part of their primary vaccination.
     
  • In October, the CDC quietly updated its website to allow people with suppressed immune systems to receive a fourth shot as a booster.
     
  • In January, the agency shortened the time that anyone must wait for a booster from six months to five.

People who received the one-dose Johnson & Johnson vaccine are eligible for a single booster, for a total of two shots, according to the CDC.

Given how often vaccine guidelines have been revised in recent months, some pharmacists have had a hard time keeping pace, said Mitchel Rothholz, chief of governance and state affiliates at the American Pharmacists Association. Pharmacy employees have coped with an ever-expanding workload but a deepening shortage of employees during the pandemic, he said.

"I don't know any provider who wants to turn away a patient," Rothholz said. "The CDC continues to make updates, and it's becoming very difficult for providers at the grassroots level to keep up. I can understand why a pharmacist would say, 'Corporate hasn't given us the green light.'"

Confusion about who is eligible for a fourth shot "was inevitable, although I'm not saying it's right or wrong," he said.

Yet many patients and their doctors are frustrated.

If patients keep up with the latest guidelines, they ask, why can't their pharmacy?

"It's ridiculous," said Dr. Dorry Segev, a transplant surgeon and researcher at Johns Hopkins University. "CDC makes it very clear that it's allowed, and even people who print out the CDC guidance and take it to their pharmacies are being turned away."

Charis Hill, 34, joined a chorus of immune-suppressed people venting their concerns on social media in recent days. When Hill tweeted Jan. 21 that Rite Aid should better educate its staff, the retailer tweeted back that day, saying, "We're very sorry you didn't have a great experience, Charis. Please check back with us early next month for more information regarding the fourth dose."

In a written statement, Rite Aid said it continually educates its staff as CDC advice changes, and "is looking into the response that was provided to the customer on social media."

Dr. Shikha Jain, an assistant professor of medicine at the University of Illinois Cancer Center in Chicago, said patients in rural areas often drive long distances to look for vaccines. One of her patients was "almost in tears" after being turned away. Jain tried to help by calling the pharmacy but was on hold so long that she had to hang up to see patients.

Jain said the CDC needs to do a better job educating doctors, pharmacists, and patients.

The CDC did not respond to a request for comment before publication.

Teresa Strahlman, 61, said she's immune-compromised due to medications she takes for lupus, an autoimmune disease. But the Maryland woman said she didn't realize she was eligible for a fourth dose until reading a KHN post on Facebook. "I had no idea, and I have a million doctors," Strahlman said. "No one has said anything to me."

The CDC estimates that 2.7% of adults — or 7 million people — are immunocompromised, a group that includes people with medical conditions that dampen their immune response, as well as those taking immune-suppressing drugs because of organ transplants, cancer, or autoimmune diseases.

Some immunocompromised people say that being turned away from a pharmacy is especially frustrating, given all that they have sacrificed during the pandemic.

Linda Rushing, 74, has given up attending church services in person, although she's deeply religious, because of a weakened immune system that leaves her prone to a variety of infections.

Rushing made three visits to local pharmacies before finding someone to administer her fourth shot.

"It's a tragedy to need help and not be able to get it," said Rushing, of Rowlett, Texas, whose daughter and granddaughter are also immunocompromised. "I don't want COVID. I don't want to give it to anybody, and I'm trying to do everything I can not to die from it."

Liz Szabo: lszabo@kff.org, @LizSzabo  

Opinion: I Write About America's Absurd Healthcare System. Then I Got Caught Up in It.

KFF Health News, January 25, 2022

A pharmacist in St. Louis said my new employer-provided insurance wouldn't cover insulin without something called a prior authorization.

This article was published on Tuesday, January 25, 2022 in Kaiser Health News.

By Bram Sable-Smith  

I got a hurried voicemail from my pharmacist in Wisconsin the day before Thanksgiving letting me know my insurance was refusing to cover my insulin.  

I had enough of the hormone that keeps me alive to last 17 days.

In my 10 years living with Type 1 diabetes, I've never really struggled to access insulin. But in my job reporting on the people left behind by our country's absurdly complex healthcare system, I've written about how insulin's steep cost leads to deadly rationing and about patients protesting to bring those prices down.

For the most part, though, I've been spared from the problems I cover. Maybe that's why I waited over a week to call my new pharmacy in St. Louis, where I recently moved for this job with KHN.

I'd been waiting since September for an appointment with an endocrinologist in St. Louis; the doctor's office couldn't get me in until Dec. 23 and wouldn't handle my prescriptions before then. When I finally called a pharmacy to sort this out, a pharmacist in St. Louis said my new employer-provided insurance wouldn't cover insulin without something called a prior authorization. I've written about these, too. They're essentially requirements that a physician get approval from an insurance company before prescribing a treatment.

Doctors hate them. The American Medical Association has a website outlining proposed changes to the practice, while the insurance industry defends it as protecting patient safety and saving money. It feels like a lot of paperwork to confirm something we already know: Without insulin, I will die.

I knew right away the prior authorization would be a problem. Since it was a Saturday when I learned about the need for the authorization, my best option was to call my old endocrinologist's practice that Monday morning and beg his staffers to fill out forms for their now former patient.

I had enough insulin to last seven days.

But late that afternoon, I got an automated message from the pharmacy about an insurance issue.

After spending 45 minutes on hold the next morning, I finally got through to the pharmacist, who said my insurer was still waiting for a completed prior authorization form from my physician. I called the doctor's office to give a nudge.

Four days' worth of insulin left.

The price of my prescription without insurance was $339 per vial of insulin, and I use about two vials per month. Normally, I pay a $25 copay. Without the prior authorization, though, I'm exposed to the list price of insulin, as is anyone with diabetes who lacks insurance, even if they live in one of the states with copay caps intended to rein in costs.

I called the pharmacy again on Thursday at 7:30 p.m., figuring it'd be less busy. I got right through to the pharmacist, who told me my insurer was still waiting on the prior authorization form. Friday morning, the diabetes nurse at my doctor's office said she'd check on it and call me back.

I'd be out of insulin the next day.

By this time, I was live-tweeting my attempt to refill my prescription and started to get the kind of messages that are familiar to anyone in what's known as the "diabetes online community." People in Missouri offered me their surplus insulin. Some suggested I go to Walmart for $25 insulin, an older type I have no idea how to safely use.

My new strategy was to use one of the programs that insulin manufacturers started recently to help people get cheaper insulin. The very same day, the U.S. House Committee on Oversight and Reform's Democrats released a report deriding these types of assistance programs as "tools to garner positive public relations, increase sales, and raise revenue."

But before I tried that option, I heard back from the nurse who had called the pharmacy (she had spent 25 minutes on hold) and learned that my new insurance wouldn't cover the brand of insulin I was using. The pharmacist was checking on a different brand.

Soon the pharmacist called: My insurance would cover the other brand. But the pharmacy might not have enough to fill my order. She said I should call a different branch of the chain. The first location I called was also out but pointed me to another one that had it.

With 12 hours' worth of insulin left, I walked out of that third store with my medicine in hand.

It took 17 days and 20 phone calls. But I know I'm lucky. My insurance really is exceptional, recent events aside. My boss insisted that being alive was part of my job as I spent hours on the phone during the workday. And my job is to be persistent as I puzzle through the labyrinth of U.S. healthcare.

The time wasted by me, the pharmacists, the nurses and probably some insurance functionaries is astounding and likely both a cause and a symptom of the high cost of medical care. The problem is also much bigger than that.

Insulin is the single most important resource in my life, and this is what I had to do to get it. But I know not everyone has my good fortune. I've interviewed the loved ones of people with Type 1 diabetes who could not get insulin, and it's not hard to imagine how my story could have ended just as tragically.

On Dec. 23, I finally saw my new doctor, who sent in a new prescription. That night, I got a message that my insurer was waiting on a prior authorization.

I had 17 days' worth of insulin left.

Bram Sable-Smith: brams@kff.org, @besables

Why Medicare Doesn't Pay for Rapid At-Home COVID Tests

KFF Health News, January 24, 2022

Finding the tests will be hard enough, but Medicare beneficiaries face an even bigger hurdle: The administration's new rule doesn't apply to them.

This article was published on Monday, January 24, 2022 in Kaiser Health News.

By Michelle Andrews

What group is especially vulnerable to the ravages of COVID-19 even if fully vaccinated and boosted? Seniors. And who will have an especially tough time getting free at-home COVID tests under the Biden administration's plan? Yes, seniors.

As of Jan. 15, private insurers will cover the cost of eight at-home rapid COVID tests each month for their members — for as long as the public health emergency lasts.

Finding the tests will be hard enough, but Medicare beneficiaries face an even bigger hurdle: The administration's new rule doesn't apply to them.

It turns out that the laws governing traditional Medicare don't provide for coverage of self-administered diagnostic tests, which is precisely what the rapid antigen tests are and why they are an important tool for containing the pandemic.

"While at this time original Medicare cannot pay for at-home tests, testing remains a critical tool to help mitigate the spread of COVID," a statement from the federal Centers for Medicare & Medicaid Services said. Medicaid and CHIP cover at-home COVID tests, with no cost to beneficiaries, based on a 2021 Biden administration mandate.

Medicare patients are left to seek free tests other ways, including through the administration's new website, COVIDtests.gov, and at community centers. The Medicare program does cover rapid antigen or PCR testing done by a lab without charging beneficiaries, but there's a hitch: It's limited to one test per year unless someone has a doctor's order.

More needs to be done, advocates say.

The administration has changed some Medicare rules during the pandemic, including improving access to telehealth services and nursing home care, said David Lipschutz, associate director and senior policy attorney at the Center for Medicare Advocacy.

"We know that the Medicare program has significant flexibility relative to the public health emergency, and it has demonstrated it has the ability to alter the rules," Lipschutz said. "We think they should find the flexibility to offer the COVID at-home tests for free."

Q: Why can't the Medicare program reimburse beneficiaries for the over-the-counter tests or pick up the tab at the pharmacy as commercial health plans will do?

The services the Medicare program pays for are spelled out in federal law.

"It generally excludes over-the-counter things," said Casey Schwarz, senior counsel for education and federal policy at the Medicare Rights Center, an advocacy group. 

The public health emergency was recently extended 90 days, through mid-April, and the administration could yet decide to expand coverage. Some lawmakers in Congress are reportedly urging the administration to cover the tests.

It may not be a simple change, as these tests appear to fall into coverage gaps. Medicare Part A covers hospitalization, and Part B generally covers provider-based services like doctor visits and lab tests. Part D covers drugs.

"So there's a little bit of a question of where this type of benefit would fit," Schwarz said.

People in private plans sometimes pay upfront for services and then are reimbursed by their health plan. But that's not how Medicare works. The program pays providers, not beneficiaries. So that's another wrinkle that would have to be ironed out.

Q: So how can a Medicare beneficiary get free at-home COVID tests?

There are a couple of options. This week, the Biden administration launched a website, COVIDtests.gov, where anyone, including Medicare beneficiaries, can order free at-home COVID tests. One billion tests eventually will be available. Each residence initially can receive four tests.

Four tests is a far cry from the eight monthly tests that people with private insurance can be reimbursed for. But it's better than nothing, experts say, especially when preventing the spread of COVID requires repeated testing over a period of days.

"Four tests is not a lot of tests," said Juliette Cubanski, deputy director of the program on Medicare policy at KFF. "This is one of the most at-risk populations, and to not have the opportunity to buy at-home tests and get reimbursed puts this whole population on their back foot."

The Biden administration is also providing up to 50 million additional free at-home tests to community health centers and Medicare-certified health clinics.

But 50 million tests won't even provide one test apiece to the 62 million Medicare beneficiaries, Lipschutz said.

About 4 in 10 Medicare beneficiaries are in Medicare Advantage managed-care plans. These private plans may offer free at-home tests to members, but it's not required. Enrollees should check with their plans to see whether that's an option.

Q: What other free COVID testing options are available to Medicare beneficiaries?

In traditional Medicare, beneficiaries can get rapid antigen or PCR diagnostic tests without paying anything out-of-pocket if the test is ordered by a doctor or other healthcare provider and performed by a lab.

The federal government has set up more than 10,000 free pharmacy testing sites across the country that Medicare beneficiaries can visit as well.

With the recent extension of the public health emergency, the situation is fluid, and Medicare beneficiaries may yet get coverage for at-home COVID tests that's comparable to what privately insured people now have.

"This is all a moving target," Lipschutz said.

Michelle Andrews: andrews.khn@gmail.com, @mandrews110

Vaccine Wars Ignite in California as Lawmakers Seek Stronger Laws

KFF Health News, January 24, 2022

Vaccine opponents say Democratic-led efforts to adopt stricter vaccine requirements are only helping propel their movement, handing them unparalleled momentum to build their ranks both in California and nationally.

This article was published on Monday, January 24, 2022 in Kaiser Health News.

By Angela Hart

SACRAMENTO — California is poised to become the front line of America's vaccination wars.

State lawmakers are drafting the toughest COVID-19 vaccine legislation in the country, backed by a new pro-vaccine lobbying force promising to counter anti-vaccine activists who have threatened government officials and shut down public meetings across the state. Legislators want to require most Californians to get the shots — not just schoolchildren and healthcare workers — and eliminate the exemptions that would allow many people to get out of them.

But vaccine opponents say Democratic-led efforts to adopt stricter vaccine requirements are only helping propel their movement, handing them unparalleled momentum to build their ranks both in California and nationally.

Vaccine opponents are focusing their ire on Democratic state Sen. Richard Pan of Sacramento, a pediatrician and the driving force behind three state vaccination laws passed since 2012. Prompted by outbreaks of pertussis and measles, the laws make it harder for schoolchildren to get out of childhood vaccinations.

"We have to be willing to take a stand," said Pan, who is developing legislation to crack down on COVID vaccine exemptions. "We need to be able to respond to this pandemic and future pandemics, but there is this asymmetrical warfare going on right now, and we're seeing the anti-vaccine movement trafficking in misinformation, threats, and violence."

The coming fight in California foreshadows looming vaccine battles across the country. President Joe Biden and Democratic governors are pressing vaccination as the most crucial public health measure for combating the coronavirus pandemic — while some prominent Republican governors cast doubt on the safety and value of vaccines, inciting anti-vaccination activists.

In California, the ultimate decision on toughening state vaccination laws will fall to Democratic Gov. Gavin Newsom, who is facing reelection in November after defeating a recall attempt last year.

Newsom has played to both sides recently. He has pushed tough vaccine mandates for groups such as healthcare workers, children, and teachers. But in nearly every pandemic-related press conference since October and on national TV, he has also reassured the public that they can receive medical, religious, and personal belief exemptions from his mandates.

"He's trying to be comforting and non-confrontational, but it sends a message that if you don't want to get the vaccine, don't get it," said Catherine Flores Martin, executive director of the California Immunization Coalition. "Gov. Newsom struggles with this — he's trying to have it both ways."

Pushing Mandates 'Aggressively'

Anti-vaccine demonstrations dominated Sacramento during California's last big vaccination fight, in 2019. In weekly rallies outside the Capitol, hundreds of activists railed against lawmakers, toting a portrait of Pan's face splattered in red. They shouted down lawmakers in legislative hearings and at one point hurled menstrual blood at state senators.

The fight that year was over Pan's bill to crack down on bogus medical exemptions for common childhood vaccinations against measles, polio, and other infectious diseases, which are required to attend in-person public and private school in California. Four years earlier, he spearheaded a law to ban personal belief exemptions for childhood vaccines.

But under state law, personal belief exemptions must be allowed for any newly required childhood vaccine unless the legislature passes a new law banning them.

Newsom issued a directive in October 2021 adding COVID vaccines to the list of required childhood immunizations — once federal officials fully authorize them for children. But because the legislature has not yet acted, Californians will be able to opt out by claiming the vaccines violate personal beliefs.

Pan and other Democratic lawmakers want to close that loophole this year, and potentially eliminate religious exemptions that healthcare workers can claim. They're also considering requiring a broad swath of Californians to get COVID vaccines to participate in much of daily life.

Lawmakers are still hashing out details but are expected to propose legislation requiring COVID vaccines for people to be in workplaces, schools, and public venues like malls, museums, and restaurants — without allowing them to avoid the shots through exemptions. Pan, who is leaving the legislature after this year because of term limits, may also push legislation to hold tech companies more accountable for spreading misinformation on social media platforms.

"Do you have the right to be safe at school? Do people deserve to be safe at work? Are businesses responsible for creating an environment that won't injure or harm you? This has to be part of the conversation," said Pan, who was shoved by a protester near the Capitol in 2019.

Last year, Buffy Wicks, a Democratic Assembly member from Oakland, and Evan Low, a Democratic Assembly member from Campbell, tried but failed to muscle through legislation establishing COVID vaccine mandates for workers and businesses. But the ongoing challenges of the pandemic have "reenergized" Democratic lawmakers this year, said state Sen. Scott Wiener (D-San Francisco), who is carrying legislation to lower the age at which someone can consent to a vaccine without parental permission from 18 to 12.

"It's important that we continue to push for vaccine mandates the most aggressively we possibly can," said Wicks, who faced death threats over her vaccine legislation last year. "We can't let ourselves be held hostage by these right-wing conspiracy theorists who are perpetrating hate and violence."

'The Firestorm Is Here'

Anti-vaccine activists acknowledge they may not succeed at defeating new legislation but welcome state lawmakers' attempts to impose stricter rules — they argue it helps them build a larger movement in California, on social media, and in other states.

"What they don't realize is the point of these rallies and protests is to bring more people into the fold, from all around the country," said Stefanie Fetzer, a chief organizer of the 2019 anti-vaccination demonstrations at the state Capitol. "Senator Pan galvanized a larger anti-vax movement that wouldn't have happened without him."

Scientists and health officials blame California's stagnating COVID vaccination rate largely on the anti-vaccine movement, which is peddling misinformation and lies. The share of Californians who are considered fully vaccinated is 69%, and booster shots are lagging — even though the state and local governments have plowed tens of millions of dollars into vaccination campaigns.

"What you see now is this movement being taken over by Republicans and this libertarian right-wing notion of individual rights and 'get government off my back.' They're believing and spreading this misinformation even though it's disproven," said Dr. Paul Offit, director of the Vaccine Education Center at the Children's Hospital of Philadelphia. "Trying to stop it is like trying to stop Niagara Falls."

Vaccine opponents have also shut down government meetings and lobbed violent threats at officials backing mandates.

The Los Angeles Unified School District delayed its student vaccine mandate after anti-vaccine demonstrations, in an effort to keep unvaccinated students from dropping out. In Stockton and elsewhere, vaccine opponents have shouted down proposed school vaccine mandates.

Joshua Coleman, who organized hundreds of protesters in 2019 under his group V Is for Vaccine, has held rallies in Sacramento this year, again targeting Pan with a 10-foot poster and his image smeared in red.

"There will be constant pressure," Coleman said. "This is happening more and more all over the country, but we are building a movement out of California. Being forced to take a vaccine in order to participate in society is absolutely totalitarian."

Vaccine supporters realize they must fight back and are launching a lobbying campaign, led by political heavyweights from Sacramento and Washington, D.C., to combat vaccine opponents with some of their own tactics.

"The firestorm is here. This is ground warfare that the anti-vax extremists are bringing, and I think we need to be able to match it," said Crystal Strait, the former president and CEO of Planned Parenthood Affiliates of California who is leading the campaign under the group ProtectUS.

Campaign leaders are organizing students, parents, and pro-vaccine activists to counter anti-vaccination demonstrators in cities and counties across California and to debunk misinformation while giving state lawmakers political cover to enact tougher laws.

"We need to draw a really bold, bright line and let these extremists know that we will not be silent," Strait said.

The campaign emerged quietly last year, sponsoring a new law to limit protests outside vaccination clinics — which has since been blocked in court — and will launch ground-game political efforts this year.

"The science is on our side, and there's a silent majority on our side, but we're being drowned out in public forums where these decisions are being made," said Rose Kapolczynski, a longtime political consultant to former U.S. Sen. Barbara Boxer, who is working on the campaign. "We're going to activate the pro-vaccine majority when policies are being considered at the state and local levels."

Whither Newsom?

Newsom is also wading into the fray.

His administration has plowed $145 million into a campaign to increase COVID vaccinations and fight misinformation, in part by monitoring social media posts and flagging vaccine myths to social media companies. The administration is also developing a pro-vaccine counternarrative based on the misinformation.

"We want to be proactive about what the truth is and put it out there while debunking misinformation," said Dr. Mark Ghaly, secretary of the state's Health and Human Services Agency.

More than half a dozen public health experts interviewed for this story said that vaccine mandates work and that Newsom can boost the state's faltering vaccination rates by eliminating exemptions.

But since Newsom announced the COVID vaccine mandate for schoolchildren, he has publicly promoted exemptions.

"The mandate we put in place for the state of California includes personal exemptions," Newsom said during an appearance on "Good Morning America" in December. "There's plenty of latitude for families to make decisions."

Newsom has declined to say whether he would support legislation banning exemptions but said he'd work with lawmakers. "We can discuss the merits and demerits" of allowing exemptions, Newsom said this month. "We did what we felt was appropriate."

Barbara Ferrer, the public health director for Los Angeles County, which has recorded nearly 28,000 COVID deaths, more than a third of the state's total, called on Newsom and state lawmakers to adopt mandates without exemptions.

"If you allow that, you may as well not have a vaccine mandate," she said. "If you don't want your child to get vaccinated, then your child doesn't have to go to school. And you don't have to go to a restaurant. I'm not trying to be mean to people. I'm just saying there are some things you shouldn't be able to do if you're not vaccinated."

Angela Hart: ahart@kff.org, @ahartreports

The Doctor Didn't Show Up, but the Hospital ER Still Charged $1,012

KFF Health News, January 24, 2022

Many patients don't understand that they can rack up huge bills almost as soon as they walk through the doors of an ER.

This article was published on Monday, January 24, 2022 in Kaiser Health News.

By Noam N. Levey

Dhaval Bhatt had been warned about hospital emergency rooms.

"People always told me to avoid the ER in America unless you are really dying," said Bhatt, an immigrant from India who got a Ph.D. in pharmacology in the U.S. and is now a research scientist at Washington University in St. Louis.

But when Bhatt's 2-year-old son burned his hand on the kitchen stove on a Wednesday morning in April, the family's pediatrician directed them the next day to the local children's hospital.

Bhatt was traveling. So, his wife, Mansi Bhatt, took their son to the hospital and was sent to the emergency room. A nurse took the toddler's vitals and looked at the wound. She said a surgeon would inspect it more closely.

When the surgeon didn't appear after more than an hour, Bhatt's wife took her son home. The hospital told her to make a follow-up appointment with a doctor, which turned out to be unnecessary because the burn healed quickly.

Then the bill came.

The Patient: Martand Bhatt, a toddler covered by a UnitedHealthcare insurance plan provided by the employer of his father, Dhaval Bhatt.

Medical Service: An emergency room visit for a burn sustained when Martand touched an electric stove.

Total Bill: $1,012. UnitedHealthcare's negotiated rate was $858.92, all of which the Bhatts were responsible for because their plan had a $3,000 deductible.

Service Provider: SSM Health Cardinal Glennon Children's Hospital, one of 23 hospitals owned by SSM Health, a Catholic, nonprofit health system with more than $8 billion in annual revenue.

What Gives: Many patients don't understand that they can rack up huge bills almost as soon as they walk through the doors of an ER.

Unlike a restaurant or a mechanic who won't charge if someone gets tired of waiting for a table or an inspection of a rattling engine, hospital emergency rooms almost invariably charge patients as soon as they check in.

And once they register, patients will be billed — often a lot — whether treatment was rendered or not.

Martand Bhatt received almost no medical service. A nurse practitioner looked over the toddler, listened to his heart and stomach, and looked in his nose, mouth and ears, according to provider notes prepared by the hospital and shared with KHN by Bhatt.

The nurse didn't change the dressing on the wound or order any testing.

"My objection to this is that there was no care provided," Bhatt wrote to Bill of the Month.

"My wife did not drive for 45 minutes to get to an ER and wait for an additional 1½ hours for someone to tell me that our child's vitals — weight, height, temperature and blood pressure — were OK," Bhatt continued. "We already knew that. … It is absolutely ridiculous and unethical."

When the Bhatts left the emergency room, Martand was "alert, active and well-appearing," according to the notes.

The nurse's assessment of Martand cost $192, which was discounted by UnitedHealthcare to a negotiated rate of $38.92. The bulk of the Bhatts' bill — $820 — was something called a facility fee.

Hospital officials defend these fees as necessary to keep the emergency room open 24 hours a day as a community asset.

SSM Health spokesperson Stephanie Zoller Mueller declined to discuss the details of Martand's medical condition even though the Bhatts gave their permission for the hospital to do so.

In an email, Zoller Mueller said the charges were "appropriate" based on the "acuity of condition, discharge instructions, vital sign monitoring, traumatic wound care (and) numerous assessments."

She added: "A patient does not have to receive additional treatment — procedure, labs, x-rays, etc. — to validate an ED [emergency department] level charge."

But some patient advocates say these facility fees are applied much too widely and should be limited to patients who actually receive medical care.

"It's just not appropriate for someone to be charged if they're not provided treatment," said Adam Fox, deputy director of the Colorado Consumer Health Initiative. "Patients aren't availing themselves of a facility if they don't get care."

At the very least, hospitals could communicate more clearly to patients about the fees they may be charged for coming to an emergency room, said Maureen Hensley-Quinn, senior program director at the National Academy for State Health Policy.

"People should know that when they walk in to receive care, there is this fee that they will be assessed," Hensley-Quinn said.

Hospitals could also post at the entrance to the ER standard fees for different levels of emergency care.

Bhatt's fee still could have been lower if the hospital had classified his son's injury as minor. But, again, the hospital billing process worked against the family … and in favor of the hospital's bottom line.

Emergency visits are usually classified for billing on a scale from 1 to 5. Level 1 is minor and routine; Level 5 requires complex care for life-threatening conditions. And hospitals are increasingly using the highest-severity codes to classify emergency visits, research shows.

"There are financial incentives for billing at a higher severity," said Aditi Sen, who directs policy and research at the nonprofit Healthcare Cost Institute, which has studied emergency room coding.

Despite the lack of severity of Martand's wound and the absence of medical care, his visit was classified as Level 3, a moderate severity problem.

Resolution: Incensed that he'd been charged so much, Bhatt made numerous attempts to get the hospital to reduce the charges. He also appealed to UnitedHealthcare to review the charges.

His efforts failed. In August, Bhatt received a letter from an SSM Health "patient advocate" informing him that the hospital would not adjust the bill and instructing him to contact patient billing to arrange for payment.

While Bhatt was trying to reach the patient advocate by phone, his bill was sent to Medicredit, a collection agency, which began sending him notices and calling him.

After KHN contacted SSM Health, Bhatt received a call from someone who worked on "patient financial experience" issues at the hospital.

The hospital agreed to forgive the $820 facility fee. Bhatt agreed to pay the remaining $38.92, the professional fee for the ER nurse's work. Bhatt also received a notice from Medicredit that it would take no further action against him.

The Takeaway: The Bhatts did what most parents would do when a pediatrician advises them to take their child to the hospital.

But emergency rooms are among the most expensive places to get care in the U.S. health system.

If you have a relatively low-level issue, think twice before even registering at the front desk, the act that initiates the billing process. If your doctor doesn't have same-day appointments or after-hours service, think about urgent care, which is often much cheaper if the center isn't attached to a hospital.

And remember that if you go to a hospital emergency room with a relatively minor issue, chances are that you'll have to wait, as the Bhatts did. Patients with more serious problems will be seen first.

Once you're taken past the front desk, you will almost certainly be hit with a substantial facility fee even if you don't receive care.

Appealing that fee to the hospital can occasionally be successful, but there are no guarantees. And, as Bhatt learned, don't expect the health insurer to offer much help. Most insurers won't challenge how a medical visit is coded except on extremely expensive medical claims that will cost them money.

In this case, Bhatt was on the hook for the whole fee because he had a high-deductible plan, so the insurer had little incentive to take up his cause.

For now, patients' best hope, many advocates believe, is to publicize the high prices that hospitals charge for their services, inside and outside the emergency room.

Bill of the Month is a crowdsourced investigation by KHN and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!

Send Us Your Medical Bills

Do you have an exorbitant or baffling medical bill? Join the KHN and NPR 'Bill of the Month' Club and tell us about your experience. We'll feature a new one each month.

Submit Your Bill

Noam N. Levey: nlevey@kff.org, @NoamLevey

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