Evidence is growing that contracting SARS-CoV-2, the virus that causes COVID-19, is generally as effective as vaccination.

This article was published on Friday, October 8, 2021 in Kaiser Health News.

By Arthur Allen  

Dr. Aaron Kheriaty, a University of California-Irvine psychiatry professor, felt he didn't need to be vaccinated against COVID because he'd fallen ill with the disease in July 2020.

So, in August, he sued to stop the university system's vaccination mandate, saying "natural" immunity had given him and millions of others better protection than any vaccine could.

A judge on Sept. 28 dismissed Kheriaty's request for an injunction against the university over its mandate, which took effect Sept. 3. While Kheriaty intends to pursue the case further, legal experts doubt that his and similar lawsuits filed around the country will ultimately succeed.

That said, evidence is growing that contracting SARS-CoV-2, the virus that causes COVID-19, is generally as effective as vaccination at stimulating your immune system to prevent the disease. Yet federal officials have been reluctant to recognize any equivalency, citing the wide variation in COVID patients' immune response to infection.

Like many disputes during the COVID pandemic, the uncertain value of a prior infection has prompted legal challenges, marketing offers and political grandstanding, even as scientists quietly work in the background to sort out the facts.

For decades, doctors have used blood tests to determine whether people are protected against infectious diseases. Pregnant mothers are tested for antibodies to rubella to help ensure their fetuses won't be infected with the rubella virus, which causes devastating birth defects. Hospital workers are screened for measles and chickenpox antibodies to prevent the spread of those diseases. But immunity to COVID seems trickier to discern than those diseases.

The Food and Drug Administration has authorized the use of COVID antibody tests, which can cost about $70, to detect a past infection. Some tests can distinguish whether the antibodies came from an infection or a vaccine. But neither the FDA nor the Centers for Disease Control and Prevention recommend using the tests to assess whether you're, in fact, immune to COVID. For that, the tests are essentially useless because there's no agreement on the amount or types of antibodies that would signal protection from the disease.

"We don't yet have full understanding of what the presence of antibodies tells us about immunity," said Kelly Wroblewski, director of infectious diseases at the Association of Public Health Laboratories.

By the same token, experts disagree on how much protection an infection delivers.

In the absence of certainty and as vaccination mandates are levied across the country, lawsuits seek to press the issue. Individuals who claim that vaccination mandates violate their civil liberties argue that infection-acquired immunity protects them. In Los Angeles, six police officers have sued the city, claiming they have natural immunity. In August, law professor Todd Zywicki alleged that George Mason University's vaccine mandate violated his constitutional rights given he has natural immunity. He cited a number of antibody tests and an immunologist's medical opinion that it was "medically unnecessary" for him to be vaccinated. Zywicki dropped the lawsuit after the university granted him a medical exemption, which it claims was unrelated to the suit.

Republican legislators have joined the crusade. The GOP Doctors Caucus, which consists of Republican physicians in Congress, has urged people leery of vaccination to instead seek an antibody test, contradicting CDC and FDA recommendations. In Kentucky, the state Senate passed a resolution granting equal immunity status to those who show proof of vaccination or a positive antibody test.

Hospitals were among the first institutions to impose vaccine mandates on their front-line workers because of the danger of them spreading the disease to vulnerable patients. Few have offered exemptions from vaccination to those previously infected. But there are exceptions.

Two Pennsylvania hospital systems allow clinical staff members to defer vaccination for a year after testing positive for COVID. Another, in Michigan, allows employees to opt out of vaccination if they present evidence of previous infection and a positive antibody test in the previous three months. In these cases, the systems indicated they were keen to avoid staffing shortages that could result from the departure of vaccine-shunning nurses.

For Kheriaty, the question is simple. "The research on natural immunity is quite definitive now," he told KHN. "It's better than immunity conferred by vaccines." But such categorical statements are clearly not shared by most in the scientific community.

Dr. Arthur Reingold, an epidemiologist at UC-Berkeley, and Shane Crotty, a virologist at the respected La Jolla Institute for Immunology in San Diego, gave expert witness testimony in Kheriaty's lawsuit, saying the extent of immunity from reinfection, especially against newer variants of COVID, is unknown. They noted that vaccination gives a huge immunity boost to people who've been ill previously.

Yet not all of those pushing for recognition of past infection are vaccine critics or torchbearers of the anti-vaccine movement.

Dr. Jeffrey Klausner, clinical professor of population and public health sciences at the University of Southern California, co-authored an analysis published last week that showed infection generally protects for 10 months or more. "From the public health perspective, denying jobs and access and travel to people who have recovered from infection doesn't make sense," he said.

In his testimony against Kheriaty's case for "natural" immunity to COVID, Crotty cited studies of the massive COVID outbreak that swept through Manaus, Brazil, early this year that involved the gamma variant of the virus. One of the studies estimated, based on tests of blood donations, that three-quarters of the city's population had already been infected before gamma's arrival. That suggested that previous infection might not protect against new variants. But Klausner and others suspect the rate of prior infection presented in the study was a gross overestimate.

A large August study from Israel, which showed better protection from infection than from vaccination, may help turn the tide toward acceptance of prior infection, Klausner said. "Everyone is just waiting for Fauci to say, 'Prior infection provides protection,'" he said.

When Dr. Anthony Fauci, the top federal expert on infectious diseases, was asked during a CNN interview last month whether infected people were as well protected as those who've been vaccinated, he hedged. "There could be an argument" that they are, he said. Fauci did not immediately respond to a KHN request for further comment.

CDC spokesperson Kristen Nordlund said in an email that "current evidence" shows wide variation in antibody responses after COVID infection. "We hope to have some additional information on the protectiveness of vaccine immunity compared to natural immunity in the coming weeks."

A "monumental effort" is underway to determine what level of antibodies is protective, said Dr. Robert Seder, chief of the cellular immunology section at the National Institute of Allergy and Infectious Diseases. Recent studies have taken a stab at a number.

Antibody tests will never provide a yes-or-no answer on COVID protection, said Dr. George Siber, a vaccine industry consultant and co-author of one of the papers. "But there are people who are not going to be immunized. Trying to predict who is at low risk is a worthy undertaking."

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

Arthur Allen: ArthurA@kff.org, @ArthurAllen202

Those who work directly with people with disabilities must be fully vaccinated by Nov. 30.

This article was published on Wednesday, October 6, 2021 in Kaiser Health News.

By Jackie Fortiér, KPCC  

Workers in adult and senior care facilities and in-home aides have been added to the list of California health workers who must be fully vaccinated against the coronavirus.

Those who work directly with people with disabilities — such as employees paid through the state's regional center network, aides contracted by agencies, and in-home support service workers who don't live with the person they assist — are now included in the vaccine mandate. This new group must be fully vaccinated by Nov. 30.

Previous health orders covered only people working in licensed congregate settings like nursing homes, leaving out staff members who support 89% of people in California with developmental disabilities living with family, on their own or in group homes.

For months, that left people like Tim Jin who rely on aides for everyday tasks to wonder: Is the person brushing my teeth vaccinated?

"Due to my disability, I cannot do anything like cooking, eating, using the restroom or even using the microwave on my own. I am totally dependent on others to assist me," Jin said.

Jin has cerebral palsy and lacks the use of his arms or hands. He communicates mainly by typing with his toes on an iPad mounted next to his feet on his electric wheelchair. Up to six health aides come in and out of his home every day, helping him with intimate tasks like eating and bathing.

"The staff who come into my home should be vaccinated. It's that simple," he said. "It's a matter of life and death."

Only health workers with religious objections or a qualifying medical condition can be exempted from the vaccine requirement. They will be tested weekly for the virus that causes COVID-19 and must wear high-grade masks when working.

In September, Los Angeles County included those aides in its vaccine mandate, following a KPCC/LAist story that reported on the discrepancy.

But the order applied only to L.A. County, leaving out the 200,000 Californians with developmental disabilities living elsewhere, including Tim Jin, who lives in neighboring Orange County.

Advocates for people with disabilities hoped state health officials would use L.A. County as a model, but California's Sept. 28 health order went further, mandating the vaccine for some in-home support service workers, as well as home health aides.

"These care settings are home to Californians with complex medical conditions, all of whom are at high risk of having severe but preventable outcomes, including hospitalization, severe illness and death," said Dr. Tomás Aragón, California's public health officer.

California has reported 19,830 confirmed COVID outbreaks throughout the pandemic, and nearly 50% of those were reported in healthcare, congregate care and direct care settings, according to the California Department of Public Health. Of these outbreaks, the most (22%) have occurred in adult and senior care facilities and in-home direct care settings.

Studies show that people with intellectual and developmental disabilities often have underlying health conditions that make them more susceptible to COVID.

"And when they do get diagnosed with COVID-19, they are about two to three times more likely to die from the disease," said Scott Landes, an associate professor of sociology at Syracuse University's Maxwell School of Citizenship and Public Affairs.

Landes said cases seem to be dependent on two variables: preexisting conditions and the amount of in-person intimate care that the developmentally disabled person needs.

"Which really just makes sense for COVID," he said. "If you've got a caregiver that's right up next to you, all day, it's going to increase the chances that you could get the disease."

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

Jackie Fortiér, KPCC: @jackiefortier

Hospitals are also dealing with a spike in retroactive claims denials by UnitedHealthcare.

This article was published on Wednesday, October 6, 2021 in Kaiser Health News.

By Jay Hancock 

Anthem Blue Cross, the country's second-biggest health insurance company, is behind on billions of dollars in payments owed to hospitals and doctors because of onerous new reimbursement rules, computer problems and mishandled claims, say hospital officials in multiple states.

Anthem, like other big insurers, is using the COVID-19 crisis as cover to institute "egregious" policies that harm patients and pinch hospital finances, said Molly Smith, group vice president at the American Hospital Association. "There's this sense of 'Everyone's distracted. We can get this through,'" she said.

Hospitals are also dealing with a spike in retroactive claims denials by UnitedHealthcare, the biggest health insurer, for emergency department care, AHA says.

Disputes between insurers and hospitals are nothing new. But this fight sticks more patients in the middle, worried they'll have to pay unresolved claims. Hospitals say it is hurting their finances as many cope with COVID surges — even after the industry has received tens of billions of dollars in emergency assistance from the federal government.

"We recognize there have been some challenges" to prompt payments caused by claims-processing changes and "a new set of dynamics" amid the pandemic, Anthem spokesperson Colin Manning said in an email. "We apologize for any delays or inconvenience this may have caused."

Virginia law requires insurers to pay claims within 40 days. In a Sept. 24 letter to state insurance regulators, VCU Health, a system that operates a large teaching hospital in Richmond associated with Virginia Commonwealth University, said Anthem owes it $385 million. More than 40% of the claims are more than 90 days old, VCU said.

For all Virginia hospitals, Anthem's late, unpaid claims amount to "hundreds of millions of dollars," the Virginia Hospital and Healthcare Association said in a June 23 letter to state regulators.

Nationwide, the payment delays "are creating an untenable situation," the American Hospital Association said in a Sept. 9 letter to Anthem CEO Gail Boudreaux. "Patients are facing greater hurdles to accessing care; clinicians are burning out on unnecessary administrative tasks; and the system is straining to finance the personnel and supplies" needed to fight COVID.

Complaints about Anthem extend "from sea to shining sea, from New Hampshire to California," AHA CEO Rick Pollack told KHN.

Substantial payment delays can be seen on Anthem's books. On June 30, 2019, before the pandemic, 43% of the insurer's medical bills for that quarter were unpaid, according to regulatory filings. Two years later that figure had risen to 53% — a difference of $2.5 billion.

Anthem profits were $4.6 billion in 2020 and $3.5 billion in the first half of 2021.

Alexis Thurber, who lives near Seattle, was insured by Anthem when she got an $18,192 hospital bill in May for radiation therapy that doctors said was essential to treat her breast cancer.

The treatments were "experimental" and "not medically necessary," Anthem said, according to Thurber. She spent much of the summer trying to get the insurer to pay up — placing two dozen phone calls, spending hours on hold, sending multiple emails and enduring unmeasurable stress and worry. It finally covered the claim months later.

"It's so egregious. It's a game they're playing," said Thurber, 51, whose cancer was diagnosed in November. "Trying to get true help was impossible."

Privacy rules prevent Anthem from commenting on Thurber's case, said Anthem spokesperson Colin Manning.

When insurers fail to promptly pay medical bills, patients are left in the lurch. They might first get a notice saying payment is pending or denied. A hospital might bill them for treatment they thought would be covered. Hospitals and doctors often sue patients whose insurance didn't pay up.

Hospitals point to a variety of Anthem practices contributing to payment delays or denials, including new layers of document requirements, prior-authorization hurdles for routine procedures and requirements that doctors themselves — not support staffers — speak to insurance gatekeepers. "This requires providers to literally leave the patient['s] bedside to get on the phone with Anthem," AHA said in its letter.

Anthem often hinders coverage for outpatient surgery, specialty pharmacy and other services in health systems listed as in-network, amounting to a "bait and switch" on Anthem members, AHA officials said.

"Demanding that patients be treated outside of the hospital setting, against the advice of the patient's in-network treating physician, appears to be motivated by a desire to drive up Empire's profits," the Greater New York Hospital Association wrote in an April letter to Empire Blue Cross, which is owned by Anthem.

Anthem officials pushed back in a recent letter to the AHA, saying the insurer's changing rules are intended partly to control excessive prices charged by hospitals for specialty drugs and nonemergency surgery, screening and diagnostic procedures.

Severe problems with Anthem's new claims management system surfaced months ago and "persist without meaningful improvement," AHA said in its letter.

Claims have gotten lost in Anthem's computers, and in some cases VCU Health has had to print medical records and mail them to get paid, VCU said in its letter. The cash slowdown imposes "an unmanageable disruption that threatens to undermine our financial footing," VCU said.

United denied $31,557 in claims for Emily Long's care after she was struck in June by a motorcycle in New York City. She needed surgery to repair a fractured cheekbone. United said there was a lack of documentation for "medical necessity" — an "incredibly aggravating" response on top of the distress of the accident, Long said.

The Brooklyn hospital that treated Long was "paid appropriately under her plan and within the required time frame," said United spokesperson Maria Gordon Shydlo. "The facility has the right to appeal the decision."

United's unpaid claims came to 54% as of June 30, about the same level as two years previously.

When Erin Conlisk initially had trouble gaining approval for a piece of medical equipment for her elderly father this summer, United employees told her the insurer's entire prior-authorization database had gone down for weeks, said Conlisk, who lives in California.

"There was a brief issue with our prior-authorization process in mid-July, which was resolved quickly," Gordon Shydlo said.

When asked by Wall Street analysts about the payment backups, Anthem executives said it partly reflects their decision to increase financial reserves amid the health crisis.

"Really a ton of uncertainty associated with this environment," John Gallina, the company's chief financial officer, said on a conference call in July. "We've tried to be extremely prudent and conservative in our approach."

During the pandemic, hospitals have benefited from two extraordinary cash infusions. They and other medical providers have received more than $100 billion through the CARES Act of 2020 and the American Rescue Plan of 2021. Last year United, Anthem and other insurers accelerated billions in hospital reimbursements.

The federal payments enriched many of the biggest, wealthiest systems while poorer hospitals serving low-income patients and rural areas struggled.

Those are the systems most hurt now by insurer payment delays, hospital officials said. Federal relief funds "have been a lifeline, but they don't make people whole in terms of the losses from increased expenses and lost revenue as a result of the COVID experience," Pollack said.

Several health systems declined to comment about claims-payment delays or didn't respond to a reporter's queries. Among individual hospitals "there is a deep fear of talking on the record about your largest business partner," AHA's Smith said.

Alexis Thurber worried she might have to pay her $18,192 radiation bill herself, and she's not confident her Anthem policy will do a better job next time of covering the cost of her care.

"It makes me not want to go to the doctor anymore," she said. "I'm scared to get another mammogram because you can't rely on it."

Jay Hancock: jhancock@kff.org, @JayHancock1

Instead of craving the company of others after release from social isolation, many former prisoners want just the opposite.

This article was published on Tuesday, October 5, 2021 in Kaiser Health News.

By Katja Ridderbusch    

ATLANTA — Sometimes, Pamela Winn isn't sure how to connect with people, even those she loves, like her 9-month-old granddaughter. When the baby is in her arms, "I sit there quietly, and I don't know what to say. What to do," she said, her eyes filling with tears. "My socializing skills are just not there anymore."  

On days like these, Winn, who lives south of Atlanta, is haunted by the memory of her 6-by-9-foot prison cell, where she spent eight months in solitary confinement more than 10 years ago. She said she now feels "safest when I'm by myself."

It's a common paradox of solitary confinement, said Craig Haney, a professor of social psychology at the University of California-Santa Cruz. Instead of craving the company of others after release from social isolation, many former prisoners want just the opposite.

"Solitary forces prisoners to live in a world without people," he said. "And they adapt to it."

Research has long shown that solitary confinement — isolating prisoners for weeks, months, years and sometimes decades — has devastating effects on their physical and mental health. Once released, either to the general prison population or to the outside world, they can face a suite of problems, like heart damage and depression. They're often hypersensitive to light, sound, smell or touch. Like Winn, they may struggle to read social cues. People, Haney said, "become a source of anxiety rather than support."

And the coronavirus pandemic may have made the situation worse.

Before the pandemic, the estimated number of people in solitary confinement in the U.S. ranged from 50,000 to 80,000 on any given day, though many advocacy organizations believe counts are underestimated. The Centers for Disease Control and Prevention states that medical isolation — the separation of people with a contagious disease from the rest of the population — should not hinge on solitary confinement. Yet, at the height of the pandemic last year, up to 300,000 incarcerated individuals were in solitary, according to estimates from Solitary Watch and The Marshall Project, non-profits focused on criminal justice.

"Jails and prisons, like many organizations, acted in fear," said Tammie Gregg, deputy director of the American Civil Liberties Union's National Prison Project. "They thought the way to keep people from infecting each other was to simply put them in solitary."

Solitary confinement can serve many goals, from punishment to protection. And it is called many things — protective custody, restrictive or secure housing, administrative or disciplinary segregation, or simply "the Hole."

"The conditions are essentially the same: It's the extreme deprivation of any meaningful social contact," Haney said.

In the so-called Mandela Rules, named for South African leader Nelson Mandela, who was imprisoned for 27 years, the United Nations associates solitary confinement lasting longer than 15 consecutive days with a form of torture. More than half of all U.S. states have introduced or passed some type of legislation restricting or regulating the use of solitary confinement — like limiting the practice for juveniles, for example. But it is still widely used in American jails and prisons.

Inmates in solitary typically live in a small cell for up to 23 hours a day. They have little sensory stimulation, like sunlight. Access to reading materials, educational programming and personal property is limited or nonexistent. Prisoners may get one hour in a recreational yard, an equally isolated area typically enclosed or surrounded by concrete walls, with a secured high window that opens for fresh air.

An analysis by researchers with the University of Colorado and Human Rights Watch suggests that more than half of all prison suicides occur in solitary confinement. A study conducted by the New York City Department of Health and Mental Hygiene found that the rate of self-harm among those in solitary is 10 times that of the general prison population.

The isolation can be particularly destabilizing for people with preexisting mental health conditions, often exacerbating underlying issues that cause people to end up behind bars in the first place. "It's a downward spiral," said Haney.

A Florida State University study published earlier this year found that prisoners with mental illness, especially bipolar disorder, severe depression and schizophrenia, were up to 170% more likely to be placed in solitary for extended periods. In many prisons, experts worry, mental health treatment is nonexistent, making matters worse.

But even among people without a history of mental health problems, it may be impossible to predict who is susceptible to the harmful effects of solitary confinement, including suicide.

Pamela Winn, a registered nurse by training, was incarcerated in 2008 and later convicted to a 6½-year federal prison sentence for healthcare fraud. As the now-53-year-old African American woman with red-colored curls sits in her ranch home, her mind goes back to what she said was the darkest time of her life.

When she entered a federal holding facility south of Atlanta, she said, she was a healthy woman. She was also six weeks pregnant. One day, she fell as she was trying to step into a van while shackled. Three months later, she miscarried and was put into solitary confinement for what she was told was medical observation.

After a few months, she was transferred to a municipal prison, where she was placed into solitary again, this time for protection. For a total of eight months, at two facilities, she lived in tiny cells, with iron beds, thin foam mattresses, and metal sinks with toilets attached.

"No window. No mirror. No clock. No concept of time," she said. She was allowed to leave her cell for one hour a day. She could shower three times a week if staffers were available.

In the beginning, she replayed the traumatic memory of the night she lost her baby. Eventually, she joined in when other inmates screamed in their cells.

"I acted out. I threw stuff against the wall. I was angry," she said. Before she went to sleep, she prayed for God to take her. "But I kept waking up."

In Haney's experience, prisoners who develop a strategy to withstand the excruciating loop of idleness have a better chance of surviving. Some individuals force themselves to maintain a routine, to act as if there is a coherence in their life, "even though there isn't," he said.

Winn said she developed a strategy: She would start the day by praying. She would picture what her two teenage sons were doing. She would do sit-ups and mental exercises, like remembering street names. After solitary, she served most of her sentence in a federal prison in Florida and was released in 2013.

Her time in solitary scarred her for life, she said. To this day, she has high blood pressure. Paranoia is a constant companion; her house is surrounded by a solid wooden fence with a security gate, and she has two Rottweilers. Small spaces make her anxious, and she can't tolerate strangers getting too close, such as in a coffee shop line.

While she struggles to connect with her granddaughter, Winn keeps a journal, hoping that one day, when her granddaughter is old enough, she'll understand.

"She can read it and learn about everything that's in my heart and on my mind … if I'm still here, if I'm not here, wherever I am."

Both Haney and Gregg said jails and prisons have alternatives to long-term, extreme isolation. Mentally ill prisoners who engage in disciplinary infractions should be put into a treatment-oriented unit, said Haney.

For someone who acts violently, solitary confinement should be only a short-term solution aimed at acutely de-escalating the outburst, said Gregg. Afterward, those individuals should go to units that provide programming to address the root cause of their behavior. This may mean separation from the general prison population, but less time in total isolation.

A similar model could also apply to prisoners in solitary for their own safety, such as former Minneapolis police officer Derek Chauvin, who is serving a 22½-year-prison sentence for the murder of George Floyd. They could be placed in smaller units with individuals who have undergone a thorough risk assessment, and with access to education and training, Haney said.

Prisoner advocates are hopeful that solitary confinement in the U.S. will eventually be a concept of the past. In April, New York became the first state to codify the U.N.'s Mandela Rules that ban solitary after 15 consecutive days, when the Halt Solitary Confinement Act was signed into law. The legislation will take effect next April.

After Winn's release from prison, she founded RestoreHER, a nonprofit that advocates to end the mass incarceration of women of color, and pregnant people, in particular. She also helped enact laws in Georgia and North Carolina that bar the shackling of pregnant women.

"What I'm doing now gives me some redemption," she said.