These Schools Use Weekly Testing to Keep Kids in Class — And COVID Out

KFF Health News, September 27, 2021

Hillside School was among the first in Illinois to start regular testing. Now, almost half of Illinois' 2 million K-12 students attend schools rolling out similar programs.

This article was published on Monday, September 27, 2021 in Kaiser Health News.

By Christine Herman, WILL / Illinois Public Media  

On a recent Monday morning, a group of preschoolers filed into the gymnasium at Hillside School in the west Chicago suburbs. These 4- and 5-year-olds were the first of more than 200 students to get tested for the coronavirus that day — and every Monday — for the foreseeable future.

At the front of the line, a girl in a unicorn headband and sparkly pink skirt clutched a zip-close bag with her name on it. She pulled out a plastic tube with a small funnel attached. Next, Hillside superintendent Kevin Suchinski led the student to a spot marked off with red tape. Suchinski coached her how to carefully release — but not "spit" — about a half-teaspoon's worth of saliva into the tube.

"You wait a second, you build up your saliva," he told her. "You don't talk, you think about pizza, hamburgers, French fries, ice cream. And you drop it right in there, OK?"

The results will come back within 24 hours. Any students who test positive are instructed to isolate, and the school nurse and administrative staff carry out contact tracing.

Hillside was among the first in Illinois to start regular testing. Now, almost half of Illinois' 2 million students in grades K through 12 attend schools rolling out similar programs. The initiative is supported by federal funding channeled through the state health department.

Schools in other states — such as Massachusetts, Maryland, New York and Colorado — also offer regular testing; Los Angeles public schools have gone further by making it mandatory.

These measures stand in sharp contrast to the confusion in states where people are still fighting about wearing masks in the classroom and other anti-COVID strategies, places where some schools have experienced outbreaks and even teacher deaths.

Within a few weeks of schools reopening, tens of thousands of students across the U.S. were sent home to quarantine. It's a concern because options for K-12 students in quarantine are all over the map — with some schools offering virtual instruction and others providing little or no at-home options.

Suchinski hopes this investment in testing prevents virus detected at Hillside School from spreading into the wider community — and keeps kids learning.

"What we say to ourselves is: If we don't do this program, we could be losing instruction because we've had to close down the school," he said.

So far, the parents and guardians of two-thirds of all Hillside students have consented to testing. Suchinski said the school is working hard to get the remaining families on board by educating them about the importance — and benefit — of regular testing.

Every school that can manage it should consider testing students weekly — even twice a week, if possible, said Becky Smith. She's an epidemiologist at the University of Illinois in Urbana-Champaign, which developed the saliva test Hillside and other Illinois schools are using. Smith pointed to several studies — including both peer-reviewed and preliminary research — that suggest rigorous testing and contact tracing are key to keeping the virus at bay in K-12 schools.

"If you're lucky, you can get away without doing testing, [if] nobody comes to school with a raging infection and takes their mask off at lunchtime and infects everybody sitting at the table with them," Smith said. "But relying on luck isn't what we like to do."

Julian Hernandez, a Hillside seventh grader, said he feels safer knowing that classmates infected with the virus will be prevented from spreading it to others.

"One of my friends — he got it a couple months ago while we was in school," Julian recalled. "[He] and his brother had to go back home. … They were OK. They only had mild symptoms."

Brandon Muñoz, who's in the fifth grade, said he's glad to get tested because he's too young for the vaccine — and he really doesn't want to go back to Zoom school.

"Because I wanna really meet more people and friends and just not stay on the computer for too long," Brandon explained.

Suchinski, the superintendent, said Hillside also improved ventilation throughout the building, installing a new HVAC system and windows with screens in the cafeteria to bring more fresh air in the building.

Regular testing is an added layer of protection, though not the only thing Hillside is relying on: About 90% of Hillside staff are vaccinated, Suchinski said, and students and staffers also wear masks.

Setting up a regular mass-testing program inside a K-12 school takes a good amount of coordination, which Suchinski can vouch for.

Last school year, Hillside school administrators facilitated the saliva sample collection without outside help. This year, the school tapped funding earmarked for K-12 coronavirus testing to hire COVID testers — who coordinate the collecting, transporting and processing of samples, and reporting results.

A couple of Hillside administrators help oversee the process on Mondays, and also facilitate testing for staff members, plus more frequent testing for a limited group of students: Athletes and children in band and extracurriculars test twice a week because they face greater risks of exposure to the virus from these activities.

Compared with a year ago, COVID testing is now both more affordable and much less invasive, said Mara Aspinall, who studies biomedical testing at Arizona State University. There's also more help to cover costs.

"The Biden administration has allocated $11 billion to different programs for testing," Aspinall said. "There should be no school — public, private or charter — that can't access that money for testing."

Creating a mass testing program from scratch is a big lift. But more than half of all states have announced programs to help schools access the money and handle the logistics.

If every school tested every student once a week, the roughly $11 billion earmarked for testing would likely run out in a couple of months. (This assumes $20 to buy and process each test.) Put another way, if a quarter of all U.S. schools tested students weekly, the funds could last the rest of the school year, Aspinall said.

In its guidance to K-12 schools, updated Aug. 5, the Centers for Disease Control and Prevention does not make a firm recommendation for this surveillance testing.

Instead, the CDC advises schools that choose to offer testing to work with public health officials to determine a suitable approach, given rates of community transmission and other factors.

The agency previously recommended screening at least once a week in all areas experiencing moderate to high levels of community transmission. As of Sept. 21, that included 95% of U.S. counties.

For school leaders looking to explore options, Aspinall suggests a resource she helped write, which is cited within the CDC guidance to schools: the Rockefeller Foundation's National Testing Action Plan.

This spring — when Hillside was operating at about half capacity and before the more contagious delta variant took over — the school identified 13 positive cases among students and staffers via its weekly testing program. The overall positivity rate of about half a percent made some wonder if all that testing was necessary.

But Suchinski said that by identifying the 13 positive cases, the school perhaps avoided more than a dozen potential outbreaks. Some of the positive cases were among people who weren't showing symptoms but still could've spread the virus.

A couple of weeks into the new school year at Hillside, operating at full capacity, Suchinski said the excitement is palpable. Nowadays he's balancing feelings of optimism with caution.

"It is great to hear kids laughing. It's great to see kids on playgrounds," Suchinski said.

"At the same time," he added, "we know that we're still fighting against the delta variant and we have to keep our guard up."

This story is from a partnership that includes Illinois Public Media, Side Effects Public Media, NPR, and KHN.

Firefighters on Front Lines, No Strangers to Risk, Push Back Against COVID Vaccine Mandates

KFF Health News, September 27, 2021

Firefighter leadership and the rank and file are divided over vaccine mandates.

This article was published on Monday, September 27, 2021 in Kaiser Health News.

By Sandy West   

Kentucky firefighter Jimmy Adams saw the ravages of the coronavirus pandemic when he served as a medic who helped care for the sick on medical calls amid surging COVID cases. He knew retired firefighters who died of complications from COVID-19. But he reasoned that they were older and likely had underlying health issues, making them susceptible to the virus.

"That's how you make peace with those things," said Adams, 51, a lieutenant. He believed the precautions his department was taking kept him safe. But he refused to get a COVID vaccine. The reason wasn't strictly political, he said. He had grown weary of the debate around masks, mitigation, caseloads and vaccines.

In mid-August, both Adams and his wife, Sara, who was fully vaccinated, tested positive for COVID. She experienced mild symptoms; however, he was hospitalized with bilateral interstitial pneumonia. His potassium spiked, causing cardiac arrhythmia. He was on oxygen throughout his hospitalization.

"I was wrong," Adams said several days after leaving the hospital. "I suffered a lot. I don't even know at this point in the game if I am going to suffer any long-term effects. Does this change who I am for the rest of my life? I don't know the answer to that. I will be sad if it does."

Adams now plans to get vaccinated as soon as his doctor allows it, post-recovery. Still, he, like many other firefighters nationwide, does not support mandates for COVID vaccines.

Firefighter leadership and the rank and file are divided over such mandates. The International Association of Fire Chiefs has expressed support for mandatory vaccinations. Conversely, the International Association of Fire Fighters has said it "strongly" encourages firefighters to get vaccinated, but does not think it should be mandated.

Firefighters, who more often than not are certified emergency medical providers, have been on the pandemic's front lines since the beginning. Officials pushed to ensure they would be among the first to receive the vaccines, given their role in the medical system. Yet why, after having seen so much, do so many who are trained to save lives still refuse to get vaccinated — while actively fighting against mandates?

JT Sullivan, a firefighter in Wyandotte County, Kansas, said that while he took precautions not to bring home the coronavirus when his wife was pregnant, he believed the pandemic was largely "vamped up" by the media — even as he saw its effects in his professional life. He understood something was happening; he just didn't believe it was quite as bad as was being reported. He believed it affected mostly the elderly and medically fragile. The 28-year-old had no plans to get vaccinated until a paramedic at his department died from COVID complications on Jan. 1. Sullivan got vaccinated soon after.

"It just caught me off guard because he was younger than my folks," said Sullivan, who encourages vaccinations but also disagrees with mandates.

Several firefighters said first responders reluctant to get vaccinated reflect the range of views held by many average Americans: Some view both the pandemic and vaccine through a political lens, some believe misinformation and conspiracies, some are generally wary of vaccines, and others don't like being told what to do. Both Adams and Sullivan attributed some vaccine resistance to having a "Type A" personality and harboring a belief that they can exert control over what happens to them.

Houston Fire Chief Samuel Peña, frustrated with his own department's vaccination rate, which he guesses to be about 50%, suspects there is some truth to that.

"Through the course of a first responder's career — whether you're a firefighter, police officer, EMT — you kind of get a higher tolerance for acceptable risk because you respond to all kinds of stuff that puts your life in dangerous situations and the majority of the time you come out unscathed," he said. "The level of acceptable risk that we're willing to take is at a different threshold than a normal, reasonable individual."

Peña said Houston officials have discussed mandating vaccinations despite Texas Republican Gov. Greg Abbott's efforts to prevent schools and cities from instituting COVID mitigation policies. The city's strained relationship with the local firefighters union could complicate matters. Such mandates elsewhere have met fierce resistance.

A Los Angeles City Fire Department captain is under investigation after posting a video denouncing the "tyranny" of an expected vaccine mandate there. The city of San Francisco's Department of Human Resources has recommended 10-day unpaid suspensions for 20 employees, including seven firefighters, for noncompliance with that city's mandate, according to the San Francisco Chronicle. News reports in multiple cities quote employees questioning the legality of such mandates.

A long-standing legal precedent exists for public health and vaccine mandates, said Sharona Hoffman, a professor of law and bioethics at Case Western Reserve University in Cleveland.

"It's not true that 'This is America and we have 100% freedom.' We have a million laws and regulations you have to comply with," she said, citing, among them, traffic laws and employer dress codes. "That's what it means to be in a civilized society. That's what's called the 'social contract.'"

Allyson Hinzman, a firefighter and the president of Tacoma Firefighters Local 31 in Washington, said local unions oppose Democratic Gov. Jay Inslee's vaccine mandate. Hinzman said it was rushed and doesn't allow for alternatives, such as weekly COVID testing. State workers filed a lawsuit this month against the governor over the mandate.

Firefighters are threatening to quit rather than comply, which Hinzman said would further strain short-staffed departments providing emergency services.

She said firefighters take precautions to prevent virus transmission when responding to calls. A University of Washington study indicates the risk of spreading the virus between first responders and patients is low, because of safety protocols followed in the field.

"This isn't about the vaccine," said Hinzman, who did get vaccinated. "This is about providing our members the opportunity to choose and make decisions for themselves. We are pro-vaccine, we are pro-public safety, but we're just anti-mandate. The fact is you can be all three things at the exact same time."

Bob McDonald, executive director of the Denver Department of Public Health, sees it differently and said vaccines are the only way to move from a COVID pandemic to a health concern that, like influenza, can be managed. Denver has implemented a vaccine mandate for all city employees, including firefighters.

"One of the things that I think is very, very important is to get people to understand that these vaccines, especially with the delta variant, are no longer just about the individual," said McDonald, adding that hospitals around Denver are at or beyond capacity due to surging COVID cases. It is everyone's responsibility to mitigate their risk to reduce strain on the nation's medical system, he said.

Peña said public servants owe it to taxpayers to get vaccinated given that taxpayers ultimately pay the bills for their workers' compensation payouts or hospitalizations.

Even if employees quit in the event of a vaccine mandate in Houston, Peña said, his department has operated throughout the pandemic with reduced staffing because of members quarantining after exposure or isolating because of illness. Four Houston firefighters have died of COVID.

"I have been doing this for 27 years, and I can tell you that I have never buried a firefighter for a line-of-duty death because of the flu," said Peña, adding that if the deaths had been from other duty-related activities, the union would push for action. "Just because this is a medical issue does not mean that we should not be looking for how to better protect our firefighters. The vaccine is one way we can achieve that."

According to the National Fallen Firefighters Foundation, which honors and recognizes firefighters who die in the line of duty, 170 firefighters and 78 EMS workers had died of COVID complications as of Sept. 17.

Sandy West: sandywestwriter@gmail.com, @_SandyWest

KHN on air: Who qualifies for a COVID booster? The list grows longer

KFF Health News, September 27, 2021

As many as 87% vaccinated adults said they would get an additional dose if it were available.

This audio report was released on Monday, September 27, 2021 by Kaiser Health News.

On Friday, CDC Director Rochelle Walensky said people whose jobs put them at risk of coronavirus infection qualify for a shot to boost the protection of their COVID-19 vaccination.

That step to include people with “institutional and occupational exposure” overrules the recommendation of her agency’s advisory panel, and the move was a surprise to many.

“It was not expected, but I think the director, Walensky, wanted to go along with what the FDA had said earlier in the week and to kind of back up the plan that President Biden had laid out in August,” said KHN senior correspondent Sarah Jane Tribble.

Others who can line up first for a covid booster include Americans age 65 and older, younger people who have underlying health conditions and nursing home residents.

So far, regulators have done a poor job of defining the universe of people considered at risk because of institutional and occupational exposure, said Arthur Allen, an editor for KHN’s California Healthline.

“We don’t know exactly who they all are. But we can think of some obvious groups who would have been very upset if they couldn’t be qualified for a booster. That includes healthcare workers and teachers,” Allen said.

“We have to remember this is not really just a purely scientific decision,” he said.

During the Sept. 23 meeting of the CDC’s Advisory Committee on Immunization Practices, members tried to get a handle on Americans’ demand for covid boosters: In surveys from August, as many as 87% vaccinated adults said they would get an additional dose if it were available. Another later survey found that 93% of adults would get the shot if a primary care provider recommended it.

Mounting COVID Deaths Fuel School Bus Drivers' Fears

KFF Health News, September 24, 2021

At least 12 school bus workers in Georgia have died of COVID since the beginning of the school year.

This article was published on Friday, September 24, 2021 in Kaiser Health News.

By Andy Miller and Phil Galewitz 

GRIFFIN, Ga. — Natalia D'Angelo got sick right after school started in August.

She was driving a school bus for special education students in Griffin-Spalding County School System about 40 miles south of Atlanta and contracted COVID-19.

One of her three sons, Julian Rodriguez-D'Angelo, said his mother, who was not vaccinated against the COVID virus, had a history of health problems, including Graves' disease and cancer.

Rodriguez-D'Angelo said his mother "was pretty certain" she got COVID from her work duties. He added that D'Angelo's assistant on the same bus also had the disease, and that his mother said some kids on the bus did not wear masks, even though it is required.

The virus spread through the whole family, including her husband, Americo Rodriguez, who came with her to the U.S. from Uruguay 20 years ago. But D'Angelo's illness grew worse, and she was hospitalized at a Griffin hospital in mid-August. On Aug. 28, she died. She was 43.

D'Angelo is among at least 12 school bus workers in Georgia — including three in the Griffin-Spalding district — who have died of COVID since the beginning of the school year. News reports and a Twitter feed called "School Personnel Lost to COVID" show that school bus drivers in at least 10 states have died of the disease since August.

The deaths raise questions about whether school bus drivers are at higher risk of getting COVID. But medical experts are split. It's difficult, if not impossible when local infection rates are high, to determine how any particular bus worker became infected — whether it occurred at home, in a community setting or on the job.

The buses should be relatively safe. The Centers for Disease Control and Prevention requires that masks be worn on public transportation, including all school buses, public or private and regardless of whether the schools themselves require masks.

"There's no enforcement of that,'' said Ronna Weber, executive director of the National Association of State Directors of Pupil Transportation Services. "Police are not going to board a school bus" to make sure the students are wearing masks.

As with school employees in general, statistics on the number of COVID deaths are sparse, without any central government repository, according to the National Education Association union. The Florida Education Association, though, lists seven bus workers among the more than 70 school staffers in the state who have died since July. The School Personnel Lost to COVID account says more than 185 bus drivers have died of the disease during the pandemic.

An estimated 500,000 school buses nationwide operate on a given day. Many drivers are retirees from previous occupations, so age and health conditions could contribute to the deaths. "Every life is an unfortunate loss," said Weber.

Xiaoyan Song, chief infection control officer at Children's National Hospital in Washington, D.C., said drivers are not at increased risk of getting COVID from students because they see children up close for only a second or two, when the kids board and exit the bus.

It typically takes several minutes of exposure to an infected person to transmit the virus, she said, adding that drivers face forward with their backs to students while driving, which also diminishes their risk. She said driving with windows open is another factor that can limit transmission of the virus.

But Ye Shen, an associate professor at the University of Georgia College of Public Health, believes drivers face a greater risk.

Shen, lead author of a JAMA Internal Medicine study on COVID transmission on buses in China, noted that the vehicles are enclosed spaces in which ventilation can be poor, creating an environment with a high risk of COVID transmission.

The danger of airborne transmission is significantly reduced if the kids and the driver are all wearing masks, Shen said. In the China study, no one was wearing a mask and there was a high rate of virus transmission. "Kids often don't fully comply with the mask rule," Shen added.

Risks may climb within school districts that lack mask mandates, he said.

The Bulloch County school district in southeastern Georgia has no mask mandate in classrooms or buses. In early September, Bulloch district bus driver Norma Jean Carter, 55, died of COVID.

Besides mask-wearing, the CDC recommends that, whenever possible, drivers and monitors open bus windows to increase air circulation. Bus surfaces should be cleaned and disinfected after each use of the vehicle, the agency said.

Even when precautions are taken, the fears surrounding COVID have worsened a nationwide shortage of school bus drivers.

Michael Cordiello, president of the Amalgamated Transit Union local chapter in New York City, representing more than 8,000 school bus workers, said more drivers have retired in 2021 than in previous years.

Officials in several states are working to find solutions to the shortages, and some are requesting that their governors send National Guard troops to help. A Wilmington, Delaware, school is paying its students' parents to drive buses. Some regular drivers have had to work extra shifts.

"Our drivers are scared to death," said Jamie Michael, president of Support Personnel Association of Lee County, a union in southwestern Florida that represents bus drivers and other school staffers.

One county school bus driver there died of COVID in mid-August, she said. It is unknown where the woman was infected. She said five drivers then quit Sept. 7 and the county school district is about 100 drivers short of what it needs.

The district requires drivers to wear masks, and they try to ensure that at least some windows are kept open on the bus no matter the weather.

"It's a scary time for anyone working with students," Michael said.

Drivers in the district get paid between $16 and $23 an hour depending on seniority, amounting to $31,000 to about $45,000 annually.

Michael said drivers like to keep the seat behind them vacant to allow for physical distancing, but that is not always possible due to demand for rides, especially amid driver shortages.

The Griffin-Spalding district temporarily switched to remote learning for students after D'Angelo, another bus driver and a bus monitor died of COVID. Several more have been infected since school started Aug. 4, said Adam Pugh, spokesperson for the Griffin-Spalding County School System. The school district added a mask requirement early in the school year.

"No one has an exact answer" as to why the district's bus workers have been hit so hard, he said. Many buses are being driven with windows open, and the vehicles are sanitized between routes, Pugh added.

Julian Rodriguez-D'Angelo said his mother "loved being a bus driver and never missed work. She drove for years."

He said he doesn't blame the students but does feel anger about district policies. The delta variant, the dominant strain of COVID, "is spreading like crazy," he said. He added he doesn't think students should have been in school amid the surge.

The vaccination rate in Spalding County for all residents, 37%, is far below the state's 46% rate. Both rates are below the national average.

Andy Miller: amiller@kff.org, @gahealthnews

Phil Galewitz: pgalewitz@kff.org, @philgalewitz

Low Wages and Pandemic Gut Staffing Support for Those With Disabilities

KFF Health News, September 24, 2021

Even before the pandemic, the nation had a shortage of direct support professionals working in private homes, group facilities, day programs and other community settings.

This article was published on Friday, September 24, 2021 in Kaiser Health News.

By Andy Miller  

Ernestine "Erma" Bryant likes her job, but the pay is a problem.

She works in a caregiver role as a "direct support professional" in Tifton, Georgia, helping people who have intellectual and developmental disabilities with basic functions such as dressing, bathing and eating.

Bryant said it's fulfilling work. "You can help people be successful — people who are confined to the bed," she said. "It gives me joy knowing that I can help that person get out of the house."

But she said she's being paid less than $10 an hour and is trying to get a second job.

In a way, Bryant is an anomaly, having worked as a support professional in the same job for five years in a field with high turnover. Even before the pandemic, the nation had a shortage of direct support professionals working in private homes, group facilities, day programs and other community settings.

Fears of contracting COVID-19 at work have made the caregiver staffing problem worse. Persistent low pay amid a tight U.S. labor market makes it that much harder to attract workers.

Worker shortages across the health care spectrum — from nurses to lower-level staffers — are an unprecedented challenge for hospitals and other medical organizations. The shortage is at an "epic level," said Elizabeth Priaulx, a legal specialist with the National Disability Rights Network.

People with disabilities who have been approved by state Medicaid programs to receive 40 hours a week in caregiver services now often get just 20 hours, Priaulx added. If family members can't help offset the gap, a person may be forced into a nursing home, she said.

The Zoller family of Flowery Branch, Georgia, is struggling with that reduction in service hours.

Katie, 34, is developmentally disabled and lives at home. Her father, John, said that instead of the 24/7 care she previously received, she is provided less than half of that at about 60 hours a week because of caregiver shortages. So John, 65, and his wife, Weda, 63, must fill in the rest. "We have to tag-team," he said. The staffing gap occurred after one caregiver for Katie moved away, and another took a warehouse job, each getting higher pay, he said.

Diane Wilush, CEO of Atlanta-based United Cerebral Palsy of Georgia, said her organization has more than 100 vacancies among 358 jobs in 24/7 residential programs. Many day programs, including those run by her group, have been unable to offer full services because of staffing gaps.

"We can't compete with every retail shop paying $15 to $18 an hour," Wilush said.

That's because several years ago the state of Georgia chose a base Medicaid reimbursement rate for residential services providers of $10.63 per hour, though they can pay caregivers more — and sometimes pay less. "It was an inadequate rate even then," Wilush said.

The strain from an increased workload has a negative effect on caregivers, said Bryant, the caregiver in Tifton. "When you don't have enough help, it makes you want to find another job," she said.

In 2019, before COVID erupted, the direct support professional turnover rate was 43% nationally, according to the National Core Indicators collaboration of public developmental disability agencies. In a February 2020 survey of providers by the American Network of Community Options and Resources, two-thirds of service providers said they were turning away new referrals. Since staffing shortages became a problem, 40% have seen a higher incidence of events that could harm a person's health or safety.

And a KFF survey released last month found that during the pandemic, two-thirds of responding states reported a permanent closure of at least one provider of Medicaid-covered home- and community-based services.

Workers have at times been forced to work 16-hour shifts during the pandemic, said Whitney Fuchs, CEO of InCommunity, an Atlanta-based provider of community services and support to people with developmental disabilities. "This crisis is going to erupt into unsafe, unhealthy situations."

His organization needs to fill 166 openings out of 490 positions. Before the pandemic, the number of job openings was 80. Even managers, who often cover work shifts, are leaving their jobs due to overwork, Fuchs said.

"People are tired constantly," he said. "This is somebody's life we're supporting. There have been adverse patient outcomes," such as medication mistakes.

Through the recently passed American Rescue Plan Act, the Biden administration has recognized the wage gap for direct care workers by adding more Medicaid funding to help compensate them for their work. The act increases the federal matching rate for state spending on home and community-based services by 10 percentage points from April 1, 2021, through March 31, 2022.

It requires states to submit spending plans for those funds. Georgia has submitted a plan that contains rate increases, as well as a study of worker wages. The proposal is under review by the Centers for Medicare & Medicaid Services, according to the Georgia Department of Behavioral Health and Developmental Disabilities. Staffers there said the department is "acutely aware" of the shortages.

Federal COVID funds have enabled Georgia to give a 10% pay increase for some provider services.

Other states are trying to buttress worker salaries on their own. Missouri recently approved $56 million to improve its direct support professional crisis.

Parents of people with disabilities, though, have concerns about the future viability of the services if the national worker shortage isn't fixed.

Bill Clarke and his wife are in their 80s. They have two children with multiple disabilities receiving services in residential homes in the Atlanta area.

"They have physical problems that require 24/7 care," Clarke said. "There are just not enough people willing to go into these lower-paying jobs. They are not compensated adequately."

If these services disappear, Clarke said, "we could not handle both of our sons physically."

Andy Miller: amiller@kff.org, @gahealthnews

Biosimilar Drugs Are Cheaper Than Biologics. Are They Similar Enough to Switch?

KFF Health News, September 23, 2021

The U.S. has been slower to adopt biosimilar drugs since the first such medicine was approved in 2015.

This article was published Thursday, September 23, 2021 in Kaiser Health News.

By Michelle Andrews  

It took years for Elle Moxley to get a diagnosis that explained her crippling gastrointestinal pain, digestion problems, fatigue, and hot, red rashes. And after learning in 2016 that she had Crohn's disease, a chronic inflammation of the digestive tract, she spent more than four years trying medications before getting her disease under control with a biologic drug called Remicade.

So Moxley, 33, was dismayed to receive a notice from her insurer in January that Remicade would no longer be covered as a preferred drug on her plan. Another drug, Inflectra, which the Food and Drug Administration says has no meaningful clinical differences from Remicade, is now preferred. It is a "biosimilar" drug.

"I felt very powerless," said Moxley, who recently started a job as a public relations coordinator for Kansas City Public Schools in Missouri. "I have this decision being made for me and my doctor that's not in my best interest, and it might knock me out of remission."

After Moxley's first Inflectra infusion in July, she developed a painful rash. It went away after a few days, but she said she continues to feel extremely fatigued and experiences gastrointestinal pain, constipation, diarrhea and nausea.

Many medical professionals look to biosimilar drugs as a way to increase competition and give consumers cheaper options, much as generic drugs do, and they point to the more robust use of these products in Europe to cut costs.

Yet the U.S. has been slower to adopt biosimilar drugs since the first such medicine was approved in 2015. That's partly because of concerns raised by patients like Moxley and their doctors, but also because brand-name biologics have kept biosimilars from entering the market. The companies behind the brand-name drugs have used legal actions to extend the life of their patents and incentives that make offering the brand biologic more attractive than offering a biosimilar on a formulary, listing which drugs are covered on an insurance plan.

"It distorts the market and makes it so that patients can't get access," said Dr. Jinoos Yazdany, a professor of medicine and chief of the rheumatology division at Zuckerberg San Francisco General Hospital.

The FDA has approved 31 biosimilar medications since 2015, but only about 60% have made it to market, according to an analysis by NORC, a research organization at the University of Chicago.

Remicade's manufacturer, Johnson & Johnson, and Pfizer, which makes the Remicade biosimilar Inflectra, have been embroiled in a long-running lawsuit over Pfizer's claims that Johnson & Johnson tried to choke off competition through exclusionary contracts with insurers and other anti-competitive actions. In July, the companies settled the case on undisclosed terms.

In a statement, Pfizer said it would continue to sell Inflectra in the U.S. but noted ongoing challenges: "Pfizer has begun to see progress in the overall biosimilars marketplace in the U.S. However, changes in policy at a government level and acceptance of biosimilars among key stakeholders are critical to deliver more meaningful uptake so patients and the healthcare system at-large can benefit from the cost savings these medicines may deliver."

Johnson & Johnson said it is committed to making Remicade available to patients who choose it, which "compels us to compete responsibly on both price and value."

Biologic medicines, which are generally grown from living organisms such as animal cells or bacteria, are more complex and expensive to manufacture than drugs made from chemicals. In recent years, biologic drugs have become a mainstay of treatment for autoimmune conditions like Crohn's disease and rheumatoid arthritis, as well as certain cancers and diabetes, among other conditions.

Other drugmakers can't exactly reproduce these biologic drugs by following chemical recipes as they do for generic versions of conventional drugs.

Instead, biosimilar versions of biologic drugs are generally made from the same types of materials as the original biologics and must be "highly similar" to them to be approved by the FDA. They must have no clinically meaningful differences from the biologic drug, and be just as safe, pure and potent. More than a decade after Congress created an approval pathway for biosimilars, they are widely accepted as safe and effective alternatives to brand biologics.

Medical experts hope that as biosimilars become more widely used they will increasingly provide a brake on drug spending.

From 2015 to 2019, drug spending overall grew 6.1%, while spending on biologics grew more than twice as much — 14.6% — according to a report by IQVIA, a healthcare analytics company. In 2019, biologics accounted for 43% of drug spending in the U.S.

Biosimilars provide a roughly 30% discount over brand biologics in the U.S. but have the potential to reduce spending by more than $100 billion in the next five years, the IQVIA analysis found.

In a survey of 602 physicians who prescribe biologic medications, more than three-quarters said they believed biosimilars are just as safe and effective as their biologic counterparts, according to NORC.

But they were less comfortable with switching patients from a brand biologic to a biosimilar. While about half said they were very likely to prescribe a biosimilar to a patient just starting biologic therapy, only 31% said they were very likely to prescribe a biosimilar to a patient already doing well on a brand biologic.

It can be challenging to find a treatment regimen that works for patients with complicated chronic conditions, and physicians and patients often don't want to rock the boat once that is achieved.

In Moxley's case, for example, before her condition stabilized on Remicade, she tried a conventional pill called Lialda, the biologic drug Humira and a lower dose of Remicade.

Some doctors and patients raise concerns that switching between these drugs might cause patients to develop antibodies that cause the drugs to lose effectiveness. They want to see more research about the effects of such switches.

"We haven't seen enough studies about patients going from the biologic to the biosimilar and bouncing back and forth," said Dr. Marcus Snow, chair of the American College of Rheumatology's Committee on Rheumatologic Care. "We don't want our patients to be guinea pigs."

Manufacturers of biologic and biosimilar drugs have participated in advertising, exhibit or sponsorship opportunities with the American College of Rheumatology, according to ACR spokesperson Jocelyn Givens.

But studies show a one-time switch from Remicade to a biosimilar like Inflectra does not cause side effects or the development of antibodies, said Dr. Ross Maltz, a pediatric gastroenterologist at Nationwide Children's Hospital in Columbus, Ohio, and former member of the Crohn's & Colitis Foundation's National Scientific Advisory Committee. Studies may be conducted by researchers with extensive ties to the industry and funded by drugmakers.

Situations like Moxley's are unusual, said Kristine Grow, senior vice president of communications at AHIP, an insurer trade group.

"For patients who have been taking a brand-name biologic for some time, health insurance providers do not typically encourage them to switch to a biosimilar because of a formulary change, and most plans exclude these patients from any changes in cost sharing due to formulary changes," she said.

Drugmakers can seek approval from the FDA of their biosimilar as interchangeable with a biologic drug, allowing pharmacists, subject to state law, to switch a physician's prescription from the brand drug, as they often do with generic drugs.

However, the FDA has approved only one biosimilar (Semglee, a form of insulin) as interchangeable with a biologic (Lantus).

Like Moxley, many other patients using biologics get copay assistance from drug companies, but the money often isn't enough to cover the full cost. In her old job as a radio reporter, Moxley said, she hit the $7,000 maximum annual out-of-pocket spending limit for her plan by May.

In her new job, Moxley has an individual plan with a $4,000 maximum out-of-pocket limit, which she expects to blow past once again within months.

But she received good news recently: Her new plan will cover Remicade.

"I'm still concerned that I will have developed antibodies since my last dose," she said. "But it feels like a step in the direction of good health again."

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

Democrats Roll the Dice on Sweeping Abortion Rights Bill — Again

KFF Health News, September 23, 2021

The question now, as it was then, is whether the legislation will help or hurt Democrats on one of the most polarizing issues in politics.

This article was published on Thursday, September 23, 2021 in Kaiser Health News.

By Julie Rovner  

A newly conservative Supreme Court agreed to hear a case most assumed it would use to overrule the 1973 landmark abortion-rights ruling, Roe v. Wade. And Democrats on Capitol Hill, convinced the issue would play to their political favor, vowed to bring up legislation that would write abortion protections into federal law. "We'll debate it. We'll vote on it. And we'll pass it," the Senate Democratic leader promised.

Sound familiar? The year was 1992. The Supreme Court case in question was Planned Parenthood of Southeastern Pennsylvania v. Casey. After the court surprised almost everyone by upholding the right to abortion, the legislation, called the "Freedom of Choice Act," never reached the floor of the Senate, nor the House. (Click on the hyperlink to go back in time.)

Lawmakers today face almost the same situation. The Supreme Court this week scheduled for Dec. 1 arguments on a case from Mississippi challenging that state's ban on abortion after 15 weeks of pregnancy. And the House, as soon as this week, could vote on the latest version of the Freedom of Choice Act, now called the "Women's Health Protection Act."

The question now, as it was then, is whether the legislation will help or hurt Democrats on one of the most polarizing issues in politics.

Just as in 1992, opponents of the current bill complain it would go much further than merely writing the protections of Roe into federal law. In addition to securing a person's right to abortion throughout pregnancy, the legislation would void many state restrictions the Supreme Court has allowed even as Roe stands, including those requiring parental involvement in a minor's abortion decision.

"This may be the most extreme legislation ever," Rep. Cathy McMorris Rodgers (R-Wash.) told the House Rules Committee on Monday. "Abortion for any reason at any stage of pregnancy until birth."

The bill would, Republicans complained, not just overturn existing state abortion restrictions, but it could also lead to mandatory public funding for abortion. Overturning the so-called Hyde Amendment that has banned most federal abortion funding since the late 1970s is a priority for many progressive Democrats, but it also marks a line that voters in many swing districts do not want their elected officials to cross.

While the scenarios seem eerily similar, some key differences emerge. The biggest: In 1992, the threat to abortion rights was theoretical; in 2021, millions of pregnant people already have lost reproductive rights after the high court failed to block a controversial Texas law that bans nearly all abortions as early as six weeks into pregnancy. To prevent courts from blocking it, the law is to be enforced not by state officials, but by individuals suing people who "aid or abet" someone in obtaining an abortion.

Under that law, Rep. Jamie Raskin (D-Md.) told the Rules Committee on Monday, "the whole country has basically been turned into bounty hunters for women exercising a constitutionally protected right."

"Texas has just completely changed what's at stake," said Cecile Richards, former president of Planned Parenthood and a longtime Texas politics observer. (Her mother, Ann Richards, who died in 2006, was governor in the 1990s.) "Women think, 'This will never happen,'" said Richards, who now co-chairs American Bridge 21st Century, a Democratic super political action committee. "Well, it just happened."

Yet the politics of abortion are both very much the same as they were three decades ago, and very different.

What's the same is that the outliers in both parties — Democrats who oppose abortion rights and Republicans who support them — would prefer not to have to vote on the issue. What's different is there are far fewer outliers today. In 1992 nearly a third of Democrats opposed abortion, including the then-governor of Pennsylvania, Robert Casey, who was the defendant in the Planned Parenthood suit and who tried, publicly and unsuccessfully, to change the party's platform in 1992 to oppose abortion. His son, Sen. Robert "Bob" Casey Jr. (D-Pa.), is one of a handful of Senate Democrats who do not strongly support abortion rights.

But it's not merely anti-abortion Democrats who are in shorter supply. In 1992 Republicans were as likely to lead abortion-rights fights as Democrats, and most efforts were bipartisan. Before 1972, in fact, Republicans were generally more supportive of abortion rights than Democrats.

And obviously the biggest difference between now and 1992 is that the Republican president, George H.W. Bush, vowed to veto the abortion rights bill if it passed. President Joe Biden would sign it, according to a formal "Statement of Administration Policy" issued Monday. "In the wake of Texas' unprecedented attack, it has never been more important to codify this constitutional right and to strengthen healthcare access for all women, regardless of where they live," the statement said.

Bush's and Biden's own abortion positions probably best demonstrate how much the parties have shifted on the issue. As a House member, the elder President Bush was the lead sponsor of the federal government's Title X family planning program — now strongly opposed by anti-abortion Republicans. Biden, a devout Catholic, opposed abortion rights early in his Senate career and has been criticized by activists for not uttering the word "abortion" as president until the Texas law took effect.

Biden, however, almost certainly will not get a chance to sign the Women's Health Protection Act. At least not anytime soon. Although the bill might have enough support to squeak through the House, support in the Senate remains far short of the 60 votes needed to break a filibuster.

That won't stop the fight from happening, though. What remains to be seen is which side in the abortion debate will ultimately win the battle for public support.

HealthBent, a regular feature of Kaiser Health News, offers insight and analysis of policies and politics from KHN's chief Washington correspondent, Julie Rovner, who has covered healthcare for more than 30 years.

Julie Rovner: jrovner@kff.org, @jrovner

Opinion: The Checkup Is in the Mail? Soliciting Letter Carriers to Help Deliver Healthcare

KFF Health News, September 23, 2021

Have letter carriers include in their responsibilities home visits and basic health checks on the growing population of frail and elderly.

This article was published on Thursday, September 23, 2021 in Kaiser Health News.

By Elisabeth Rosenthal

Two of America's toughest problems can be tempered with one solution.

The baby boom generation is graying, creating an ever-larger population of older people, many isolated, whose needs the nation is ill equipped to meet or even monitor.

Meanwhile, the U.S. Postal Service has gone $160 billion into debt, in part as digital communications have replaced snail mail. This year it has requested two rate increases for stamps and other services, bringing the price of a first-class stamp to 58 cents. It is running an aggressive TV ad campaign, presumably to build support for Congress to step in with some kind of rescue.

So here's a potential win-win solution: Have letter carriers spend less time delivering mail, much of which now involves fliers and solicitations. Instead, include in their responsibilities — "the swift completion of their appointed rounds" — home visits and basic health checks on the growing population of frail and elderly.

This may sound out-of-the-box, but it's already done successfully and profitably in other countries, like France and Japan. Indeed, the idea that the USPS could get more involved in home health services — to fill a need and earn money — was suggested by the agency's own Office of Inspector General in March.

So far, other solutions to fill the need for home healthcare have proved elusive. President Joe Biden proposed $400 billion in his initial infrastructure plan to improve services for the homebound elderly, a feature that Congress didn't retain. But Democrats' congressional reconciliation budget resolution, currently under debate, could allot money to the cause.

Meanwhile tens of millions of older Americans — the "old old" — are not so sick that they need a hospital but are unable to live safely at home without help. In Maine, the state with the oldest population, an estimated 10,000 hours of needed and approved home care is not provided every week because of a dearth of workers. That, for example, leaves patients with early dementia fending for themselves at great risk. People who need help preparing medicine or meals can be missing both.

Postal workers are already on virtually every block of America six days a week. They are "people people," as the recent TV ads portray, often beloved by their customers.

Yes, letter carriers are already busy, in part because of the volume of package deliveries, which jumped during the pandemic. But what about scrapping the idea of everyday delivery? That too was suggested by the agency's inspector general, a decade ago. Mail could be delivered just a few times a week, say, every other day. And on the off days, presto — we get a new on-the-ground home health workforce.

They could do home visits, to redress an epidemic of loneliness among older homebound Americans and check on whether a customer has an adequate supply of food and medicines. With a bit of retraining, they could check and record blood pressure, test blood sugar levels in people with diabetes and even administer pills.

Letter carriers already effectively serve as informal watchdogs, noticing if an older client hasn't picked up mail, for example. In some parts of the country, that function is formalized under a voluntary program called Carrier Alert, in which the Postal Service notifies a participating service agency, noted Brian Renfroe, executive vice president of the National Association of Letter Carriers.

But the USPS could be paid, by the government or by individuals, for this and other valuable services.

In France, since 2017, families have been able to pay a small monthly fee to La Poste — about 20 euros or $24 — to have home check-ins for an older relative. The service, called Watch Over My Parents, offers one to six visits per week, and the postal worker reports the resident's condition to the client each time.

Japan launched a similar postal program through a public-private partnership in 2017, to underwrite paid, monthly, half-hour visits (a friendly chat and health check) with members of the aging at-home population.

The post office's essential functions — like delivering the federal government's $1,200 pandemic relief checks, mail-in ballots and prescription medicines — are too important to lose. And USPS finances have improved recently, in part because of package deliveries and a $10 billion loan through the 2020 American Recovery and Reinvestment Act.

But when was the last time you ran to the mailbox to hear from a friend, check the news, or collect a bank statement or bill? It just makes sense financially and socially for the agency to evolve to meet the nation's current needs.

Of course, this alone will not close the USPS' $160 billion budget gap, the bulk of which resulted from a government mandate that it prefund the agency's pension plan and, especially, its retiree health benefits. Without that, the USPS would have been in the black (often just barely) for about half of the years since 2006 — though, overall, it was nearly $10 billion in debt during the period.

Solving that requirement will take congressional intervention; changes will also be needed in a law that currently requires six-day-a-week delivery and generally precludes the USPS from offering "nonpostal" products. Bipartisan legislation introduced in the Senate this year seeks to loosen the latter restriction to help the USPS earn money from services of "enhanced value to the public" (like selling hunting and fishing licenses).

Today, the postal service delivers vast amounts of "junk mail," also called direct mail. Companies spend about $167 annually on direct mail per person, yielding good returns, the industry says. But much of it ends up unread and unopened in the trash or recycling bin, an environmental nightmare.

Why not instead redeploy some of the U.S. Postal Service's vast supply of human resources to deliver a service our aging population — and our country — desperately needs?

Elisabeth Rosenthal: erosenthal@kff.org, @rosenthalhealth

Home Births Gain Popularity in 'Baby Bust' Decade

KFF Health News, September 22, 2021

From 2009 to 2019, the proportion of births nationwide outside hospitals rose from 1.01% in 2009 to 1.56% in 2019.

This article was published on Wednesday, September 22, 2021 in Kaiser Health News.

By Phillip Reese   

In a back-to-the-future twist on birth trends, California is seeing a sustained rise in the number of women choosing to deliver their babies in settings other than a hospital, a shift that accelerated as the pandemic created more risky and onerous conditions in many hospitals.

About 5,600 people gave birth outside a hospital in California in 2020, up from about 4,600 in 2019 and 3,500 in 2010. The shift took place during a widespread "baby bust," so the proportion of births outside hospitals rose from 0.68% in 2010 to 1.34% in 2020, according to a KHN analysis of provisional data from the California Department of Public Health. The proportion of births outside hospitals stayed relatively high — 1.28% — from January through July 2021.

From 2009 to 2019, the proportion of births nationwide outside hospitals rose from 1.01% in 2009 to 1.56% in 2019. Nationwide data for 2020 and 2021 is not yet available.

Births away from hospitals usually take place with the help of licensed midwives working at the homes of clients or at free-standing "birth centers." In either setting, expectant parents typically meet with midwives several times during the pregnancy to get comfortable, express their hopes for the pregnancy and learn about the birthing process.

Intentional at-home births and deliveries at midwife-run birthing centers are typically restricted to "low-risk" pregnancies. Women giving birth in those settings generally do not have serious preexisting health conditions like diabetes or high blood pressure that could complicate their babies' births; they are giving birth to one child — no twins or triplets; and they are not expected to undergo a breech delivery, in which the baby emerges feet first, said Erina Angelucci, a certified nurse midwife at Best Start Birth Center in San Diego. 

Midwives interviewed said they've heard from far more women in recent years turning to home births to avoid epidurals, induced labor and other invasive procedures common in hospital delivery rooms.

"I think people are looking to be more empowered in their birth and less 'just go along with whatever happens,'" said Shari Stone-Ulrich, a certified nurse midwife and midwife services clinical director at Best Start.

Many people want to avoid cesarean sections unless absolutely necessary, several midwives said. About 30% of births in California hospitals last year were via C-section, though that figure has dropped some in recent years, state data shows.

"For first-time moms, C-sections in hospitals are very high," said Miriam Singer, 32, who gave birth to her son, Eitan, at Best Start a few weeks ago. "So, knowing that the birth center is going to work with you and understand it's going to be a longer process and just make sure everything's going well, you really minimize your chances of having a C-section or an emergency situation."

Singer has three older children, ages 4, 6 and 9. Three of her kids were born in a free-standing birth center and one was born at home.

"Birth is just a very natural part of life, and it should be approached as something that is natural, and we should follow our body and listen to our body going through the process," she said. "I find the approach maybe in the hospitals a little bit more like it's an emergency."

As the coronavirus swept across California, families sought births outside hospitals for other reasons. Some didn't want to give birth in a setting where they feared contracting COVID-19. Others bristled at rules restricting when partners and family members could be present during labor.

"The home-birth practices were just filled to capacity immediately," said Kaleem Joy, a certified professional midwife and clinical director at California Birth Center in Rocklin. More recently, when some local hospitals announced they would again restrict visitors, "we went from having maybe six to 10 calls in a week to … I think we had a hundred in a day," Joy added.

State health data show positive outcomes for the vast majority of out-of-hospital births. However, those figures don't account for the fact that complicated, risky deliveries are, when feasible, transferred to a hospital.

A 2015 study in the New England Journal of Medicine found that planned out-of-hospital births in Oregon were associated with higher rates of perinatal death and neonatal seizures than hospital births, though such outcomes were rare in either setting. On the other hand, the study also found that planned out-of-hospital births led more often to unassisted vaginal deliveries and lower rates of obstetrical procedures.

Out-of-hospital birth rates ranged widely among California's urban and rural counties. These births were most prevalent in Nevada County, a rustic north state community known for its bohemian enclaves and passionate home-schooling movement. About 1 in 10 mothers gave birth at home last year in Nevada County. Four other largely rural Northern California counties also saw notably high rates: Tuolumne (6.8%), Mendocino (6.6%), Shasta (5.4%) and Humboldt (5.3%).

Among more populous counties with at least 2,500 births in 2020, the highest rates of out-of-hospital deliveries were in Sonoma (3.6%), Placer (2.9%) and Santa Barbara (2.1%). Rates were lowest in the largely agricultural Central Valley, particularly in Tulare, Merced, Solano, Fresno, San Joaquin and Kern counties.

The analysis also revealed racial and educational disparities between people giving birth in a hospital and those delivering at home or in a free-standing birth center last year.

Whites gave birth outside hospitals at a rate twice that of African Americans, about four times that of Hispanics and about six times that of Asians. In addition, people with a four-year college degree gave birth outside hospitals at a rate almost three times that of people without a four-year degree, state figures show.

Those numbers likely reflect long-standing socioeconomic disparities in healthcare that are exacerbated by the unwillingness of some insurance companies to cover births outside a hospital, said Katherine Hemple, a legislative consultant for the California Association of Licensed Midwives.

Also, Medi-Cal, the public insurance program for low-income Californians, typically does not cover at-home births, a policy that is the subject of intense debate. The program is more likely to cover deliveries in midwife-run birthing centers.

A client paying with cash for a delivery at the California Birth Center or Best Start Birth Center will be charged around $8,000, officials at those facilities said. By comparison, the average out-of-pocket cost for families nationwide with employer-based insurance giving birth in a hospital was about $4,500, according to a 2020 study in the journal Health Affairs.

Rosanna Davis, a certified professional midwife and president of the board of directors of the California Association of Licensed Midwives, said the preference for out-of-hospital births would increase even faster if the state and insurance companies offered more financial support for the choice.

"There are significant numbers of people who would choose midwife care," she said, "but the access is limited."

Phillip Reese is a data reporting specialist and an assistant professor of journalism at California State University-Sacramento.

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

Will 'Dr. Disinformation' Ever Face the Music?

KFF Health News, September 22, 2021

Three physicians in this article are members of the "Disinformation Dozen," a group of top superspreaders of COVID vaccine misinformation on social media.

This article was published on Wednesday, September 22, 2021 in Kaiser Health News.

By Victoria Knight  

Earlier this month, Dr. Rashid Buttar posted on Twitter that COVID-19 "was a planned operation" and shared an article alleging that most people who got the COVID vaccine would be dead by 2025.

His statement is a recent example in what has been a steady stream of spurious claims surrounding the COVID vaccines and treatments that swirl around the public consciousness. Others include testimony in June by Dr. Sherri Jane Tenpenny before Ohio state legislators that the vaccine could cause people to become magnetized. Clips from the hearing went viral on the internet. On April 9, 2020, Dr. Joseph Mercola posted a video titled "Could hydrogen peroxide treat coronavirus?" which was shared more than 4,600 times. In the video, Mercola said inhaling hydrogen peroxide through a nebulizer could prevent or cure COVID.

These physicians are identified as members of the "Disinformation Dozen," a group of top superspreaders of COVID vaccine misinformation on social media, according to a 2021 report by the nonprofit Center for Countering Digital Hate. The report, based on an analysis of anti-vaccine content on social media platforms, found that 12 people were responsible for 65% of it. The group is composed of physicians, anti-vaccine activists and people known for promoting alternative medicine.

The physician voices are of particular concern because their medical credentials lend credence to their unproven, often dangerous pronouncements. All three continue to hold medical licenses and have not faced consequences for their COVID-related statements.

But leaders of professional medical organizations increasingly are calling for that to change and urging medical oversight boards to take more aggressive action.

In July, the Federation of State Medical Boards, the national umbrella organization for the state-based boards, issued a statement making clear that doctors who generate and spread COVID misinformation could be subject to disciplinary action, including the suspension or revocation of their licenses. The American Board of Family Medicine, American Board of Internal Medicine and American Board of Pediatrics issued a joint statement Sept. 9 in support of the state boards' position, warning that "such unethical or unprofessional conduct may prompt their respective Board to take action that could put their certification at risk."

And the superspreaders identified by the center's report are not alone. KHN identified 20 other doctors who have made false or misleading claims about COVID by combing through published fact checks and other news coverage.

For example, at an Indiana school board meeting in August, Dr. Dan Stock claimed the surge in COVID cases this summer was due to "antibody mediated viral enhancement" from people receiving COVID vaccines. PolitiFact rated his claim "Pants on Fire" false.

Dr. Stella Immanuel, a member of a group America's Frontline Doctors, which has consistently made false statements about COVID, said in a video that went viral in July 2020 that masks weren't needed because COVID could be cured by hydroxychloroquine. Immanuel's website currently promotes a set of vitamins, as well as hydroxychloroquine and ivermectin, as COVID treatments.

Two of the doctors mentioned by name in this article responded to requests for comment. Mercola offered documents to rebut criticisms of his hydrogen peroxide COVID treatment and took issue with the center's "Disinformation Dozen" report methodology. Buttar defended his positions, saying via email that "the science is clear and anyone who contests it, has a suspect agenda at best and/or lacks a moral compass." He also pointed to data from the Centers for Disease Control and Prevention's Vaccine Adverse Event Recording System, considered inconclusive by many experts.

Since the onset of the COVID pandemic, misinformation has been widespread on social media platforms. And many experts blame it for undermining efforts to curb the coronavirus's spread. A recent poll showed that more than 50% of Americans who won't get vaccinated cited conspiracy theories as their reasons — for example, saying the vaccines cause infertility or alter DNA.

Some physicians have gained notoriety by embracing COVID-related fringe ideas, quack treatments and falsehoods via social media, conservative talk shows and even in person with patients. Whether promoting the use of ivermectin, an anti-parasitic drug for animals, or a mix of vitamins to treat COVID, doctors' words can be especially powerful. Public opinion polls consistently show that Americans have high trust in doctors.

"There is a sense of credibility that comes with being a doctor," said Rachel Moran, a researcher who studies COVID misinformation at the University of Washington. "There is also a sense they have access to insider info that we don't. This is a very confusing time, and it can seem that if anyone knows what I should be doing in this situation, it's a doctor."

While COVID is a novel and complicated infectious disease, physicians spreading misinformation generally have no particular expertise in infectious diseases. Dr. Scott Atlas, who endorsed former President Donald Trump's unproven statements about the course of the pandemic, is a radiation oncologist.

Traditionally, the responsibility of policing physicians has fallen to state medical boards. Beyond overseeing the licensing process, these panels investigate complaints about doctors and discipline those who engage in unethical, unprofessional or, in extreme cases, criminal activity. Any member of the public can submit a complaint about a physician.

"The boards are relatively slow and weak and it's a long, slow process to pull somebody's license," said Arthur Caplan, founding head of the Department of Medical Ethics at New York University. "In many states, they have their hands full with doctors who have committed felonies, doctors who are molesting their patients. Keeping an eye on misinformation is somewhat down on the priority list."

To date, only two doctors have reportedly faced such sanctions. In Oregon, Dr. Steven LaTulippe had his license suspended in December 2020 for refusing to wear a face mask at his clinic and telling patients that masks were ineffective in curbing the spread of COVID, and even dangerous. Dr. Thomas Cowan, a San Francisco physician who posted a YouTube video that went viral in March 2020 stating that 5G networks cause COVID, voluntarily surrendered his medical license to California's medical board in February 2021.

Dr. Humayun Chaudhry, president of the Federation of State Medical Boards, however, said it's possible some doctors could already be the subject of inquiries and investigations, since these actions are not made public until sanctions are handed down.

KHN reached out to the medical and osteopathic boards of all 50 states and the District of Columbia to see if they had received COVID misinformation complaints. Of the 43 that responded, only a handful shared specifics.

During a one-week period in August, Kansas' medical board received six such complaints. In all, the state has received 35 complaints against 20 licensees about spreading COVID misinformation on social media and in person. Indiana has received about 30 in the past year. South Carolina said it had about 10 since January. Rhode Island didn't share the number of complaints but said it has taken disciplinary action against one doctor for spreading misinformation, though it hasn't moved to suspend his license. (The disciplinary measures include a fine, a reprimand on the doctor's record and a mandate to complete an ethics course.) Five states said they had received only a couple, and 11 states reported receiving no complaints regarding COVID misinformation.

Confidentiality laws in 13 states prevented those boards from sharing information about complaints.

Social media companies have also been slow to take action. Some doctors' accounts — specifically those among the Disinformation Dozen — have been suspended, but others are still active and posting misinformation.

Imran Ahmed, CEO of the Center for Countering Digital Hate, said social media platforms often don't consistently apply their rules against spreading misinformation.

"Even when it's the same companies, Facebook will sometimes take posts down, but Instagram will not," Ahmed said, referring to Facebook's ownership of Instagram. "It goes to show their piecemeal, ineffective approach to enforcing their own rules."

A Facebook spokesperson said the company has removed over 3,000 accounts, pages and groups for repeatedly violating COVID and vaccine misinformation policies since the beginning of the pandemic. Buttar's Facebook and Instagram pages and Tenpenny's Facebook page have been removed, while Mercola's Facebook posts have been demoted, which means fewer people will see them. Tenpenny and Mercola still have Instagram accounts.

Part of the challenge may be that these doctors sometimes present scientific opinions that aren't mainstream but are viewed as potentially valid by some of their colleagues.

"It can be difficult to prove that what is being said is outside the range of scientific and medical consensus," said Caplan. "The doctors who were advising Trump — like Scott Atlas — recommended herd immunity. That was far from the consensus of epidemiologists, but you couldn't get a board to take his license away because it was a fringe opinion."

Even if these physicians don't face consequences, it is likely, experts said, that the public health will.

"Medical misinformation doesn't just result in people making bad personal and community health choices, but it also divides communities and families, leaving an emotional toll," said Moran, the University of Washington researcher. "Misinformation narratives have real sticking power and impact people's ability to make safe health choices."

Victoria Knight: vknight@kff.org, @victoriaregisk

Pages