Surprise-Billing Rule 'Puts a Thumb on the Scale' to Keep Arbitrated Costs in Check

KFF Health News, October 14, 2021

What's not clear is whether the new law will have the unintended consequences of shifting costs and leading to higher insurance premiums.

This article was published on Thursday, October 14, 2021 in Kaiser Health News.

By Julie Appleby 

Patients are months away from not having to worry about most surprise medical bills — those extra costs that can amount to hundreds or thousands of dollars when people are unknowingly treated by an out-of-network doctor or hospital.

What's not clear is whether the changes in law made by the No Surprises Act — which takes effect Jan. 1 — will have the unintended consequences of shifting costs and leading to higher insurance premiums.

Probably not, many policy experts told KHN. Some predict it may slightly slow premium growth.

The reason, said Katie Keith, a research faculty member at the Center on Health Insurance Reforms at Georgetown University, is that a rule released Sept. 30 by the Biden administration appears to "put a thumb on the scale" to discourage settlements at amounts higher than most insurers generally pay for in-network care.

That rule drew immediate opposition from hospital and physician groups, with the American Medical Association calling it "an undeserved gift to the insurance industry," while the American College of Radiology said it "does not reflect real-world payment rates" and warned that relying on it so heavily "will cause large imaging cuts and reduce patient access to care."

Such tough talk echoes comments made while Congress was hammering out the law.

The most recent guidance is the third issued to implement the law, which passed in late 2020 after a years-long battle. It was signed by then-President Donald Trump.

The No Surprises Act takes aim at a common practice: large, unexpected "balance bills" being sent to insured patients for services such as emergency treatment at out-of-network hospitals or via air ambulance companies. Some patients get bills even after using in-network facilities because they receive care from a doctor who has not signed on with an insurer's network.

Patients were caught in the middle and liable for the difference between what their insurer paid toward the bill and the often-exorbitant charges they received from the provider.

Once the law takes effect next year, patients will pay only what they would have if their care had been performed in network, leaving any balance to be settled between insurers and the out-of-network medical providers. The law also gives insurers and providers 30 days to sort out discrepancies.

After that, unsettled bills can enter "baseball-style" arbitration, in which both sides put forth their best offer and an arbitrator picks one, with the loser paying the arbitration cost, which the rule sets for next year as between $200 and $500.

Uninsured patients who are billed more than $400 over an upfront estimate of the cost of their care may also bring cases to arbitration for a $25 administrative fee.

Businesses, like government services companies or those that review coverage disputes, can start applying now for certification as arbitrators. The rule estimates that about 50 will be selected by the three agencies overseeing the program, the Departments of Health and Human Services, Labor and Treasury, after showing "expertise in arbitration, healthcare claims experience, managed care, billing and coding, and healthcare law." The rule also spells out that either party can object to a chosen arbitrator, and the one that is selected cannot be associated with an insurer or medical provider.

But which price to pick in arbitration?

The new rule specifies that the arbitrator generally should pick the amount closest to the median in-network rate negotiated by insurers for that type of care. Other factors, such as the experience of the provider, the type of hospital or the complexity of the treatment, can be considered in some circumstances, but not given equal weight.

By contrast, some of the more than a dozen state laws taking aim at surprise bills allow arbitrators to consider higher rates, such as billed charges set by hospitals or doctors, rather than negotiated rates, which potentially drive up spending.

A recent study, for example, found that in New Jersey — which has different arbitration rules than what is being set up for the federal program — cases were settled at a median of 5.7 times higher than in-network rates for the same services.

Unlike New Jersey, the federal government is specifically barring consideration of the highest amounts — the billed charges — and the lowest payment amounts, including those from Medicaid and Medicare programs.

"This seems likely to reduce premiums in addition to protecting patients from surprise bills," said Loren Adler, associate director of the University of Southern California-Brookings Schaeffer Initiative for Health Policy, who co-authored the New Jersey study.

Still, the law's impact on premiums is open to debate. Keith doubts they will change either way, although Adler thinks the slowdown in premium growth would be small.

Even the final rule says "there is uncertainty around how premiums will be ultimately affected" with much depending on how often disputed bills go to arbitration.

The latest rule cited a Congressional Budget Office estimate that provisions in the No Surprises Act could reduce premium growth by 0.5% to 1% in most years, but also noted an estimate from the Centers for Medicare & Medicaid Services that premiums  could slightly increase. Neither study isolated the effect of the arbitration guidelines from the rest of the statute.

Adler noted that relying heavily on the median in-network price likely means lower payments as compared with other measures but, still, "by definition a median is what half of doctors get paid, so this could, in theory, raise that for the other half."

What's likely, health policy experts said, is that the new law will prompt more providers to join insurer networks.

Some physicians — most often, emergency room doctors, anesthesiologists and radiologists — have avoided signing contracts with insurers. Instead, they typically set charges above the level of insurers' reimbursement and sent surprise bills to patients for the difference.

The rule undercuts the incentive to use this business model.

It makes it "pretty clear" that hospitals, physicians, air ambulances and other medical professionals "should not count on staying out of network and then trying to use the federal process to capture higher reimbursement," said Keith.

Some medical societies and advocacy groups predicted the law could have the opposite effect.

Insurers will use the disputes to "drive down payment to the point that it is no longer feasible for many providers to take that, or any insurance," warned Katie Keysor, senior director of economic policy for the American College of Radiology, in an emailed statement.

Adler said that argument doesn't fly when looking across the experience of states with similar laws. (Those state rules don't apply to many types of job-based health insurance, but the federal rule will.)

"Every single surprise billing debate has done the opposite and pushed more people into the network," he said.

Whether a group signs a contract with an insurer may matter less in the future, he said.

Once the law takes effect, "it's completely irrelevant whether an emergency room doctor is in network or not," he said. "For all intents and purposes, that doctor is in network. The patient will pay the in-network cost sharing and there is a price the provider has to accept, and the insurer has to pay."

Julie Appleby: jappleby@kff.org, @Julie_Appleby

Reluctant Localities Are Being Dragged Into Court to Fix Sidewalks for People With Disabilities

KFF Health News, October 13, 2021

In Baltimore and many other communities across the U.S., there has been widespread noncompliance with parts of the ADA.

This article was published on Wednesday, October 13, 2021 in Kaiser Health News.

By Maureen O'Hagan   

From her Baltimore dining room, Susan Goodlaxson can see her neighbor gardening across the street. But while other neighbors stop to chat, Goodlaxson just watches from the window. She uses a wheelchair, and there isn't a single curb ramp on her block.

If the 66-year-old wanted to join, she'd have to jump her wheelchair down the 7½-inch curb and risk a fall. Ditto if she wanted to wheel over to the library, a trip that would require riding in the street to avoid rampless curbs and broken sidewalks.

"I don't feel like it's asking too much to be able to move your wheelchair around the city," she said.

Federal law backs her up. Since 1990, the Americans With Disabilities Act has required governmental entities to provide people with disabilities access to programs and services enjoyed by their nondisabled peers. That includes sidewalks and curb ramps that make it possible to safely cross the street.

In Baltimore and many other communities across the U.S., there has been widespread noncompliance with this part of the law.

"An awful lot of [communities] have either disregarded their obligations under the ADA or made it the last priority," noted Tom Stenson, a lawyer with Disability Rights Oregon, a nonprofit advocacy group. "There's a culture throughout America of not taking the needs of people with disabilities seriously."

In Baltimore, just 1.3% of curb ramps meet federal standards, according to the city's own figures. In Oregon, about 9% of corners maintained by the state transportation department are compliant. San Jose, California, counted 27,621 corners with faulty or nonexistent curb ramps. Boston estimates fewer than half of its curb ramps are compliant.

In recent years, there's been a flurry of class-action lawsuits, including one filed against Baltimore in June, with Goodlaxson among the plaintiffs.

Philadelphia was sued in 2019 over the condition of its sidewalks. Chicago was sued the same year for failure to install audible pedestrian signals, more than a decade after settling a suit over curb ramps. In 2018, Atlanta was sued. A survey there determined that only 20% of sidewalks were in sufficient condition to be used by people in wheelchairs or motorized scooters and about 30% had curb ramps. Seattle settled a class-action suit in 2017. San Francisco and Long Beach, California, were sued in 2014 to make their sidewalks more accessible to wheelchairs.

The city of New York and its transit authority have faced repeated major ADA lawsuits, some alleging the same lack of access for people with disabilities that was supposed to be addressed in a lawsuit that was filed in the 1990s and later settled.

Los Angeles settled what is believed to be the largest of these suits in 2015. Its problems with sidewalks and curb ramps were so widespread that the city estimated it would cost $1.4 billion and take 30 years to get into compliance. In the years leading up to the suit, the city wasn't allocating money for sidewalk repairs, for the ADA or otherwise, even while paying out millions in injury claims.In all, hundreds of jurisdictions have faced lawsuits or entered settlement agreements after failing to meet ADA requirements for pedestrians and mass transit users.

The sheer number of noncompliant sidewalks, curb ramps, pedestrian signals and subway stations illustrates the challenges for people with disabilities. It also leaves cities in a legal and financial squeeze, with the average curb ramp costing between $9,000 and$19,000. When the court requires a jurisdiction to build thousands of them to catch up, it can strain budgets.

The ADA and the 1973 Rehabilitation Act resulted in significant changes that improved access and accommodations for people with disabilities. The ADA is clear that people with disabilities have the same right to pedestrian infrastructure as anyone else.

There are requirements covering a curb ramp's width, slope and other specifications. Even a 1-inch lip can be too high for a wheelchair user to navigate. A slope that is a few degrees too steep can tip someone to the ground. Sidewalks that are crumbling, pothole-filled or otherwise obstructed — with utility poles, for example — force wheelchair users into the street for a dangerous ride.

No one expected the ADA to fix all these problems immediately. Under the law, new sidewalks must be built for accessibility. As for existing sidewalks, a federal appeals court in 1993 ruled that curb ramps must be installed or regraded when the road is altered — say, when it's repaved.

Yet by 1999 it was clear many jurisdictions were ignoring the law. The U.S. Department of Justice began enforcement efforts, entering into settlement agreements with more than 200 noncompliant jurisdictions representing every state since 2000.

Still, compliance still lags.

Officials in Baltimore, New York and Los Angeles declined to comment for this article. Tony Snyder, manager of the Oregon Department of Transportation's ADA program, said siloed funding sources, strict regulations and costs have been among the hurdles over the years.

"It wasn't that ODOT doesn't value accessibility," he said. While fewer than 10% of the state's ramps meet standards, he said, a lot of noncompliant ramps are nonetheless "usable."

Kelly Lynch, deputy director and general counsel for the Montana League of Cities and Towns, an association that represents 127 municipal governments, agreed that costs can add up. She's been working to help fellow Montanans —and, she hopes, officials in other jurisdictions across the country through the National League of Cities — find a path toward full accessibility, even if the steps are incremental.

Some changes, including educating road crews on the rules, are relatively simple. But a bigger problem is a widespread lack of spending on the nation's infrastructure. "Our streets are falling apart, and so are our sidewalks," Lynch said.

In August, the Senate defeated an amendment by Sen. Tammy Duckworth (D-Ill.) to a $1 trillion infrastructure bill that would have required state and local entities to describe how they would use federal dollars to improve accessibility for people with disabilities and for underserved communities. Sen. Pat Toomey (R-Pa.) called Duckworth's amendment "politically correct virtue signaling" and argued that transit agencies don't need that kind of federal oversight.

On top of the broader infrastructure issues, many officials don't fully understand the ADA or its requirements, Lynch believes. And as the mother of a disabled son, she also said there's another big factor at play: "People still discriminate against people with disabilities."

As for Baltimore, Goodlaxson said she repeatedly called the city asking for curb cuts and sidewalk repairs. She remembers a crew coming to look at the sidewalks — and then nothing happening. Advocacy organizations tried to negotiate with city officials, hoping to get Baltimore's infrastructure brought into compliance on a timetable. When that didn't work, they filed suit.

Most of these kinds of ADA cases begin similarly, with negotiations long before lawsuits. Some jurisdictions settled quickly and worked hard at improvements. Other cases go less smoothly. Oregon's transportation department, which was also sued, is in danger of missing its construction deadlines under the settlement. Some repairs had to be redone because they still fell short of ADA requirements.

Sometimes cities try to get cases thrown out of court by pointing to the 1993 appeals court decision and arguing there's no evidence the road has been altered since then, so ADA requirements haven't kicked in. In New York, the transit authority argues in an ongoing lawsuit that while wheelchair users can't ride, say, three-quarters of the city's subways because there are no elevators, they can instead take the bus.

Some jurisdictions fight bitterly. Los Angeles spent five years in court before agreeing to settle. Linda Dardarian, one of the plaintiff's attorneys, said cities don't fully recognize sidewalk and curb ramp accessibility as a civil right. "They have viewed it as just another maintenance obligation, [like] grooming street trees."

When the case was settled, the judge ordered Los Angeles to pay nearly $12 million to cover the other side's legal fees and costs, on top of the estimated $1.4 billion it will cost to come into compliance.

Under these settlements, repairs often stretch a decade or more, and the city or town typically must pay for surveys, measurements and disability consultants to ensure compliance.

From the plaintiffs' point of view, the challenge of these lawsuits is that there isn't a huge hammer to hold governments accountable.

"If you don't build the ramps, the penalty is you have to build the ramps," said Stenson of Disability Rights Oregon, which provided legal representation to a plaintiff in the Oregon transportation department suit.

For those who can easily get around town, the issue can be invisible.

Goodlaxson didn't see the problem until she began using a wheelchair five years ago, after surgery for a brain tumor. She remembers seeing people riding their wheelchairs in the street, thinking, "that doesn't look safe. But I didn't give it any more thought."

Now, she realizes "people are terrified, but they can't do it any other way."

Health Industry Wields Power in California's High-Stakes Battle to Lower Healthcare Costs

KFF Health News, October 13, 2021

Lobbyist used their political clout and close ties with the governor to devise a friendlier alternative that doctors, hospitals and insurance companies could live with.

This article was published on Wednesday, October 13, 2021 in Kaiser Health News.

By Angela Hart and Samantha Young  

SACRAMENTO — Gavin Newsom put California's healthcare industry on notice when he was a candidate for governor, vowing in 2018 to go after the insurance companies, doctors and hospitals that leave many Californians struggling with enormous medical bills and rising insurance premiums.

He pledged to lead California's single-payer movement, a high-stakes liberal dream that would eliminate private health insurance and slash how much providers are paid. The tough rhetoric continued after he was elected, when Newsom told insurers to "do their damn job" to improve mental health treatment or face fines, and he vowed to cut the healthcare industry's soaring revenues.

"We've got to get serious about reducing healthcare costs," the first-term Democrat said in January 2020 as he unveiled his proposal to establish an Office of Healthcare Affordability that would do the unthinkable in a system powered by profits: set caps on healthcare spending and require doctors and hospitals to work for less money. "We mean business."

Industry leaders were rattled. But rather than mobilize a full-throttle defense to sink Newsom's effort to regulate them, they have used their political clout and close ties with the governor to devise a friendlier alternative that doctors, hospitals and insurance companies could live with.

When Newsom ultimately drafted legislation for the office, he took an idea healthcare executives had pitched and made it his own: Instead of capping prices or cutting revenues, he would allow industry spending to grow — but with limits.

Political infighting killed the legislation this year, but it is expected to come back in January and spark one of next year's blockbuster healthcare battles.

"They're fearful of what might happen to them, and they're trying to protect their interests because they're threatened," David Panush, a veteran Sacramento health policy consultant, said about healthcare industry players. They know "there's blood in the water and the sharks are coming."

If Newsom's plan to rein in healthcare spending succeeds, it could provide him some political cover as he campaigns for reelection next year, giving him a major healthcare win even as he sidesteps progressive demands such as creating a single-payer system.

But it could also cement the power of an industry that continues to wield immense influence — negotiating behind the scenes to protect its massive revenues and secure exemptions and side deals in exchange for its support.

"Every time we try to do something to reduce healthcare costs, it meets with huge opposition," said state Assembly member Jim Wood (D-Santa Rosa), head of the Assembly Health Committee, who is working closely with the Newsom administration on this proposal.

Industry power players have only pushed back harder as lawmakers have tried to take them on, Wood said. "Anybody or anything that disrupts the status quo is met with huge resistance and huge resources to fight it," he said.

◆◆◆

When Newsom took office in 2019, he knew public sentiment was turning against the healthcare industry. On average, healthcare costs were around $11,600 per person that year, up from $4,600 in 1999, according to federal data. In California, hospitals account for the biggest share of spending, nearly one-third, while 20% of healthcare dollars goes to doctors.

California consumers are demanding action, with 82% of state residents saying it's "extremely" or "very" important for the governor and legislature to make healthcare more affordable, according to a 2021 poll from the California Healthcare Foundation.

Much of Newsom's tough talk on industry spending came early in his term. "We're going to create specific cost targets for all sectors to achieve, and we are going to assess penalties if they don't achieve those targets," Newsom said in January 2020. "If that didn't wake up members of the system, I don't know what will."

Newsom's wake-up call came on the heels of tense legislative debates on bills that would have empowered the state to set healthcare prices and created a single-payer system. The measures gained surprising momentum but ultimately buckled under opposition from healthcare giants.

Then the COVID-19 crisis hit and propelled the recall effort to oust him from office — and the wake-up call was met with a slap of the snooze button. The governor and his health industry allies nestled closer. Just as he needed them to be the state's front line of defense, they needed him to keep hospitals from overflowing, to secure protective gear and to push vaccinations.

Healthcare titans became regular fixtures in Newsom's orbit. His calendars, obtained by KHN, show that doctors, hospitals and health insurance leaders have routinely received access to the governor.

Carmela Coyle, head of the California Hospital Association, stood beside Newsom at the state emergency operations center in the early days of the COVID crisis, and Paul Markovich, CEO of Blue Shield of California, obtained a lucrative no-bid state vaccination contract to implement Newsom's vaccination effort.

The coziness of the industry's relationship with Newsom burst into public view in late 2020 when he was photographed dining at the ritzy French Laundry restaurant with Dustin Corcoran and Janus Norman, the CEO and top lobbyist, respectively, of the state doctors' lobby, the California Medical Association.

"There is no possible way we could have come out of this COVID crisis where the healthcare industry was given so much power without influence coming along with that," said Carmen Balber, executive director of the advocacy group Consumer Watchdog.

Newsom did not respond to questions about the industry's influence, but spokesperson Alex Stack said his proposal to regulate healthcare spending "is a priority for this administration, and we look forward to continuing to work on this issue to get it done."

Doctors and Blue Shield have given Newsom millions of dollars to support his political career over many years, including a $20 million donation in September 2020 from Blue Shield for his homelessness initiatives.

The recall effort earlier this year only solidified Newsom's relationship with healthcare executives. Industry groups wrote checks to the California Democratic Party, which fought to keep Newsom in office. It received $1 million each from Blue Shield and the hospital lobby and $875,000 from the doctors' lobby, according to state campaign finance records.

◆◆◆

Though Newsom vowed to go after the industry, he hasn't aggressively taken it on, and healthcare executives and lobbyists continue to wield their influence as they shape the debate over the Office of Healthcare Affordability.

That could put Newsom in a political bind as he runs for reelection — first in the June 2022 primary and then the November general election — because he will face intense opposing political pressure from liberal Democrats who want him to keep his campaign promise and adopt single-payer.

Health and political experts say Newsom can help alleviate that pressure by adopting a strict law going after spiraling healthcare spending.

"This issue isn't going away — it does need to be addressed," acknowledged Corcoran. The push to control costs "should be uncomfortable for everybody, but not horribly so."

But it won't be easy. After powerful industry leaders joined forces with organized labor and consumer advocates to propose a plan to the governor, they jammed negotiations with their demands, splintering the coalition and killing the effort this year.

Coyle, with the hospital association, had left the coalition early out of concern that hospitals were the primary target, and approached the Newsom administration independently. She is also asking Newsom to relax stringent earthquake safety standards for hospitals.

Corcoran wants to exempt "small" doctor practices — which he defines as practices with up to 100 doctors — from regulation, arguing that restrictive government cost controls could put them out of business, leading to increased industry consolidation and higher prices.

"The goal posts were constantly shifting," said Yasmin Peled, a lobbyist for the advocacy group Health Access California, which was involved in negotiations. "The asks were constantly changing."

Before negotiations completely broke down, Newsom embraced the idea floated by Coyle: The state should control growth, not impose revenue cuts. And it should not focus only on hospitals, but apply to all healthcare sectors, including doctors and insurers. (The pharmaceutical industry would not be subject to the cost control provisions of the measure because of restrictions in federal law, according to Wood's office.)

With battle lines drawn, industry groups are poised for a major fight next year as Newsom and state Democratic lawmakers muscle through legislation. Their primary goal will be to protect their interests, said Mark Peterson, a professor of public policy, political science and law at UCLA.

"There's no question this industry has power. The real question is what they do with it," Peterson said. "They're getting wins, and important ones."

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

Angela Hart: ahart@kff.org, @ahartreports

Samantha Young: syoung@kff.org, @youngsamantha

Perspective: A Wrenching Farewell -- Bidding Adieu to My Primary Care Doctor After Nearly 30 Years

KFF Health News, October 12, 2021

It feels like an essential lifeline is being severed. I'll miss him dearly.

This article was published on Tuesday, October 12, 2021 in Kaiser Health News.

By Judith Graham  

I hadn't expected the tears.

My primary care doctor and I were saying goodbye after nearly 30 years together.

"You are a kind and a good person," he told me after the physical exam, as we wished each other good luck and good health.

"I trust you completely — and always have," I told him, my eyes overflowing.

"That means so much to me," he responded, bowing his head.

Will I ever have another relationship like the one with this physician, who took time to ask me how I was doing each time he saw me? Who knew me from my first months as a young mother, when my thyroid went haywire, and who since oversaw all my medical concerns, both large and small?

It feels like an essential lifeline is being severed. I'll miss him dearly.

This isn't my story alone; many people in their 50s, 60s and 70s are similarly undergoing this kind of wrenching transition. A decade from now, at least 40% of the physician workforce will be 65 or older, according to data from the Association of American Medical Colleges. If significant numbers of doctors retire, as expected, physician shortages will swell. Earlier this year, the AAMC projected an unmet need for up to 55,200 primary care physicians and 86,700 specialists by 2033, amid the rapid growth of the elderly population.

Stress from the COVID pandemic has made the outlook even worse, at least in the near term. When the Physicians Foundation, a nonprofit research organization, surveyed 2,504 doctors in May and June, 61% reported "often experiencing" burnout associated with financial and emotional strain. Two percent said they had retired because of the pandemic; another 2% had closed their practices.

Twenty-three percent of the doctors surveyed said they'd like to retire during the next year.

Baby boomers, like me, whose medical needs are intensifying even as their longtime doctors bow out of practice, are most likely to be affected.

"There's a lot of benefit to having someone who's known your medical history for a long time," especially for older adults, said Dr. Janis Orlowski, AAMC's chief healthcare officer. When relationships with physicians are disrupted, medical issues that need attention can be overlooked and people can become less engaged in their care, said Dr. Gary Price, president of the Physicians Foundation.

My doctor, who's survived two bouts of cancer, didn't mention the pandemic during our recent visit. Instead, he told me he's turning 75 a week before he closes the practice at the end of October. Having practiced medicine for 52 years, 40 as a solo practitioner, "it's time for me to spend more time with family," he explained.

An intensely private man who's averse to publicity, he didn't want his name used for this article. I know I'm lucky to have had a doctor I could rely on with complete confidence for so long. Many people don't have this privilege because of where they live, their insurance coverage, differences in professional competence, and other factors.

With a skeletal staff — his wife is the office manager — my doctor has been responsible for 3,000 patients, many of them for decades. One woman sobbed miserably during a recent visit, saying she couldn't imagine starting over with another physician, he told me.

At one point, when my thyroid levels were out of control, I saw my physician monthly. After my second pregnancy, when this problem recurred, I brought the baby and her toddler brother in a double stroller into the exam room. One or the other would often cry sympathetically when he drew my blood.

I remember once asking when a medical issue I was having — the flu? a sore throat? — would resolve. He pointed upward and said, "Only Hashem knows." A deeply religious man, he wasn't afraid to acknowledge the body's mysteries or the limits of medical knowledge.

"Give it a few days and see if you get better," he frequently advised me. "Call if you get worse."

At each visit, my doctor would open a large folder and scribble notes by hand. My file is more than 4 inches thick. He never signed up for electronic medical records. He's not monetizing his practice by selling it. For him, medicine was never about money.

"Do you know the profit margins this hospital makes?" he asked at our last visit, knowing my interest in healthcare policy and finance. "And how do you think they do it? They cut costs wherever they can and keep the nursing staff as small as possible."

Before a physical exam, he'd tell a joke — a way to defuse tension and connect with a smile. "Do you know the one about …" he'd begin before placing his fingers on my throat (where the thyroid gland is located) and squeezing hard.

Which isn't to say that my doctor was easygoing. He wasn't. Once, he insisted I go to the emergency room after I returned from a long trip to South Asia with a very sore leg and strange pulsing sensations in my chest. An ultrasound was done and a blood clot discovered.

The young doctors in the ER wanted to give me intravenous blood thinner and send me home with a prescription. My doctor would have nothing of it. I was to stay in the hospital overnight and be monitored every few hours, efficiency and financial considerations be damned. He was formidable and intransigent, and the younger physicians backed down.

At that last meeting, my doctor scribbled the names of two physicians on a small sheet of paper before we said our goodbyes. Both would take good care of me, he said. When I called, neither was accepting new patients. Often, I hear this from older friends: They can't find physician practices that are taking new patients.

Price, who's 68, went through this when his family physician announced she was retiring and met with him in January to work out who might take over his care. Price was admitted into the practice of a younger physician with a good reputation only because he asked a medical colleague to intervene on his behalf. Even then, the first available appointment was in June.

Orlowski had a similar experience two years ago when searching for a new primary care doctor for her elderly parents. "Most of the practices I contacted weren't accepting new patients," she told me. It took six months to find a physician willing to see her parents — again, with the help of medical colleagues.

I'm lucky. A friend of mine has a physician daughter, part of an all-women medical practice at a nearby university hospital. One of her colleagues had openings and I got on her schedule in December. My friend's daughter recommends her highly.

Still, it will mean starting over, with all the dislocation that entails. And these transitions are hard, for patients and doctors alike.

Several weeks ago, I received a letter from my doctor, likely his last communication, which I read with a lump in my throat.

"To my beloved patients," he wrote. "I feel so grateful for the opportunity to treat you and develop relationships with you and your families that I will always treasure. … I bid you all adieu. I hope and pray for your good health. I will miss each and every one of you and express to you my appreciation for so many wonderful years of doing what I love, caring for and helping people."

We're eager to hear from readers about questions you'd like answered, problems you've been having with your care and advice you need in dealing with the healthcare system. Visit khn.org/columnists to submit your requests or tips.

Judith Graham: khn.navigatingaging@gmail.com, @judith_graham

6 Months to Live or Die: How Long Should an Alcoholic Liver Disease Patient Wait for a Transplant?

KFF Health News, October 12, 2021

A widespread practice requires patients with alcoholic liver disease to complete a period of sobriety before they can get on the waiting list for a liver.

This article was published on Tuesday, October 12, 2021 in Kaiser Health News.

By Aneri Pattani   

When he arrived at the rehab facility in North Kansas City, Missouri, they sent him directly to the adjoining hospital. There, Gorzney, then 50, and his family learned he had severe alcoholic hepatitis, an inflammation of the liver typically associated with excessive alcohol use.

Gorzney had been drinking heavily on and off for years and, by February 2020, was having as many as a dozen drinks a day. His only chance of survival was a liver transplant, doctors said.

"So let's do that," his daughter Cameron Gorzney, now 22, told them. She was ready for anything that would save her dad, the man who had coached her softball team until high school and later cheered from the stands at every game.

But Gorzney wasn't eligible for a transplant, the doctors said. He hadn't been six months sober.

In the U.S., a widespread practice requires patients with alcoholic liver disease to complete a period of sobriety before they can get on the waiting list for a liver.

This informal policy, often called "the 6-month rule," can be traced to the 1980s. The thinking then — and among proponents of the practice today — was that six months of abstinence gave a patient's liver time to heal and, thus, avoid a transplant. If that didn't work, the patient would have proven they can stay sober and would not return to drinking after a transplant.

However, a landmark European study published in 2011 and several American studies in the decade since have exposed flaws in that premise. Six months of abstinence is not a good predictor of long-term sobriety, and for people with conditions like Gorzney's, more than half die within that time. Now, as the understanding of addiction evolves — viewing it as a disease rather than a personal failing — many surgeons and families say the six-month hold unfairly penalizes those with substance use disorder. And with alcoholic liver disease rising among young adults and pandemic-related drinking exacerbating those numbers, it has become a pressing concern.

"We have to move beyond denying people lifesaving therapy because we think they don't deserve it," said Dr. Andrew Cameron, head of the liver transplant program at Johns Hopkins Medicine in Baltimore. Doctors don't withhold treatment from people with diabetes who are obese or people with sexually transmitted infections who had unprotected sex, he said.

Cameron and his colleagues published a study this August, which found that among patients with alcoholic liver disease who were made to wait six months and those who were not, about 20% in each group returned to drinking one year after their transplants. That means about 80% stayed sober, regardless of how long they abstained from alcohol before the surgery.

"There was nothing at all helpful or predictive about a six-month waiting period," Cameron said.

No national regulation determines how long a patient needs to be abstinent before being added to the waitlist; each transplant center sets its own policies. As of 2019, only about one-third of liver transplant hospitals in the U.S. had performed a transplant without one. Patients who don't live near those hospitals — or don't have the knowledge and resources to get to them — can die without ever making it onto the waitlist, Cameron said.

On the other hand, some physicians worry abandoning the six-month rule could overwhelm the limited supply of donor organs. With nearly 12,000 people on the waiting list for a liver, it's crucial to ensure patients who receive transplants are ready to care for themselves and the "gift of the donated organ," said Dr. Kenneth Andreoni, a transplant surgeon and past president of the United Network for Organ Sharing, which manages the nation's transplant system. (UNOS determines who ultimately receives a donor organ, but it does not determine who can or cannot be put on the waitlist.)

Since 2016, alcoholic liver disease has been the most commonly identified justification for a liver transplant, and since these patients often have dire prognoses with little time to live, they can quickly jump to the top of the waiting list, surpassing those with liver cancer or other diseases. When one patient receives a liver, "someone else is not getting that organ," Andreoni said. "It's just math."

He said more long-term research is needed. "If all these people [who receive transplants without the waiting period] are doing great and living 15 years, then that's the right answer." Only time and statistics will tell.

Dr. Josh Levitsky, treasurer of the American Society of Transplantation, said some hospitals may worry that transplanting organs into patients with a higher risk of relapse could result in poor outcomes and threaten their accreditation or insurance contracts.

In fact, some insurance companies require patients to provide documentation of a sobriety period before agreeing to cover the cost of surgery. A study examining Medicaid policies in 2017 found 24 states had such policies, while 14 did not. (Twelve states didn't perform any liver transplants that year.)

In Brian Gorzney's case, insurance wasn't the issue. Finding a hospital to say yes was.

When the team at North Kansas City Hospital, which is not a transplant center, suggested Gorzney look into hospice options, his family refused. They took him across state lines to the University of Kansas Health System for a second opinion.

There, Gorzney's daughter Cameron, his ex-wife (Cameron's mom), his then-girlfriend and his sister teamed up to explain why they knew Gorzney would stay sober and care for a new liver responsibly. He had held steady jobs throughout his life, they said. He had never had a DUI. He coached his daughters' softball teams and was like a father figure to his sister, who is 10 years younger. He was headed to rehab before this crisis started, and he had a supportive family to help him sustain sobriety after surgery.

But, ultimately, the hospital's transplant committee said no.

In a statement about the general transplant process, Dr. Ryan Taylor, medical director of liver transplantation at the hospital, said each candidate is reviewed by a committee of more than 30 members. "High risk transplant patients may be required to complete 6 months of counseling to demonstrate an ongoing commitment to sobriety," he wrote, but there is an "expedited pathway" for people with alcoholic hepatitis who also have a "low risk for recidivism."

Gorzney was considered for this pathway, but the committee didn't approve him, his daughter Cameron said.

She was devastated by the no. But she's stubborn, she said, just like her dad. So, she and the rest of the family frantically scoured news articles and academic studies and called transplant hospitals across the country for another option.

"My dad was really deteriorating each day," she said.

They finally settled on the University of Iowa, where Cameron Gorzney had attended her first year of college and heard of its renowned medical system. The family made their case on Gorzney's behalf again. This time, they got a yes. The family's group text exploded, Cameron recalled.

Dr. Alan Gunderson, medical director of liver transplantation at the University of Iowa Hospitals and Clinics, said most hospitals that allow transplants without the six-month wait look at similar factors: the patient's medical need, financial stability, social support, understanding of their addiction and desire to recover. But the subjectivity of these measures means different transplant committees can come to different decisions.

In a letter to Gorzney, the Iowa transplant team explained they'd typically recommend a six-month waiting period but were approving him for the waiting list immediately because he wouldn't survive otherwise. In return, Gorzney agreed to attend counseling and treatment programs after the transplant.

Within 24 hours of being put on the waitlist, Gorzney received a new liver.

Today, more than a year and a half later, Gorzney, 52, is still sober and embracing the "opportunity to be somebody that I haven't been in a while," he said.

He and his girlfriend are engaged, and he's grateful to see his daughters, Cameron and Carson, grow into young adults. A lifelong Illinois Fighting Illini football fan, he even considers rooting for the Iowa Hawkeyes now.

But it worries him that the six-month rule, which led his family to travel to three hospitals in three states, still stymies others.

"People are, unfortunately, passing away … not knowing that there may be other options for them because they don't have a support group that I had that was aggressive enough and strong enough to reach out and not accept no on the first response they got."

Aneri Pattani: apattani@kff.org, @aneripattani

The Public Backs Medicare Rx Price Negotiation Even After Hearing Both Sides' Views

KFF Health News, October 12, 2021

The argument that drug companies need to charge high prices to develop new drugs does little to change that sentiment.

This article was published on Tuesday, October 12, 2021 in Kaiser Health News.

By Amanda Michelle Gomez  

As Congress debates cutting prescription drug costs, a poll released Tuesday found the vast majority of adults — regardless of their political party or age — support letting the federal government negotiate drug prices for Medicare beneficiaries and those in private health insurance plans.

The argument that pharmaceutical companies need to charge high prices to invest in research and develop new drugs does little to change that sentiment, according to the new KFF poll. Most respondents agreed the negotiation strategy is needed because Americans pay more than people in other countries and because companies' profits are too high.

Various polls, in addition to KFF's, have found the plan to allow Medicare to negotiate prescription drug prices to be very popular. (KHN is an editorially independent program of KFF.) The policy has polled favorably for at least the past six years, according to Ashley Kirzinger, associate director of public opinion and survey research at KFF.

Still, congressional lawmakers have yet to reach a consensus on whether to include such a provision in the major reconciliation bill aimed at funding President Joe Biden's domestic policy agenda and enhancing social programs. Republican lawmakers generally oppose efforts to impose price restraints on prescription drugs. Democrats in the House are pushing a bill that would allow changes in Medicare drug policies, including negotiations of prices for some medications. The bill passed the House last year but has run into opposition this fall. A few moderate Democrats have introduced a narrower approach.

The KFF poll found 83% of the public — including 91% of Democrats, 85% of Independents, 76% of Republicans and 84% of seniors — initially favored the federal government negotiating lower drug prices for both Medicare and private insurance. These opinions were relatively unchanged by the arguments in favor or against the policy, the poll found. Even Republican support remained relatively steady, at 71%, after hearing concerns about how negotiations could upend the pharmaceutical industry. However, the share of Republicans who "strongly" favored the plan dipped from 44% to 28%.

For example, large majorities regardless of party identification and age found the following argument convincing: "Those in favor say negotiation is needed because Americans pay higher prices than people in other countries, many can't afford their prescriptions, and drug company profits are too high."

A third, including a slight majority of Republicans 65 or older, found the following argument convincing: "Those opposed say it would have the government too involved and will lead to fewer new drugs being available in the future."

In addition, 93% — including 90% of Republicans — said that even if prescription prices were lower "drug companies would still make enough money to invest in the research needed to develop new drugs," while just 6% said "drug companies need to charge high prices in order to fund the innovative research necessary for developing new drugs."

These findings represent a change from a June KFF poll, which found attitudes changed after hearing assertions that allowing the federal government to negotiate Medicare prescription drug prices could lead to less research and development or limited access to newer prescriptions.

"This [latest] poll did a better job of representing what's happening in the debate," said Kirzinger. "The public is hearing both sides of the argument."

Pharmaceutical companies have spent a lot of money on messaging. PhRMA, the industry's trade group, launched a seven-figure ad campaign against legislation to lower drug prices through negotiation. Pharmaceutical companies have spent the most of any single industry on federal lobbying this year and donated sizable sums to House Democrats opposed to the plan, according to Open Secrets.

But the Medicare drug-pricing negotiation plan outlined in H.R. 3 (or the "Elijah E. Cummings Lower Drug Costs Now Act") is estimated to save roughly $500 billion in federal spending for Medicare drugs over 10 years, according to a Congressional Budget Office estimate. Many Democrats hope to use the savings to expand coverage in Medicare and Medicaid as they piece together their larger spending plan.

The KFF poll also found most people have little or no confidence that Biden or Congress will "recommend the right thing" for the country on prescription drug prices. The vast majority expressed the same about drug companies. A slight majority reported confidence in what AARP recommends — and the advocacy group backs the negotiated Medicare prices.

The KFF Health Tracking Poll was conducted from Sept. 23 to Oct. 4 among a nationally representative sample of 1,146 adults, including an oversample of adults 65 and older. The margin of sampling error is plus or minus 4 percentage points for the full sample.

Amanda Michelle Gomez: amandag@kff.org, @amanduhgomez

Community Clinics Shouldered Much of the Vaccine Rollout. Many Haven't Been Paid.

KFF Health News, October 11, 2021

Clinics are owed tens of millions of dollars, at minimum, for shots they've given since the vaccines received emergency authorization.

This article was published on Monday, October 11, 2021 in Kaiser Health News.

By Rachana Pradhan and Rachel Bluth

Community clinics in California say they haven't been paid for at least 1 million COVID-19 vaccine doses given since January, creating a "massive cash flow problem" for some and complicating efforts to retain staff. Clinics in other states, including Michigan and Mississippi, are also awaiting payment.

The delays stem from the distinct way federally qualified health centers are reimbursed for care under Medicaid, the joint federal-state program providing health coverage for low-income people. Some centers are not even billing for the shots because they say it's too complicated.

Clinics are owed tens of millions of dollars, at minimum, for shots they've given since the vaccines received emergency authorization.

Of the roughly 70,000 doses administered by La Clínica de la Raza, an organization with more than 30 Bay Area locations, almost none of those costs have been reimbursed, chief financial officer Susan Moore said. And the clinics don't expect to receive reimbursement for around half of those shots because they were administered to the community without collecting insurance information. The extra staff time and supplies were covered with grant money.

"We were monitoring our cash very closely," Moore said. "Early in the pandemic I was very concerned, but by the time the vaccine came out, it was clear to me that we were going to have enough cash in the short term."

The Biden administration has relied on the clinics to boost vaccination rates among racial and ethnic minorities and people living in poverty. Health centers have administered nearly 15 million vaccine doses, federal data shows, although it is unclear how many of those were given during a patient visit.

Under federal law, the government pays health centers a set rate for patient visits, each potentially costing hundreds of dollars. Many state Medicaid agencies have said that if a patient receives a COVID shot along with other care, the clinic's cost to give the vaccine is covered as part of its normal payment rate.

Troubles getting paid occur when the COVID vaccination is the only service provided, officials say, such as during a mass immunization clinic.

During large-scale vaccine events, "we're usually administering vaccines without that broader service," said Phillip Bergquist, chief operating officer of the Michigan Primary Care Association, which lobbies for health centers.

Some states have told health centers they can bill Medicaid separately for each dose administered in that situation, such as at the Medicare payment level of approximately $40 per shot. But others, like Michigan and California, have endured a months-long process with the Centers for Medicare & Medicaid Services to devise a payment formula for how much it costs a clinic to give a shot.

CMS said it is reviewing proposals from 13 states to pay clinics for the vaccinations. "We are continuing to work with states on their proposals," a CMS spokesperson said. If they are approved, the clinics would be paid retroactively.

Michigan has been working with CMS to figure out reimbursement "when those vaccines are administered as a stand-alone service," said Bob Wheaton, spokesperson for the state's health department. Bergquist said the calculated cost in Michigan was just shy of $40 a dose.

California devised a plan that "meets federal requirements that reimbursement to these clinics be based on cost to provide services," said Carol Sloan, spokesperson for the California Department of Healthcare Services.

California's average cost to provide each dose is about $67, based on data clinics provided.

Because of the short shelf life of an open vial of vaccine, health centers opted for dedicated vaccination clinics instead of individual appointments, to avoid wasting doses, said Andie Martinez Patterson, a senior vice president at the California Primary Care Association, which lobbies for the state's health centers.

Lack of payment is "untenable given these providers' financial restraints and tremendous outlay of resources during this historic pandemic response," Barbara Ferrer, director of the Los Angeles County Department of Public Health, wrote in a Sept. 22 letter to CMS Administrator Chiquita Brooks-LaSure. In interviews, clinics cited high expenses related to vaccination, including running community-based clinics and targeted social media campaigns.

"There's a tremendous amount of misinformation and disinformation out there," said Jim Mangia, CEO of the St. John's Well Child & Family Center in Los Angeles, which opened 26 vaccination sites and operates three mobile units. "You kind of have to do double the work to counter it."

Angel Greer, CEO of Coastal Family Health Center on Mississippi's Gulf Coast, said not receiving payment to help cover the clinic's staffing costs is detrimental. More than 50% of the health center's patients are uninsured — and 14% each are on Medicare or Medicaid. The federal Health Resources and Services Administration separately reimburses clinics for vaccines administered to uninsured people.

In Mississippi, state officials initially proposed a plan that would have reimbursed health centers at the Medicare rate for stand-alone vaccinations. CMS has not approved it.

"I'm sure, across the nation is no different than Mississippi in our struggles to maintain adequate workforce. It's extremely difficult to be competitive with these workforce constraints when we're not being reimbursed for these services," Greer said. The health center administered 1,000 COVID vaccine doses in September, with the "overwhelming majority" occurring outside a regular medical visit, Greer said.

In winter 2020, it became clear California clinics were going to have to eat the costs of vaccination for a while, Martinez Patterson said. They were "hoping on a prayer that most of their costs would be reimbursed" but went ahead and vaccinated patients anyway.

Scott McFarland, CEO of MCHC Health Centers, said his staff at four clinics in rural Lake and Mendocino counties have administered 3,500 shots without reimbursement.

"I'm fairly confident that we will eventually get paid, but this is one of the downsides to being a community health center," McFarland said, a sentiment others expressed. The clinic is still giving shots, and he thinks the money will come eventually. "It's just a timing issue, I guess."

Health centers are pulling from different pots to stay afloat: The American Rescue Plan Act provided $7.6 billion to clinics to support COVID vaccination, testing and treatment. Clinics relied on small-business loans from the Paycheck Protection Program, as well as state money, for vaccination efforts. "I do think because of the federal relief, there is not a fire," Martinez Patterson said.

Health centers in other states echoed that.

"We do not have an issue with reimbursement," said Dr. Andrea Caracostis, CEO of the Hope Clinic in Houston. She noted that the federal government paid for vaccines and that some health centers' payment rates cover vaccines.

Fifty-one federally qualified health centers in California earlier this year reported unpaid claims for 1 million doses. The actual total is probably higher; California has 188 health centers.

"We don't view this small subset, nor the data provided, as sufficiently representative" to accurately estimate the extent of unpaid vaccination claims, Sloan said.

Health centers in California have administered 4.8 million doses, according to federal data.

"We're just whittling away at it," said Mangia, of St. John's.

St. John's anticipates getting reimbursed for doses under Medicaid in November or December, the clinic said through a spokesperson.

"We know they're good for it. We know it's coming," Louise McCarthy, CEO of the Community Clinic Association of Los Angeles County, said of the Medicaid payments. "But it's really hard to hire people when you don't have cash flow."

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

Rachana Pradhan: rpradhan@kff.org, @rachanadixit

Rachel Bluth: rbluth@kff.org, @RachelHBluth

'Are You Going to Keep Me Safe?' Hospital Workers Sound Alarm on Rising Violence

KFF Health News, October 11, 2021

Eighteen months into the pandemic, healthcare workers say they are experiencing an alarming rise in violence in their workplaces.

This article was published on Monday, October 11, 2021 in Kaiser Health News.

By Bram Sable-Smith and Andy Miller  

The San Leandro Hospital emergency department, where nurse Mawata Kamara works, went into lockdown recently when a visitor, agitated about being barred from seeing a patient due to COVID-19 restrictions, threatened to bring a gun to the California facility.

It wasn't the first time the department faced a gun threat during the pandemic. Earlier in the year, a psychiatric patient well known at the department became increasingly violent, spewing racial slurs, spitting toward staffers and lobbing punches before eventually threatening to shoot Kamara in the face.

"Violence has always been a problem," Kamara said. "This pandemic really just added a magnifying glass."

In the earliest days of the pandemic, nightly celebrations lauded the bravery of front-line healthcare workers. Eighteen months later, those same workers say they are experiencing an alarming rise in violence in their workplaces.

A nurse testified before a Georgia Senate study committee in September that she was attacked by a patient so severely last spring she landed in the ER of her own hospital.

At Research Medical Center in Kansas City, Missouri, security was called to the COVID unit, said nurse Jenn Caldwell, when a visitor aggressively yelled at the nursing staff about the condition of his wife, who was a patient.

In Missouri, a tripling of physical assaults against nurses prompted Cox Medical Center Branson to issue panic buttons that can be worn on employees' identification badges.

Hospital executives were already attuned to workplace violence before the pandemic struck. But stresses from COVID have exacerbated the problem, they say, prompting increased security, de-escalation training and pleas for civility. And while many hospitals work to address the issue on their own, nurses and other workers are pushing federal legislation to create enforceable standards nationwide.

Paul Sarnese, an executive at Virtua Health in New Jersey and president of the International Association for Healthcare Security and Safety, said many studies show healthcare workers are much more likely to be victims of aggravated assault than workers in any other industry.

Federal data shows healthcare workers faced 73% of all nonfatal injuries from workplace violence in the U.S. in 2018. It's too early to have comprehensive stats from the pandemic.

Even so, Michelle Wallace, chief nursing officer at Grady Health System in Georgia, said the violence is likely even higher because many victims of patient assaults don't report them.

"We say, 'This is part of our job,'" said Wallace, who advocates for more reporting.

Caldwell said she had been a nurse for less than three months the first time she was assaulted at work — a patient spit at her. In the four years since, she estimated, she hasn't gone more than three months without being verbally or physically assaulted.

"I wouldn't say that it's expected, but it is accepted," Caldwell said. "We have a lot of people with mental health issues that come through our doors."

Jackie Gatz, vice president of safety and preparedness for the Missouri Hospital Association, said a lack of behavioral health resources can spur violence as patients seek treatment for mental health issues and substance use disorders in ERs. Life can also spill inside to the hospital, with violent episodes that began outside continuing inside or the presence of law enforcement officers escalating tensions.

A February 2021 report from National Nurses United — a union in which both Kamara and Caldwell are representatives — offers another possible factor: staffing levels that don't allow workers sufficient time to recognize and de-escalate possibly volatile situations.

COVID unit nurses also have shouldered extra responsibilities during the pandemic. Duties such as feeding patients, drawing blood and cleaning rooms would typically be conducted by other hospital staffers, but nurses have pitched in on those jobs to minimize the number of workers visiting the negative-pressure rooms where COVID patients are treated. While the workload has increased, the number of patients each nurse oversees is unchanged, leaving little time to hear the concerns of visitors scared for the well-being of their loved ones — like the man who aggressively yelled at the nurses in Caldwell's unit.

In September, 31% of hospital nurses surveyed by that union said they had faced workplace violence, up from 22% in March.

Dr. Bryce Gartland, hospital group president of Atlanta-based Emory Healthcare, said violence has escalated as the pandemic has worn on, particularly during the latest wave of infections, hospitalization and deaths.

"Front-line healthcare workers and first responders have been on the battlefield for 18 months," Garland said. "They're exhausted."

Like the increase in violence on airplanes, at sports arenas and school board meetings, the rising tensions inside hospitals could be a reflection of the mounting tensions outside them.

William Mahoney, president of Cox Medical Center Branson, said national political anger is acted out locally, especially when staffers ask people who come into the hospital to put on a mask.

Caldwell, the nurse in Kansas City, said the physical nature of COVID infections can contribute to an increase in violence. Patients in the COVID unit often have dangerously low oxygen levels.

"People have different political views — they're either CNN or Fox News — and they start yelling at you, screaming at you," Mahoney said.

"When that happens, they become confused and also extremely combative," Caldwell said.

Sarnese said the pandemic has given hospitals an opportunity to revisit their safety protocols. Limiting entry points to enable COVID screening, for example, allows hospitals to funnel visitors past security cameras.

Research Medical Center recently hired additional security officers and provided de-escalation training to supplement its video surveillance, spokesperson Christine Hamele said.

In Branson, Mahoney's hospital has bolstered its security staff, mounted cameras around the facility, brought in dogs ("people don't really want to swing at you when there's a German shepherd sitting there") and conducted de-escalation training — in addition to the panic buttons.

Some of those efforts pre-date the pandemic but the COVID crisis has added urgency in an industry already struggling to recruit employees and maintain adequate staffing levels. "The No. 1 question we started getting asked is, 'Are you going to keep me safe?'" Mahoney said.

While several states, including California, have rules to address violence in hospitals, National Nurses United is calling for the U.S. Senate to pass the Workplace Violence Prevention for Healthcare and Social Service Workers Act that would require hospitals to adopt plans to prevent violence.

"With any standard, at the end of the day you need that to be enforced," said the union's industrial hygienist, Rocelyn de Leon-Minch.

Nurses in states with laws on the books still face violence, but they have an enforceable standard they can point to when asking for that violence to be addressed. De Leon-Minch said the federal bill, which passed the House in April, aims to extend that protection to healthcare workers nationwide.

Destiny, the nurse who testified in Georgia using only her first name, is pressing charges against the patient who attacked her. The state Senate committee is now eyeing legislation for next year.

Kamara said the recent violence helped lead her hospital to provide de-escalation training, although she was dissatisfied with it. San Leandro Hospital spokesperson Victoria Balladares said the hospital had not experienced an increase in workplace violence during the pandemic.

For healthcare workers such as Kamara, all this antagonism toward them is a far cry from the early days of the pandemic when hospital workers were widely hailed as heroes.

"I don't want to be a hero," Kamara said. "I want to be a mom and a nurse. I want to be considered a person who chose a career that they love, and they deserve to go to work and do it in peace. And not feel like they're going to get harmed."

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

Andy Miller: amiller@kff.org, @gahealthnews

From Sewers to Golf Courses, Cities See Green With New Federal COVID Relief Dollars

KFF Health News, October 8, 2021

The American Rescue Plan Act provides $130 billion to cities and counties — with few restrictions on how the money can be spent.

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

By Phil Galewitz    

Duluth, Minnesota, is hiring a social worker to help people with addiction and mental health problems.

Pueblo, Colorado, started paying homeless residents to clean city streets.

Palm Beach Gardens, Florida — in Palm Beach County, home to 160 golf courses — is building a new golf course.

These are among the thousands of ways cities and counties have started spending the first tranche of COVID relief money from the American Rescue Plan Act passed by Congress in March.

That economic rescue package provides $130 billion to cities and counties — with few restrictions on how the money can be spent. For many, it was their first economic relief directly received from the federal government.

States received $195 billion from ARPA. They had gotten other stimulus funding in earlier relief packages, including the CARES Act last year.

The infusion of dollars to cities and counties is intended to aid residents and businesses hurt by the COVID-19 pandemic, invest in long-term projects or supplement budgets hit by a drop in tax revenue caused by shutdown restrictions and economic slowdowns.

Half the money was made available in May and the rest will be available next year. The localities have until 2026 to spend it.

The money cannot be used to reduce taxes, add to rainy day funds, pay for legal settlements or buttress pension funds.

Other than that, local governments can spend the money virtually as they will. Many cities, such as Buffalo, New York and Houston, are initially classifying large chunks of the allocation as "revenue replacement," meaning they will use the funds to make up for shortfalls over what would have been expected if the pandemic had not occurred. This gives them the most flexibility, according to a Brookings Institution report.

Many jurisdictions, including West Palm Beach, Florida, and Livonia, Minnesota, have allocated some ARPA money for employee bonuses.

Chautauqua County, New York, approved nearly $95,000 for handguns and bulletproof vests for its sheriff's office. The county, which averages 120 inches of snow a year, also approved $480,000 for two snowplows/dump trucks and $810,000 for a snowblower.

Dubois County, Indiana, is using $350,000 of its $8 million to add campsites and a bathroom and make other improvements to a county park.

ARPA — a $1.9 trillion package that in addition to the relief money for localities included funding for COVID testing, unemployment benefits, child tax credits and a host of other programs — was a top priority of President Joe Biden and congressional Democrats after they took control in Washington earlier this year. The law was passed without support from Republicans, who argued that earlier COVID relief funding had not been fully spent and its effects were still being realized.

The echoes of that argument are still reverberating on Capitol Hill as Republicans fight Democrats on their plans to expand spending for social programs such as Medicare and Medicaid and climate change.

In contrast to past federal fiscal relief efforts — including the CARES Act — ARPA provides support to thousands of cities and counties. Cities with more than 50,000 people get money based on population size, poverty rates and overcrowding. Smaller cities receive money based on population.

The CARES Act provided money to 160 of the country's largest 1,300 counties, but ARPA money goes to all 3,000-plus counties, said Eryn Hurley, deputy director of government affairs for the National Association of Counties. "This money is very vital," she said, noting how the pandemic and economic downturn cost counties billions in revenue. "Counties are working hard to invest these funds as fast as possible for their communities and residents," she said.

Alan Berube, a senior fellow at the Brookings Institution who is tracking the relief dollars, said this is the first new massive grant funding program to city and counties in nearly 50 years with such flexible spending requirements. Most local governments, he added, are still trying to figure out how to spend the cash.

"You have to use this money to address the impact of the pandemic or an underlying condition in the community exacerbated by the pandemic, Berube said.

Some cities, including Seattle and Austin, Texas, are using the money to build affordable housing and programs to deal with the rise in the homeless population.

Berube said the Treasury Department may question whether Palm Beach Gardens, a largely upscale city just north of West Palm Beach, can use $2 million of its $2.9 million ARPA money to help build a golf course.

"That is a very aggressive reading of the regulation," he said.

Palm Beach Gardens officials defend the spending as "an investment in our community." Candice Temple, a city spokesperson, noted the money will go to develop the 115-acre site, which will include a par-3 golf course, clubhouse and bike paths. The total cost of the project is $16.8 million, with the rest of the money coming from a bond financing. The city plans to hire seven people to work at the course.

Pueblo, Colorado, Mayor Nicholas Gradisar said his city was grateful for the money even though sales tax revenue rose 3% last year and is up 30% in 2021. He credits the increase to the federal stimulus checks residents received and used to shop and eat out.

"All in all, it could have been a lot worse," Gradisar said.

His city used some of its ARPA funding to give its employees a $500 incentive payment for getting vaccinated. The money helped improve the vaccination rate from 43% in early August to about 66% when the program ended Sept. 15.

"Obviously, we were pleased more people signed up, but we still have a ways to go," Gradisar said.

Pueblo will also use some of the ARPA funding to address homelessness and lack of child care, he said.

The city put $500,000 into a summer reading program that rewards children with $100 for completing their assignments and targeted $376,000 for mental health specialists to work with the police. It's also paying people at a homeless shelter to clean city streets. So far, Pueblo has committed $2.3 million of the $18 million in ARPA money it expects to receive.

Martin Brown, a program manager for the National League of Cities, said city officials have been contacting the organization to ask how they can use the money. "For the $65 billion in revenue, there's probably 65 billion ways to spend it," he said.

Phil Galewitz: pgalewitz@kff.org, @philgalewitz

NY Reaches Agreement With DOJ Over Vaccine Access for Blind People

KFF Health News, October 8, 2021

State officials say they have corrected issues that prevent blind or visually impaired users from accessing forms or navigating vaccine websites.

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

By Lauren Weber and Hannah Recht

Five New York state and local government agencies agreed to fix COVID-19 vaccine websites to make them accessible for blind users following a Department of Justice investigation spurred by a KHN story.

New York State's Department of Health, the City of New York's Department of Health, New York City Health and Hospitals Corp., Nassau County and Suffolk County entered into written agreements with the U.S. Attorney's Office for the Eastern District of New York, saying they have corrected issues that prevent blind or visually impaired users from accessing forms or navigating vaccine websites. In the agreements announced Tuesday, they pledged to maintain accessibility on those sites.

KHN's February investigation detailed how COVID vaccination registration and information websites at the federal, state and local levels violated disability rights laws and hindered the ability of blind people to sign up for the potentially lifesaving vaccines.

The investigation was cited in a March letter sent to the Departments of Justice and Health and Human Services from several senators, including Sen. Maggie Hassan (D-N.H.), who also asked HHS and Centers for Disease Control and Prevention leadership about the issue in a congressional hearing. The Department of Justice issued a memo the next month highlighting that "civil rights protections and responsibilities still apply" for those with vision disabilities, and HHS did as well.

In response to the KHN investigation, the Department of Justice reached out to WebAIM, according to the group's associate director, Jared Smith. WebAIM, a nonprofit web accessibility organization, ran an analysis at KHN's request that found accessibility issues on nearly all 50 states' vaccine websites, which provide general vaccine information, lists of vaccine providers and registration forms. WebAIM then helped the U.S. attorney's office in its investigation, Smith said.

Clark Rachfal, director of advocacy for the American Council of the Blind, said the public agreements are vital as they put "other jurisdictions on notice that this is a violation of the civil rights of people with disabilities."

Sachin Dev Pavithran, executive director of the U.S. Access Board, an independent agency of the federal government that works to increase accessibility, said he knew the department had investigations in progress in other states.

Inaccessibility for government websites is unlawful under the Rehabilitation Act of 1973 and the 1990 Americans with Disabilities Act, said Albert Elia, a blind attorney who works with the San Francisco-based TRE Legal Practice on accessibility cases.

He hopes the pandemic has shown just how vital online accessibility can be as so many people shifted to ordering their groceries, clothes and even medicine online.

"The notion that it's fine if online things are inaccessible — I hope we're beyond that now," he said. "I hope the general public realizes that to cut people out of online access is effectively cutting them out of life."

The National Federation of the Blind settled this summer with Curative, a startup that has administered COVID vaccines and tests in cities across the country. Curative admitted no wrongdoing but agreed to make its website accessible within 30 days and pay NFB's attorney fees, plus donate $2,500.

One blind California resident, Byran Bashin, who was unable to use Curative to register for his vaccine appointment online, was featured in the KHN investigation. "We hear a lot of lip service about inclusion and respect for diversity," he said Thursday. "Respect for our diversity begins with intelligently designing these processes."

Andy Imparato, a member of the White House's COVID-19 Health Equity Task Force and executive director of Disability Rights California, said he expects a report on inequities from the task force to be given to President Joe Biden within the month. He said the report will likely call for an outside evaluation of access issues in the COVID response, including website accessibility.

"The story that published had an impact across the country," Imparato said. "It was very specific, it was very detailed, and it was hard to ignore. I think it was incredibly helpful."

The National Federation of the Blind is pushing for a legislative fix to codify online accessibility rights, but Rachfal said a fix can be done without Congress.

"What's needed is some leadership from the administration and the Department of Justice to promulgate regulations that they already have the authority to do," Rachfal said.

Lauren Weber: LaurenW@kff.org, @LaurenWeberHP

Hannah Recht: hrecht@kff.org, @hannah_recht

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