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

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

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

Many transplant programs have chosen to either bar patients who refuse to take the COVID vaccines from receiving transplants, or give them lower priority on waitlists.

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

By JoNel Aleccia  

A Colorado kidney transplant candidate who was bumped to inactive status for failing to get a COVID-19 vaccine has become the most public example of an argument roiling the nation's more than 250 organ transplant centers.

Across the country, growing numbers of transplant programs have chosen to either bar patients who refuse to take the widely available COVID vaccines from receiving transplants, or give them lower priority on crowded organ waitlists. Other programs, however, say they plan no such restrictions — for now.

At issue is whether transplant patients who refuse the shots are not only putting themselves at greater risk for serious illness and death from a COVID infection, but also squandering scarce organs that could benefit others. The argument echoes the demands that smokers quit cigarettes for six months before receiving lung transplants or that addicts refrain from alcohol and drugs before receiving new livers.

"It is a matter of active debate," said Dr. Deepali Kumar, an expert in transplant infectious diseases at the University of Toronto and president-elect of the American Society of Transplantation. "It's really an individual program decision. In many programs, it's in flux."

Leilani Lutali, 56, a late-stage kidney disease patient from Colorado Springs, Colorado, learned in a Sept. 28 letter from UCHealth in Denver that if she didn't begin a COVID vaccine series within 30 days, she would lose her spot on the transplant waiting list. Both she and her living donor, Jaimee Fougner, 45, of Peyton, Colorado, refused to get vaccinated, citing religious objections and uncertainty about the safety and effectiveness of the vaccines.

"I have too many questions that remain unanswered at this point. I feel like I'm being coerced into not being able to wait and see and that I have to take the shot if I want this lifesaving transplant," Lutali said.

She said she offered to be tested for COVID before the surgery or to sign a waiver absolving the hospital of legal risk for her refusal of the vaccine. "At what point do you no longer become a partner in your own care regardless of your own concerns?" she said.

Lutali now hopes to take her transplant quest to Texas, where several hospitals, including Houston Methodist and Baylor University Medical Center in Dallas, said they don't require COVID vaccinations to approve active candidates for the national waiting list.

The difference between policies in Denver and Dallas — and elsewhere — underscore a tense national divide. As of late April, fewer than 7% of transplant programs nationwide reported inactivating patients who were unvaccinated or partially vaccinated against COVID, according to research by Dr. Krista Lentine, a nephrologist at the Saint Louis University School of Medicine.

But that was just a snapshot in late spring, and like all COVID-related practices, it's "rapidly changing," Lentine said.

UCHealth in Denver began requiring COVID vaccinations for transplant patients in late August, citing the American Society of Transplantation's August recommendation that "all solid organ transplant recipients should be vaccinated against SARS-CoV-2."

Patients who undergo transplant surgery have their immune systems artificially suppressed during recovery, to keep their bodies from rejecting the new organ. That leaves unvaccinated transplant patients at "extreme risk" of severe illness if they are infected by COVID, with mortality rates estimated at 20% to 30%, depending on the study, Dan Weaver, a spokesperson for UCHealth said. For the same reason, transplant patients who receive COVID vaccines after surgery may fail to mount a strong immune response, research shows.

UW Medicine in Seattle began mandating COVID vaccines this summer, said Dr. Ajit Limaye, director of the solid organ transplant infectious diseases program. Patients were already required to meet other stringent criteria to be considered for transplantation, including receiving inoculations against several illnesses, such as hepatitis B and influenza.

"For anyone who does not have a medical contraindication, basically, we're requiring it," he said. "There's a very strong sense to make it a requirement, like all the other hoops, straight up."

By contrast, Northwestern Medicine in Chicago, where doctors performed the first double-lung transplant on a COVID patient in June 2020, is encouraging — but not requiring — vaccination against the pandemic disease.

"We don't decline care of transplant based on vaccine status," said Jenny Nowatzke, Northwestern's manager of national media relations. "The patient also doesn't get any lower scores."

The lack of consistent practice across programs sends a mixed message to the public, said Dr. Kapilkumar Patel, director of the lung transplant program at Tampa General Hospital in Florida, where COVID vaccines are not required.

"We mandate hepatitis and influenza vaccines, and nobody has an issue with that," he said. "And now we have this one vaccination that can save lives and make an impact on the post-transplant recovery phase. And we have this huge uproar from the public."

Nearly 107,000 candidates are waiting for organs in the U.S.; dozens die each day still waiting. Transplant centers evaluate which patients are allowed to be placed on the national list, taking into account medical criteria and other factors like financial means and social support to ensure that donor organs won't fail.

"We really make all kinds of selective value judgments," said Dr. David Weill, former director of Stanford University Medical Center's lung and heart-lung transplant program who now works as a consultant. "When we're selecting in the committee room, I hear the most subjective, value-based judgments about people's lives. This is just another thing."

The centers can choose to place candidates on inactive status for a variety of reasons, including medical noncompliance, according to data from the United Network for Organ Sharing, which oversees transplants. As of Sept. 30, that category accounted for 738 of more than 47,000 registrants waiting in inactive status, though it's not clear how many are tied to vaccination status.

A particularly thorny question involves unvaccinated people who need transplants specifically because COVID infections destroyed their organs. As of late September, more than 200 lungs, as well as at least six hearts and two heart-lung combinations, had been transplanted for COVID-related reasons in the U.S., according to UNOS data.

Many of those organs were transplanted earlier in the pandemic, before any COVID vaccine was widely available. That's no longer the case, Weill said. "If you're just now getting vaccinated, you've done it at gunpoint, actually," he said. "It's not just a personal choice; they're making some kind of a statement."

Such patients are usually younger and healthier than other transplant candidates, aside from the COVID-related damage, and they're often acutely ill enough to go to the top of any transplant list. "The sick COVID patient might go ahead of the stable cystic fibrosis patient," Weill said.

Tampa General's Patel said he performed a lung transplant on a patient who was transferred to Florida after being delisted at another center because he wasn't vaccinated for COVID. "I mandated with him basically on a handshake that he will get his vaccine post-transplant," Patel said. "But his family? They haven't agreed."

Eventually, Patel said, he thinks nearly all transplant programs will mandate COVID vaccination, largely because transplant centers are evaluated on the longer-term survival of their patients.

"I think it's going to spread like wildfire across the country," he said. "If you start losing patients in a year due to COVID, it will be mandated sooner rather than later.

JoNel Aleccia: jaleccia@kff.org, @JoNel_Aleccia