Nonprofit Carafem delivers abortion pills to a patient's home after a telemedicine visit for $375 or less.

This article was published on Friday, September 3, 2021 in Kaiser Health News.

By Amy Littlefield  

Allison Hansen had just gone through a breakup with her boyfriend last year when she discovered she was pregnant. She already had an 8-year-old son and did not want another child.

Hansen called the Planned Parenthood facility near her home in Savannah, Georgia, to inquire about abortion services and was told the procedure would cost $500 and require four to six hours at the clinic.

Hansen didn't have that kind of time. Her son was at home, attending school online, and needed supervision. While Googling for alternatives, she came across Carafem — a nonprofit that delivers abortion pills to a patient's home after a telemedicine visit for $375 or less.

"It just seemed almost too good to be true," Hansen recalled.

Patients like Hansen have benefited from a quiet but monumental shift in abortion access enabled by the COVID-19 pandemic. In July 2020, in response to advocates' concerns about the risks posed by in-person visits in a pandemic, a federal court placed on hold a long-standing FDA rule that required mifepristone — the first pill in a two-step regimen used in medical abortions — to be dispensed in clinics. After the Trump administration appealed that decision, the conservative-majority Supreme Court agreed to reinstate the rule, with Chief Justice John Roberts writing that courts should defer to government experts who set the rules. The Biden administration put the rule back on hold in April during the remaining public health emergency and said it is reviewing the agency's restriction.

In the meantime, telemedicine abortion operations are growing in some places, although not in such states as Texas and Alabama with strict laws designed to curb or end abortions.

A new slate of digital abortion options like Just the Pill, Hey Jane, Abortion on Demand and Choix proliferated, mailing abortion pills to patients in many states after a telemedicine visit. Carafem, which had been mailing the pills to patients in Georgia before the pandemic as part of a research project, streamlined its process for patients who are eligible for medical abortions.

These services can be a lifeline for patients who haven't hit the 10- or 11-week threshold typically used for medical abortion and who can't get to a clinic or need a less expensive choice. But reproductive health advocates worry that telemedicine abortion options don't reach the patients who need it the most because they live in states with laws that actively discourage abortions and have made in-clinic care harder to access. At the same time, these new options could be endangering brick-and-mortar clinics by siphoning away the first-trimester visits that make up more than 90% of abortions.

"If [clinics] lose a considerable amount of the clientele for first-trimester abortions, they might have to close, or some of them will," said Carole Joffe, a professor focusing on reproductive health at the University of California-San Francisco and co-author of "Obstacle Course: The Everyday Struggle to Get an Abortion in America." "Potentially, we see people needing second-trimester procedures, not to mention even later ones, with literally nowhere to go."

Many clinics, which charge higher prices to support the costs of running a building and providing security, are closing around the country amid an avalanche of state restrictions. That is especially true of independent clinics, which perform 58% of abortions, according to the Abortion Care Network, an association of independent providers. Since 2012, the number of independent abortion clinics has dropped by 34%.

Concerns about access to abortion deepened this week when a Texas law took effect banning abortions after six weeks of pregnancy and a divided Supreme Court did not block it, at least for now. The court is also scheduled to hear a case this term on Mississippi's 15-week abortion ban. If the justices allow either state law to stand, it would likely lead other states to further restrict abortion, forcing patients in many conservative states across the South, Midwest and West to travel for services or seek out overseas options like Aid Access, according to Mary Ziegler, a Florida State University law professor who focuses on legal issues surrounding reproductive health and sexuality.

"If you're in New York or California or Boston, you can get abortion pills online, you can go to a clinic — there are tons of options. Whereas if you're in a state like Alabama, you're probably going to be worried that you can't do any of those things," Ziegler said.

Carafem, which operates clinics in Georgia, Illinois, Tennessee and Maryland, began mailing abortion pills to patients in Georgia in 2019 when it joined the TelAbortion Study, an ongoing project run by the reproductive health nonprofit Gynuity that received federal permission to study the safety of telemedicine abortions. Over four years, abortion providers mailed 1,390 medication packages to patients in 13 states and Washington, D.C. Researchers reported that 95% of tracked participants had a complete abortion without a procedure. They reported 10 serious adverse events, including five cases of patients needing blood transfusions, none of which could have been avoided by an in-person visit, the researchers said. Participants made 70 unplanned visits to emergency rooms or urgent care centers.

Anti-abortion advocates, however, stress that medical abortion should require in-person exams.

"Women deserve excellent healthcare, and excellent healthcare does not involve talking to someone online," said Dr. Christina Francis, board chair of the American Association of Pro-Life Obstetricians and Gynecologists. "It involves actually being seen and being evaluated to make sure that if she's going to make this decision, she's an appropriate candidate to make this decision and she's not putting herself at severe risk by taking these medications."

Many states require in-person counseling or ultrasounds before an abortion, forcing patients to make more than one trip to a clinic. In 19 states, laws require a physician who prescribes a medical abortion to be physically present when the medication is administered.

Alabama is one of those states. "I use telemedicine all the time because I'm a full-spectrum OB-GYN," said Dr. Sanithia Williams, an abortion provider at Alabama Women's Center for Reproductive Alternatives in Huntsville. "But for the abortion portion of my practice, it just is completely nonexistent."

Even in states with relatively few abortion restrictions, patients with medical risk factors, unreliable periods, unsafe living situations or pregnancies beyond 11 weeks generally can't get care online. "There will always be a need for clinic-based healthcare," said Melissa Grant, chief operations officer of Carafem. "This is not a panacea."

On a Thursday morning in late June, Leah Coplon, a certified nurse midwife, sat down in the Augusta office of Maine Family Planning for a televisit with a patient seeking an abortion who was in her home miles away. The young patient nodded and messaged her boyfriend, telling him to go buy her menstrual pads, as Coplon ran through a detailed list of warning signs like excessive bleeding that should prompt a call to the clinic or trip to an emergency room. "This is all very rare, but I've got to tell you the scary things. That's my job," Coplon said, the blue light of the monitor reflecting off her glasses.

For uninsured patients, the out-of-pocket cost for a telemedicine visit like this is $500, about average for brick-and-mortar clinics.

Maine is among a minority of states that cover abortions under Medicaid. The state also requires private plans to cover abortion if they cover prenatal care. Yet even here, with 8% of the population uninsured, cost is the biggest barrier Coplon's patients face, she said. To meet the needs of low-income patients, clinics like hers haven't raised their out-of-pocket rates in years. If the price of abortion had kept pace with medical inflation, a procedure that cost $200 in 1974 would cost $2,686 today, according to a Bloomberg Businessweek calculation last year.

Maine Family Planning has 18 locations across the sprawling, mostly rural state. In 2014, it became one of the first clinics to launch a telehealth pilot program. When COVID struck, providers like Coplon used existing telemedicine equipment to shift to a "no-test" protocol, bypassing ultrasounds and blood tests that research shows can be safely skipped in order to minimize contact with patients.

For many patients choosing between a clinic and an online service, cost will be a deciding factor — and that concerns Dr. Jamie Phifer, founder of Abortion on Demand, which serves patients in 20 states and Washington, D.C. Like many other digital options, Phifer's service does not take insurance, but she worries her low out-of-pocket price — $239, or less than half of what a typical clinic charges — could put abortion clinics out of business.

"I am very worried that in-person clinics are already bearing the brunt of the challenges of abortion access," Phifer said. "They already have to hire security and deal with protesters, and they have been on the ground working for access for 50 years, longer than I have been around."

Phifer, who lost her job as a primary care doctor following a profile of her work on Abortion on Demand in a magazine, plans to donate 60% of the profits from her business to the Abortion Care Network to support brick-and-mortar clinics.

"I didn't want to contribute to creating a two-tiered system," Phifer said.

States are rolling back many pandemic workarounds.

This article was published on Tuesday, August 31, 2021 in Kaiser Health News.

By Julie Appleby  

If you live in one state, does it matter that the doctor treating you online is in another? Surprisingly, the answer is yes, and the ability to conduct certain virtual appointments may be nearing an end.  

Televisits for medical care took off during the worst days of the pandemic, quickly becoming commonplace. Most states and the Centers for Medicare & Medicaid Services temporarily waived rules requiring licensed clinicians to hold a valid license in the state where their patient is located. Those restrictions don't keep patients from visiting doctors' offices in other states, but problems could arise if those same patients used telemedicine.

Now states are rolling back many of those pandemic workarounds.

Johns Hopkins Medicine in Baltimore, for example, recently scrambled to notify more than 1,000 Virginia patients that their telehealth appointments were "no longer feasible," said Dr. Brian Hasselfeld, medical director of digital health and telemedicine at Johns Hopkins. Virginia is among the states where the emergency orders are expiring or being rolled back.

At least 17 states still have waivers in effect, according to a tracker maintained by the Alliance for Connected Care, a lobbying group representing insurers, tech companies and pharmacies.

As those rules end, "it risks increasing barriers" to care, said Hasselfeld. Johns Hopkins, he added, hosted more than 1 million televisits, serving more than 330,000 unique patients, since the pandemic began. About 10% of those visits were from states where Johns Hopkins does not operate facilities.

The rollbacks come amid a longer and larger debate over states' authority around medical licensing that the pandemic — with its widespread adoption of telehealth services — has put front and center.

"Consumers don't know about these regulations, but if you all of a sudden pull the rug out from these services, you will definitely see a consumer backlash," said Dr. Harry Greenspun, chief medical officer for the consultancy Guidehouse.

Still, finding a way forward pits high-powered stakeholders against one another, and consumers' input is likely to be muted.

State medical boards don't want to cede authority, saying their power to license and discipline medical professionals boosts patient safety. Licensing is also a source of state revenue.

Providers have long been split on whether to change cross-state licensing rules. Different state requirements — along with fees — make it cumbersome and expensive for doctors, nurses and other clinicians to get licenses in multiple states, leading to calls for more flexibility. Even so, those efforts have faced pushback from within the profession, with opposition from other clinicians who fear the added competition that could come from telehealth could lead to losing patients or jobs.

"As with most things in medicine, it's a bottom-line issue. The reason telehealth has been blocked across state lines for many years related fundamentally to physicians wanting to protect their own practices," said Greenspun.

But the pandemic changed the equation.

Even though the initial spike in telehealth visits has eased, utilization remains 38 times higher than before the pandemic, attracting not only patients, but also venture capitalists seeking to join the hot business opportunity, according to a report from consulting firm McKinsey and Co.

Patients' experience with televisits coupled with the growing interest by investors is focusing attention on this formerly inside-baseball issue of cross-state licensing.

Greenspun predicts consumers will ultimately drive the solution by "voting with their wallets," aided by giant, consumer-focused retailers like Amazon and Walmart, both of which in recent months made forays into telemedicine.

In the short term, however, the focus is on both the protections and the barriers state regulations create.

"The whole challenge is to ensure maximum access to health while assuring quality," said Barak Richman, a Duke University law professor, who said laws and policies haven't been updated to reflect new technological realities partly because state boards want to hang onto their authority.

Patients and their doctors are getting creative, with some consumers simply driving across state lines, then making a Zoom call from their vehicle.

"It's not ideal, but some patients say they are willing to drive a mile or two and sit in a parking lot in a private space and continue to get my care," said Dr. Shabana Khan, director of telepsychiatry at NYU Langone Health's department of child and adolescent psychiatry and a member of the American Psychiatric Association's Telepsychiatry Committee. She and other practitioners ask their patients about their locations, mainly for safety reasons, but also to check that they are in-state.

Still, for some patients, driving to another state for an in-person or even a virtual appointment is not an option.

Khan worries about people whose care is interrupted by the changes, especially those reluctant to seek out new therapists or who cannot find any clinicians taking new patients.

Austin Smith hopes that doesn't happen to him.

After initial treatment for what he calls a "weird flavor of cancer" didn't help reduce his gastrointestinal stromal tumors, he searched out other experts, landing in a clinical trial. But it was in San Diego and the 28-year-old salesman lives in Phoenix.

Although he drives more than five hours each way every couple of months for treatment and to see his doctors, he does much of his other follow-up online. The only difference is "if I was in person, and I said I was hurting here, the doctor could poke me," he said.

And if the rules change? He'll make the drive. "I'll do anything to beat this," he said of his cancer.

But will doctors, whose patients have spent the past year or more growing comfortable with virtual visits, also be willing to take steps that could likely involve extra costs and red tape?

To get additional licenses, for instance, practitioners must submit applications in every state where their patients reside, each of which can take weeks or months to process. They must pay application fees and keep up with a range of requirements such as continuing education, which vary by state.

States say their traditional role as overseer ensures that all applicants meet educational requirements and pass background checks. They also investigate complaints and argue there's an advantage to keeping local officials in charge.

"It's closer to home," said Lisa Robin, chief advocacy officer with the Federation of State Medical Boards. "There's a remedy for residents of the state with their own state officials."

Doctor groups such as the American Medical Association agree.

Allowing a change that doesn't put centralized authority in a patient's home state would raise "serious enforcement issues as states do not have interstate policing authority and cannot investigate incidents that happen in another state," said then-AMA President-elect Jack Resneck during a congressional hearing in March.

But others want more flexibility and say it can be done safely.

Hasselfeld, at Johns Hopkins, said there is precedent for easing multistate licensing requirements. The Department of Veterans Affairs, for example, allows medical staffers who are properly licensed in at least one state to treat patients in any VA facility.

The Alliance for Connected Care and other advocates are pushing states to extend their pandemic rules. A few have done so. Arizona, for example, made permanent the rules allowing out-of-state medical providers to practice telemedicine for Arizona residents, as long as they register with the state and their home-state license is in good standing. Connecticut's similar rules have now been stretched until June 2023.

The alliance and others also back legislation stalled in Congress that would temporarily allow medical professionals licensed in one state to treat — either in person or via televisits — patients in any other state.

Because such fixes are controversial, voluntary interstate pacts have gained attention. Several already exist: one each for nurses, doctors, physical therapists and psychologists. Proponents say they are a simple way to ensure state boards retain authority and high standards, while making it easier for licensed medical professionals to expand their geographic range.

The nurses' compact, enacted by 37 states and Guam, allows registered nurses with a valid license in one state to have it recognized by all the others in the pact.

A different kind of model is the Interstate Physician Licensure Compact, which has been enacted by 33 states, plus the District of Columbia and Guam, and has issued more than 21,000 licenses since it began in 2017, said Robin, of the Federation of State Medical Boards.

While it speeds the paperwork process, it does not eliminate the cost of applying for licenses in each state.

The compact simplifies the process by having the applicant physician's home state confirm his or her eligibility and perform a criminal background check. If the applicant is eligible, the home state sends a letter of qualification to the new state, which then issues a license, Robin said. Physicians must meet all rules and laws in each state, such as requirements for continuing medical education. Additionally, they cannot have a history of disciplinary actions or currently be under investigation.

"It's a fairly high bar," said Robin.

Such compacts — especially if they are bolstered by new legislation at the federal level — could help the advances in telehealth made during the pandemic stick around for good, expanding access to care for both mental health services and medical care across the U.S. "What's at stake if we get this right," said Richman at Duke, "is making sure we have an innovative marketplace that fully uses virtual technology and a regulatory system that encourages competition and quality."

Julie Appleby: jappleby@kff.org, @Julie_Appleby

Most dialysis patients face a harrowing choice between continuing dialysis or receiving hospice services.

This article was published on Monday, August 30, 2021 in Kaiser Health News.

By JoNel Aleccia  

After a decade of living with chronic kidney disease, Vonita McGee knows her body is wearing out.

At 63, McGee undergoes dialysis sessions three times each week at a Northwest Kidney Centers site near her Burien, Washington, home to rid her blood of waste and water. She has endured the placement of more than a dozen ports, or access sites, in her arms and chest as sites became scarred and unusable. Late last month, doctors performed surgery to install yet another port near her left elbow, but no one is certain it will hold.

"Because of scar tissue, I was told this is my last viable access," she said.

Without ongoing dialysis, McGee knows she could face death within days or weeks. But, unlike many of the nearly 500,000 U.S. patients who require dialysis, McGee said she's had help making peace with the process.

"I know that things are coming," she said. "I'm in awe of death, but I'm not afraid of it anymore."

That's largely attributed to a novel effort in Washington state that embeds palliative care within a kidney center whose clinics treat patients living with kidney disease; and then later pair dying patients with hospice care without forcing them to forgo the comfort that dialysis may still provide.

Traditional hospice services require kidney patients to abandon dialysis, a decision that hastens death, and almost inevitably comes with acute symptoms, including muscle spasms and nausea.

McGee is one of 400 patients enrolled since 2019 in a first-in-the-nation palliative care program housed at Northwest Kidney Centers, a Seattle-based operation with clinics throughout the region. The organization founded the first dialysis center in the U.S. — and the world — nearly 50 years ago.

Chronic kidney disease, or CKD, encompasses five stages, from mild damage in the organs' functioning in stage 1 to complete kidney failure in stage 5. Most patients start preparing for dialysis — and kidney failure — in stage 4. Dialysis does not cure kidney failure. The only other option for treatment is an organ transplant.

Dialysis patients typically face distressing physical, emotional and spiritual symptoms throughout their treatment, ranging from pain, shortness of breath and intense itching to depression and panic. The symptoms can grow dire as years pass.

But only a fraction of those patients, 4% or fewer, ever receive specialized palliative care that can effectively target those issues, said Dr. Daniel Lam, the University of Washington nephrologist and palliative care expert who launched the program with the help of a two-year, $180,000 grant from the Cambia Health Foundation. Attention to palliative care in nephrology has lagged behind its use for advanced cancer, for instance.

That's especially true for Black patients and other minorities, who are disproportionately more likely than white patients to require dialysis, but far less likely to receive quality palliative or end-of-life care.

"We're trying to address this current and projected gap," Lam said. "What we are doing is asking people how do they want to live their lives and what's most important to them."

If McGee's condition deteriorates to the point that she has a prognosis of six months or less to live, she will then be a candidate for a related partnership between the kidney center and the nonprofit Providence Hospice of Seattle, which would allow her to continue to receive dialysis even after hospice care begins.

While the goal of both hospice and palliative care is pain and symptom relief, hospice has traditionally been regarded as comfort care without the intent to treat or cure the primary disease. The nuance with dialysis is that it is central to keeping a kidney patient's body functioning; discontinuing it abruptly results in death within days.

"The goal of this program is to provide kind of a smooth off-ramp from curative dialysis to the end of their lives," said Mackenzie "Mack" Daniek, who co-directs the hospice.

Most dialysis patients face a harrowing choice between continuing dialysis or receiving hospice services. That's because the Medicare hospice benefit, which took effect in 1983, provides palliative care and support for terminally ill patients who have six months or less to live — and who agree to forgo curative or life-prolonging care.

That rigid requirement could change in the future. The Centers for Medicare & Medicaid Services has approved an experimental model that will allow concurrent care for some patients starting next year. But, for now, Medicare will not simultaneously pay for dialysis and hospice care for patients with a terminal diagnosis of kidney failure.

Hospices receive a daily per-patient rate from Medicare, typically $200 or less, and must use it to cover all services related to the terminal diagnosis. Dialysis can easily cost $250 a session, which means only the largest hospices, those with 500 or more patients, can absorb the costs of providing concurrent care. Only about 1% of the more than 4,500 hospices in the U.S. meet that mark.

The result? About a quarter of dialysis patients receive hospice care, compared with about half of the general Medicare population. And their median time spent in hospice care is about five days compared with more than 17 days for the general population. This means that dialysis patients often receive aggressive medical treatment until the very end of life, missing out on the comfort of targeted end-of-life care.

"What's happened through the years is when a dialysis patient is ready to stop treatment, that's when they come to hospice," said Dr. Keith Lagnese, chief medical officer of the University of Pittsburgh Medical Center Family Hospice. "They're forced to draw that line in the sand. Like many things in life, it's not easy to do."

Lagnese said the Seattle program is among the first in the U.S. to address palliative and hospice care among dialysis patients. His UPMC program, which has experimented with concurrent care, allows patients up to 10 dialysis treatments after they enter hospice care.

In the Washington state program, there's no limit on the number of sessions a patient can receive. That helps ease the patient into the new arrangement, instead of abruptly halting the treatment they've been receiving, often for years.

"If they're faced with immediately stopping, they feel like they're falling off of a cliff," said Lam, the program's founder.

In McGee's case, she's had the benefit of palliative care for three years to help negotiate the daily struggles that come with dialysis. The care focuses on relieving the physical side effects, and emotional symptoms such as depression and anxiety. It also addresses spiritual needs, which McGee said has helped augment the comfort she finds as a member of the Baha'i religious faith.

"They provide mental support, and they inform you what you need to do to do things properly, and they're your liaisons," McGee said. "Basically, I was just living before without knowing the information."

When she considers her degenerating medical condition and the possibility that it will become too difficult, even impossible, to continue dialysis long term, she said she welcomes the option to ease into the final stage of her life.

"Do I feel scared? At one point, I did," McGee said. "But they are assuring me that my rights will be honored, they will be advocates for me when it happens. By having that support, it gives me my time to live."

JoNel Aleccia: jaleccia@kff.org, @JoNel_Aleccia

Florida, Georgia and the rest of the South, are battling high infection rates.

This article was published on Friday, August 27, 2021 in Kaiser Health News.

By Andy Miller 

Two state government websites in Georgia recently stopped posting updates on COVID-19 cases in prisons and long-term care facilities, just as the dangerous delta variant was taking hold.

Data has been disappearing recently in other states as well.

Florida, for example, now reports COVID cases, deaths and hospitalizations once a week, instead of daily, as before.

Both states, along with the rest of the South, are battling high infection rates.

Public health experts are voicing concern about the pullback of COVID information. Dr. Georges Benjamin, executive director of the American Public Health Association, called the trend "not good for government and the public" because it gives the appearance of governments "hiding stuff."

A month ago, the Georgia agency that runs state prisons stopped giving public updates on the number of new COVID cases among inmates and staff members. The Department of Corrections, in explaining this decision, cited its successful vaccination rates and "a declining number of COVID-19 cases among staff and inmates."

Now, a month later, Georgia has among the highest COVID infection rates in the U.S. — along with one of the lowest vaccination rates. But the corrections department hasn't resumed posting case data on its website.

When asked by KHN about the COVID situation in prisons, department spokesperson Joan Heath said Monday that it currently has 308 active cases among inmates.

"We will make a determination whether to begin reposting the daily COVID dashboard over the next few weeks, if the current statewide surge is sustained," Heath said.

Another state website, run by the Department of Public Health, no longer links to a listing of the number of COVID cases among residents and staffers of nursing homes and other long-term care residences by facility. The data grid, launched early in the pandemic, gave a running total of long-term care cases and deaths from the virus.

Asked about the lack of online information, public health officials directed a reporter to another agency, the Department of Community Health, which explained that COVID information on nursing homes could be found on a federal health website. But locating and navigating that link can be difficult.

"Residents and families cannot easily find this information," said Melanie McNeil, the state's long-term care ombudsman. "It used to be easily accessible."

Georgia gives updates on overall numbers of COVID cases, hospitalizations and deaths in the state five days a week but has recently stopped its weekend COVID reporting.

Other states also have cut back their public case reporting, despite the nation being engulfed in a fourth, delta-driven COVID surge.

Florida had issued daily reports on cases, deaths and hospitalizations until the rate of positive test results dropped in June. Even when caseloads soared in July and August, the state stuck with weekly reporting.

Florida has been accused of being less than transparent with COVID health data. Newspapers have sued or threatened to sue the state several times for medical examiner reports, long-term care data, prison data and weekly COVID reports the state received from the White House.

Florida Agriculture Commissioner Nikki Fried, a Democrat running for governor in 2022, has repeatedly questioned Republican Gov. Ron DeSantis' decision to delay the release of public data on COVID cases and has called for restoring daily reporting of COVID data.

Nebraska discontinued its daily COVID dashboard June 30, then recently resumed reporting, but only weekly. Iowa also reports weekly; Michigan, three days a week.

Public health experts said full information is vital for a public dealing with an emergency such as the pandemic — similar to the government reports needed during a hurricane.

"All the public health things we do are dependent on trust and transparency," Benjamin said.

A government, when removing public data, should provide a link redirecting people to where they can get that data, he said. And if a state doesn't have enough staff members to provide regular data, he said, that argues for investment in staff and technology.

People in prisons and long-term care facilities, living in close quarters indoors, are especially vulnerable to infectious diseases such as COVID.

"They are usually hotbeds of disease," said Amber Schmidtke, a microbiologist who tracks COVID in Georgia. Family members "want to know what's going on in there."

Prison data has been removed or reduced in several states, according to the UCLA School of Law's COVID Behind Bars Data Project, which tracks the spread of COVID in prisons, jails and detention facilities.

The group said Alaska provides only monthly updates on COVID cases in such facilities, while Florida stopped reporting new data in June.

When Georgia stopped reporting on COVID in prisons, the project found, only 24% of employees reported being vaccinated. Prison workers can spread the virus inside the facilities and then in their homes and the community.

The group reports that at least 93 incarcerated people and four staffers have died of COVID in Georgia and that the state has the second-highest case fatality rate, or percentage of those with reported infections who die, among all state and federal prison systems.

"Right now, if there was a massive outbreak in prisons, there would be no way to know it," said Hope Johnson of the COVID Behind Bars Data Project.

Recent Facebook posts point to cases at Smith State Prison in southeastern Georgia.

Heath, when asked about cases there, said Tuesday that the prison has 19 active COVID cases and its transitional center has one.

Mayor Bernie Weaver of Glennville, the Tattnall County town where the prison is located, said he hasn't been told about recent COVID cases at the prison. But he noted that Tattnall itself has had a spike in cases. The county has a 26% vaccination rate, among the lowest in the state.

KHN senior correspondent Phil Galewitz contributed to this report.

Andy Miller: amiller@kff.org, @gahealthnews