At Texas Border, Pandemic's High Toll Lays Bare Gaps in Health and Insurance

KFF Health News, June 23, 2021

Texas' refusal to expand Medicaid under the ACA, a shortage of healthcare options and the state's lax strategy toward the pandemic have contributed to a higher death rate at the border.

This article was published on Wednesday, June 23, 2021 in Kaiser Health News.

By René Kladzyk, El Paso Matters and Phil Galewitz and Elizabeth Lucas

EL PASO, Texas — Alfredo "Freddy" Valles was an accomplished trumpeter and a beloved music teacher for nearly four decades at one of the city's poorest middle schools.

He was known for buying his students shoes and bow ties for their band concerts, his effortlessly positive demeanor and a suave personal style — "he looked like he stepped out of a different era, the 1950s," said his niece Ruby Montana.

While Valles was singular in life, his death at age 60 in February was part of a devastating statistic: He was one of thousands of deaths in Texas border counties — where coronavirus mortality rates far outpaced state and national averages.

In the state's border communities, including El Paso, not only did people die of COVID-19 at significantly higher rates than elsewhere, but people under age 65 were also more likely to die, according to a KHN-El Paso Matters analysis of COVID death data through January. More than 7,700 people died of COVID in the border area during that period.

In Texas, COVID death rates for border residents younger than 65 were nearly three times the national average for that age group and more than twice the state average. And those ages 18-49 were nearly four times more likely to die than those in the same age range across the U.S.

"This was like a perfect storm," said Heide Castañeda, an anthropology professor at the University of South Florida who studies the health of border residents. She said a higher-than-normal prevalence of underlying health issues combined with high uninsurance rates and flagging access to care likely made the pandemic even more lethal for those living along the border than elsewhere.

That pattern was not as stark in neighboring New Mexico. Border counties there recorded COVID death rates 41% lower than those in Texas, although the New Mexico areas were well above the national average as of January, the KHN-El Paso Matters analysis found. Texas border counties tallied 282 deaths per 100,000, compared with 166 per 100,000 in New Mexico.

That stark divide could be seen even when looking at neighboring El Paso County, Texas, and Doña Ana County, New Mexico. The death rate for residents under 65 was 70% higher in El Paso County.

Health experts said Texas' refusal to expand Medicaid under the Affordable Care Act, a shortage of healthcare options and the state's lax strategy toward the pandemic also contributed to a higher death rate at the border. Texas GOP leaders have opposed Medicaid expansion for a litany of economic and political reasons, though largely because they object to expanding the role or size of government.

"Having no Medicaid expansion and an area that is already underserved by primary care and preventive care set the stage for a serious situation," Castañeda said. "A lot of this is caused by state politics."

Texas was one of the first states to reopen following the nationwide coronavirus shutdown in March and April last year. Last June — even as cases were rising — Gov. Greg Abbott allowed all businesses, including restaurants, to operate at up to 50% capacity, with limited exceptions. And he refused to put any capacity restrictions on churches and other religious facilities or let local governments impose mask requirements.

In November, Texas Attorney General Ken Paxton filed an injunction to stop a lockdown order implemented by the El Paso county judge, the top administrative officer, at a time when El Paso hospitals were so overwhelmed with COVID patients that 10 mobile morgues had to be set up at an area hospital to accommodate the dead.

Unlike Texas, New Mexico expanded Medicaid under the ACA and, as a result, has a much lower uninsured rate than Texas for people under age 65 — 12% compared with Texas' 21%, according to Census figures. And New Mexico had aggressive rules for face masks and public gatherings. Still, that didn't spare New Mexico from the crisis. Outbreaks in and around the Navajo reservation hit hard. Overall, its state death rate exceeded the state rate for Texas, but along the border New Mexico's rates were lower in all age groups.

For some border families, the immense toll of the pandemic meant multiple deaths among loved ones. Ruby Montana lost not only her uncle to COVID in recent months, but also her cousin Julieta "Julie" Apodaca, a former elementary school teacher and speech therapist.

Montana said Valles' death surprised the family. He had been teaching remotely at Guillen Middle School in El Paso's Segundo Barrio neighborhood, an area known as "the other Ellis Island" because of its adjacency to the border and its history as an enclave for Mexican immigrant families.

When Valles first got sick with COVID in December, Montana and the family were not worried, not only because he had no preexisting health conditions, but also because they knew his lungs were strong from practicing his trumpet daily over the course of decades.

In early January, he went to an urgent care center after his condition deteriorated. He had pneumonia and was told to go straight to the emergency room.

"When I took him to the [hospital], I dropped him off and went to go park," said his wife, Elvira. But when she returned, she was not allowed inside. "I never saw him again," she said.

Valles, a father of three, had been teaching one of his three grandchildren, 5-year-old Aliq Valles, to play the trumpet.

They "were joined at the hip," Montana said. "That part has been really hard to deal with too. [Aliq] should have a whole lifetime with his grandpa."

Hispanic adults are more than twice as likely to die of COVID as white adults, according to the Centers for Disease Control and Prevention. In Texas, Hispanic residents died of COVID at a rate four times as high as that of non-Hispanic white people, according to a December analysis by The Dallas Morning News.

Ninety percent of residents under 65 in Texas border counties are Hispanic, compared with 37% in the rest of the state. Latinos have high rates of chronic conditions like diabetes and obesity, which increases their risks of COVID complications, health experts say.

Because they were more likely to die of COVID at earlier ages, Latinos are losing the most years of potential life among all racial and ethnic groups, said Coda Rayo-Garza, an advocate for policies to aid Hispanic populations and a professor of political science at the University of Texas-San Antonio.

Expanding Medicaid, she said, would have aided the border communities in their fight against COVID, as they have some of the highest rates of residents without health coverage in the state.

"There has been a disinvestment in border areas long before that led to this outcome that you're finding," she said. "The legislature did not end up passing Medicaid expansion, which would have largely benefited border towns."

The higher death rates among border communities are "unfortunately not surprising," said Rep. Veronica Escobar (D-El Paso).

"It's exactly what we warned about," Escobar said. "People in Texas died at disproportionate rates because of a dereliction on behalf of the governor. He chose not to govern … and the results are deadly."

Abbott spokesperson Renae Eze said the governor mourns every life lost to COVID.

"Throughout the entire pandemic, the state of Texas has worked diligently with local officials to quickly provide the resources needed to combat COVID and keep Texans safe," she said.

Ernesto Castañeda, a sociology professor at American University in Washington, D.C., who is not related to Heide Castañeda, said structural racism is integrally linked to poor health outcomes in border communities. Generations of institutional discrimination — through policing, educational and job opportunities, and healthcare — worsens the severity of crisis events for people of color, he explained.

"We knew it was going to be bad in El Paso," Ernesto Castañeda said. "El Paso has relatively low socioeconomic status, relatively low education levels, high levels of diabetes and overweight [population]."

In some Texas counties along the border more than a third of workers are uninsured, according to an analysis by Georgetown University's Center for Children and Families.

"The border is a very troubled area in terms of high uninsured rates, and we see all of those are folks put at increased risk by the pandemic," said Joan Alker, director of the center.

In addition, because of a shortage of health workers along much of the border, the pandemic surge was all the deadlier, said Dr. Ogechika Alozie, an El Paso specialist in infectious diseases.

"When you layer on top not having enough medical personnel with a sicker-on-average population, this is really what you find happens, unfortunately," he said.

The federal government has designated the entire Texas border region as both a health professional shortage area and a medically underserved area.

Jagdish Khubchandani, a professor of public health at New Mexico State University in Las Cruces, about 40 miles northwest of El Paso, said the two cities were like night and day in their response to the crisis.

"Restrictions were far more rigid in New Mexico," he said. "It almost felt like two different countries."

Manny Sanchez, a commissioner in Doña Ana County, credits the lower death rates in New Mexico to state and local officials' united message to residents about COVID and the need to wear masks and maintain physical distance. "I would like to think we made a difference in saving lives," Sanchez said.

But, because containing a virus requires community buy-in, even El Paso residents who understood the risks were susceptible to COVID. Julie Apodaca, who had recently retired, had been especially careful, in part because her asthma and diabetes put her at increased risk. As the primary caregiver for her elderly mother, she was likely exposed to the virus through one of the nurse caretakers who came to her mother's home and later tested positive, said her sister Ana Apodaca.

Julie Apodaca had registered for a COVID vaccine in December as soon as it was available but had not been able to get an appointment for a shot by the time she fell ill.

Montana found out that Apodaca had been hospitalized the day after her uncle died. One month later, and after 16 days on a ventilator, she too died on March 13.

She was 56.

This story was done in partnership with El Paso Matters, a member-supported, nonpartisan media organization that focuses on in-depth and investigative reporting about El Paso, Texas, Ciudad Juárez across the border in Mexico, and neighboring communities.

Methodology

To analyze COVID deaths rates along the border with Mexico, KHN and El Paso Matters requested COVID-related death counts by age group and county from Texas, New Mexico, California and Arizona. California and Arizona were unable to fulfill the requests. The Texas Department of State Health Services and the New Mexico Department of Health provided death counts as of Jan. 31, 2021.

Texas' data included totals by age group for border counties as a group and for the state with no suppression of data. New Mexico provided data for individual counties, and small numbers were suppressed, totaling 1.6% of all deaths in the state. (Data on deaths is commonly suppressed when it involves very small numbers to protect individual identities.)

National death counts by age group were calculated using provisional death data from the Centers for Disease Control and Prevention, and included deaths as of Jan. 31, 2021.

Rates were calculated per 100,000 people using the 2019 American Community Survey.

The ethnic breakdown in Texas' border counties comes from the Census Bureau's 2019 population estimates.

Phil Galewitz: pgalewitz@kff.org, @philgalewitz

Elizabeth Lucas: elucas@kff.org, @eklucas

Thousands of Young Children Lost Parents to COVID. Where's Help for Them?

KFF Health News, June 23, 2021

Researchers calculate that more than 46,000 children have lost one or both parents to COVID since February 2020.

This article was published on Wednesday, June 23, 2021 in Kaiser Health News.

By JoNel Aleccia

Five months after her husband died of COVID-19, Valerie Villegas can see how grief has wounded her children.

Nicholas, the baby, who was 1 and almost weaned when his father died, now wants to nurse at all hours and calls every tall, dark-haired man "Dada," the only word he knows. Robert, 3, regularly collapses into furious tantrums, stopped using the big-boy potty and frets about sick people giving him germs. Ayden, 5, recently announced it's his job to "be strong" and protect his mom and brothers.

Her older kids — Kai Flores, 13, Andrew Vaiz, 16, and Alexis Vaiz, 18 — are often quiet and sad or angry and sad, depending on the day. The two eldest, gripped by anxiety that makes it difficult to concentrate or sleep, were prescribed antidepressants soon after losing their stepfather.

"I spend half the nights crying," said Villegas, 41, a hospice nurse from Portland, Texas. She became a widow on Jan. 25, just three weeks after Robert Villegas, 45, a strong, healthy truck driver and jiujitsu expert, tested positive for the virus.

"My kids, they're my primary concern," she said. "And there's help that we need."

But in a nation where researchers calculate that more than 46,000 children have lost one or both parents to COVID since February 2020, Villegas and other survivors say finding basic services for their bereaved kids — counseling, peer support groups, financial assistance — has been difficult, if not impossible.

"They say it's out there," Villegas said. "But trying to get it has been a nightmare."

Interviews with nearly two dozen researchers, therapists and other experts on loss and grief, as well as families whose loved ones died of COVID, reveal the extent to which access to grief groups and therapists grew scarce during the pandemic. Providers scrambled to switch from in-person to virtual visits and waiting lists swelled, often leaving bereft children and their surviving parents to cope on their own.

"Losing a parent is devastating to a child," said Alyssa Label, a San Diego therapist and program manager with SmartCare Behavioral Health Consultation Services. "Losing a parent during a pandemic is a special form of torture."

Children can receive survivor benefits when a parent dies if that parent worked long enough in a job that required payment of Social Security taxes. During the pandemic, the number of minor children of deceased workers who received new benefits has surged, reaching nearly 200,000 in 2020, up from an average of 180,000 in the previous three years. Social Security Administration officials don't track cause of death, but the latest figures marked the most awards granted since 1994. COVID deaths "undoubtedly" fueled that spike, according to the SSA's Office of the Chief Actuary.

And the number of children eligible for those benefits is surely higher. Only about half of the 2 million children in the U.S. who have lost a parent as of 2014 received the Social Security benefits to which they were entitled, according to a 2019 analysis by David Weaver of the Congressional Budget Office.

Counselors said they find many families have no idea that children qualify for benefits when a working parent dies, or don't know how to sign up.

In a country that showered philanthropic and government aid on the 3,000 children who lost parents to the 9/11 terror attacks, there's been no organized effort to identify, track or support the tens of thousands of kids left bereaved by COVID.

"I'm not aware of any group working on this," said Joyal Mulheron, the founder of Evermore, a nonprofit foundation that focuses on public policy related to bereavement. "Because the scale of the problem is so huge, the scale of the solution needs to match it."

COVID has claimed more than 600,000 lives in the U.S., and researchers writing in the journal JAMA Pediatrics calculated that for every 13 deaths caused by the virus, one child under 18 has lost a parent. As of June 15, that would translate into more than 46,000 kids, researchers estimated. Three-quarters of the children are adolescents; the others are under age 10. About 20% of the children who've lost parents are Black, though they make up 14% of the population. 

"There's this shadow pandemic," said Rachel Kidman, an associate professor at Stony Brook University in New York, who was part of the team that found a way to calculate the impact of COVID deaths. "There's a huge amount of children who have been bereaved."

The Biden administration, which launched a program to help pay funeral costs for COVID victims, did not respond to questions about offering targeted services for families with children.

Failing to address the growing cohort of bereaved children, whether in a single family or in the U.S. at large, could have long-lasting effects, researchers said. The loss of a parent in childhood has been linked to higher risks of substance use, mental health problems, poor performance in school, lower college attendance, lower employment and early death.

"Bereavement is the most common stress and the most stressful thing people go through in their lives," said clinical psychologist Christopher Layne of the UCLA/Duke University National Center for Child Traumatic Stress. "It merits our care and concern."

Perhaps 10% to 15% of children and others bereaved by COVID might meet the criteria of a new diagnosis, prolonged grief disorder, which can occur when people have specific, long-lasting responses to the death of a loved one. That could mean thousands of children with symptoms that warrant clinical care. "This is literally a national, very public health emergency," Layne said.

Still, Villegas and others say they have been left largely on their own to navigate a confusing patchwork of community services for their children even as they struggle with their own grief.

"I called the counselor at school. She gave me a few little resources on books and stuff," Villegas said. "I called some crisis hotline. I called counseling places, but they couldn't help because they had waiting lists and needed insurance. My kids lost their insurance when their dad died."

The social disruption and isolation caused by the pandemic overwhelmed grief care providers, too. Across the U.S., nonprofit agencies that specialize in childhood grief said they have scrambled to meet the need and to switch from in-person to virtual engagement.

"It was a huge challenge; it was very foreign to the way we work," said Vicki Jay, CEO of the National Alliance for Grieving Children. "Grief work is based on relationships, and it's very hard to get a relationship with a piece of machinery."

At Experience Camps, which each year offers free weeklong camps to about 1,000 bereaved kids across the country, the waiting list has grown more than 100% since 2020, said Talya Bosch, an Experience Camps associate. "It is something that we are concerned about — a lot of kids are not getting the support they need," she said.

Private counselors, too, have been swamped. Jill Johnson-Young, co-owner of Central Counseling Services in Riverside, California, said her nearly three dozen therapists have been booked solid for months. "I don't know a therapist in the area who isn't full right now," she said.

Dr. Sandra McGowan-Watts, 47, a family practice doctor in Chicago, lost her husband, Steven, to COVID in May 2020. She feels fortunate to have found an online therapist for her daughter, Justise, who helped explain why the 12-year-old was suddenly so sad in the mornings: "My husband was the one who woke her up for school. He helped her get ready for school."

Justise was also able to get a spot at an Experience Camps session this summer. "I am nervous about going to camp, but I am excited about meeting new kids who have also lost someone close in their life," she said.
 

Jamie Stacy, 42, of San Jose, California, was connected with an online counselor for her daughter, Grace, 8, and twin sons, Liam and Colm, 6, after their father, Ed Stacy, died of COVID in March 2020 at age 52. Only then did she learn that children can grieve differently than adults. They tend to focus on concrete concerns, such as where they'll live and whether their favorite toys or pets will be there. They often alternate periods of play with sadness, cycling rapidly between confronting and avoiding their feelings of loss.

"The boys will be playing Legos, having a great time, and all of a sudden drop a bomb on you: 'I know how I can see Daddy again. I just have to die, and I'll see Daddy again,'" she said. "And then they're back to playing Legos."

Stacy said counseling has been crucial in helping her family navigate a world where many people are marking the end of the pandemic. "We can't escape the topic of COVID-19 even for one day," she said. "It's always in our face, wherever we go, a reminder of our painful loss."

Villegas, in Texas, has returned to her work in hospice care and is starting to reassemble her life. But she thinks there should be formal aid and grief support for families like hers whose lives have been indelibly scarred by the deadly virus.

"Now everybody's lives are going back to normal," she said. "They can get back to their lives. And I'm thinking my life will never be normal again."

This story was produced by KHN (Kaiser Health News), a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

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

JoNel Aleccia: jaleccia@kff.org, @JoNel_Aleccia

In a Murky Sea of Mental Health Apps, Consumers Left Adrift

KFF Health News, June 22, 2021

For tech startups looking to cash in on unmet need, that translates into more than 50 million potential customers.

This article was published on Tuesday, June 22, 2021 in Kaiser Health News.

By Jenny Gold

In the eyes of the tech industry, mental health treatment is an area ripe for disruption.

In any given year, 1 in 5 adults in the U.S. experience a form of mental illness, according to federal estimates. And research indicates only about half of them receive treatment in a system that is understaffed and ill distributed to meet demand.

For tech startups looking to cash in on unmet need, that translates into more than 50 million potential customers.

Venture capital firms invested more than $2.4 billion in digital behavioral health apps in 2020 — more than twice the amount invested in 2019 — touting support or treatment for issues from burnout and depression to ADHD and bipolar disorder. At least seven mental health app companies have achieved “unicorn” status and are valued at more than $1 billion.

But even as industry hype mounts, researchers and companies are scrambling to prove these apps actually work. Of the estimated 20,000 mental health apps available for download on personal computers and smartphones, just five have been formally vetted and approved by the Food and Drug Administration, which largely has taken a hands-off approach to regulating the space.

“Development has really outpaced the science,” said Stephen Schueller, a clinical psychologist at the University of California-Irvine who specializes in the development and evaluation of digital mental health products.

Type “depression” or “anxiety” into an app store, and you’ll be met with a dizzying list of results. There are thousands of “wellness” apps like Headspace that counsel people on breathing exercises and other techniques to help them feel more mindful. Apps such as Woebot and TalkLife profess to help manage conditions like anxiety and postpartum depression using games, mood journaling or text exchanges with peers or automated bots.

Some apps are meant to be used alongside in-person therapy, and others on their own. Several of the most popular, like Talkspace, BetterHelp and Ginger, promise access to treatment with a licensed therapist over text message, phone or video. Others, including Brightside and Cerebral, connect users to psychiatrists who can prescribe antidepressants.

Most products make their money by charging consumers a monthly or annual fee, with the option to purchase extras like video sessions with a therapist. Others contract directly with employers or insurers.

And, yes, a small portion of these apps have promising research to back them up. Several studies, for example, have found that cognitive behavioral therapy, a mainstay of treatment for depression and anxiety that seeks to help patients change negative thought patterns, is as effective when delivered using web-based platforms as when done in person by a licensed professional. And the pandemic has bolstered claims that patients are willing to trade in-person visits for the ease of online connection.

“Digital mental health can be viewed as a way to extend the mental resources that we have,” said David Mohr, who directs the Center for Behavioral Intervention Technologies at the Northwestern University Feinberg School of Medicine. A step-care model, for example, would allow patients with milder symptoms to be treated via technology while reserving in-person care for patients who need something more.

The challenge for consumers is separating the apps that might help from those that offer little more than distraction — or could actually do harm.

Some companies offering mental health treatment had recently been doing something totally different — for example, an online seller of erectile dysfunction and hair loss treatments has started offering psychiatric evaluations and prescribing and selling antidepressants.

Tech companies are by nature for-profit and, in the rush to compete in a saturated market, many are selling a product with an appealing user interface but little evidence of effectiveness. A 2020 analysis by Australian researchers reviewing nearly 300 apps for anxiety and depression found just 6% of the companies that boasted an evidence-based framework in the app store description for their products had published any evidence.

Nor do star ratings and download totals offer much context: An April study from Beth Israel Deaconess Medical Center and Harvard Medical School found little correlation between app store metrics and treatment quality.

“No one is competing based on privacy, safety or evidence. They’re competing on aesthetics, in part, on page ranking, marketing on brand awareness,” said Dr. John Torous, director of the digital psychiatry division at Beth Israel Deaconess Medical Center and one of the authors of the April study. “There’s an implicit assumption that the app is better than nothing. But what if it isn’t better than nothing?”

One problem, said Dr. Ipsit Vahia, a geriatric psychiatrist and medical director of the McLean Institute for Technology in Psychiatry, is that randomized control studies of the kind that might prove an app’s effectiveness can take years, far slower than the rapid innovation in tech. “In general, the health care industry and the technology industry work at very different paces,” Vahia said.

Dr. David Mou, a psychiatrist at Massachusetts General Hospital who is chief medical officer at Cerebral, said he agrees that everything new in health care must be done deliberately and conservatively to avoid patient harm. But he said some people in the mental health field are painting all companies with the same brush and failing to differentiate those that are data-driven from those trying to grow at any cost.

“They look at us and say we’re all VC-backed bros in a basement trying to redesign health care. And that’s not true. It may have been true 10 years ago, but it isn’t true today,” said Mou. The long-term winners, he said, will be those that are “evidence-based and measure quality like crazy.”

Cerebral offers online therapy and medication management and delivery for a range of mental illnesses. The monthly subscription fees range from $29 to $325, depending on the level and frequency of care, as well as insurance coverage. Mou said Cerebral is already able to demonstrate some advantages. While many top hospital systems might have a months-long wait for care, he said, someone in crisis can reach a Cerebral provider almost immediately. “Within minutes you are able to talk with someone with one of our instant live visits. That in itself is a huge win.”

Even critics of the tech explosion are quick to acknowledge that the current brick-and-mortar system of mental health is dated and inadequate. In recent years, the issues surrounding mental illness and lack of access to treatment have infiltrated public dialogue. Brain illnesses that many families once squirreled away from view have become the stuff of celebrity culture and dinner-table chatter.

Yet even as advocates have made strides in acceptance, truly improving the lives of people with mental illness has proven stubbornly difficult. Over the past several decades — while the U.S. successfully lowered death rates for cancer, heart disease and other major illnesses — deaths by suicide and drug overdose have continued to climb.

Federal law theoretically requires insurance companies to cover brain illness as they would any other illness. But finding affordable care remains a challenge, largely because of a shortage of licensed mental health professionals and ongoing inequities in insurance coverage.

In a nation where huge swaths of the population lack a primary care doctor and health insurance — but most everyone has a cellphone — connecting people to treatment via mobile apps would seem a logical solution. And, for some, the opportunity to talk about their mental health challenges anonymously makes online treatment an attractive alternative.

Still, many of the experts who welcome the potential for innovation in mental health treatment acknowledge that consumers are getting little guidance in how to choose a reputable option. “Wellness” apps that promote a healthy lifestyle or apps that help people manage their disease without providing specific treatment suggestions can avoid FDA regulation. But even those that offer patient-specific diagnoses and treatment recommendations that would seem to fall squarely under the FDA’s authority do not seem to garner the agency’s attention, according to industry experts.

“The FDA has been really, really lax on enforcing in digital health for reasons that are not entirely clear to me,” said Bradley Merrill Thompson, a lawyer at Epstein Becker Green who advises companies on FDA regulations. “Anybody could spend 20 minutes on the app store and find dozens of examples of apps that make medical device claims, and that have been doing so for some time, without any effort by the FDA to rein them in.”

In response to questions from KHN about its approach to regulating mental health apps, the FDA sent a brief statement. “As circumstances change and new needs arise, FDA is ready to meet and address these challenges, especially in the areas of mental health,” the statement reads in part. “We would like to see more evidence-based products in this area, which is why we remain committed to facilitating the development of additional safe and effective therapies for patients who rely on these products.”

Dr. Tom Insel, a psychiatrist and neuroscientist, has a unique view of the evolving landscape. In 2015, Insel left his job as director of the National Institute of Mental Health, a post he had held since 2002, trading the halls of government for the open floor plans of Silicon Valley to work in digital mental health. He started at Google’s Verily, then co-founded Mindstrong Health, a startup researching how smartphone technology could be used to predict and diagnose mental health crises. He has since left to advise California officials on behavioral health issues.

Insel said he believes in the promise of digital mental health but that it will take time to find its highest and best use. He noted, for example, that most of the apps on the market focus on the problem of access: They make care more convenient. But they’re overlooking a more basic problem: quality. Unlike most fields of medicine, mental health providers rarely measure whether the care they provide makes patients better.

“A lot of what we need is not just more access. It’s not just recreating the brick-and-mortar system and letting people do it by phone or Zoom,” Insel said. Instead, he argued, digital health should focus on measuring whether treatments improve people’s lives.

“I have no doubt that this field will transform mental health treatment and diagnosis,” Insel said, “but we’re in the first act of a five-act play. I don’t think we’re anywhere near the kinds of solutions that we need in the real world.”

Jenny Gold: jgold@kff.org, @JennyAGold

Is Rand Paul Mixing Up the Vaccine Message for COVID Survivors?

KFF Health News, June 22, 2021

Paul's social media communication represented his latest salvo in the ongoing debate over whether natural immunity is equivalent or even better than vaccination.

This article was published on Tuesday, June 22, 2021 in Kaiser Health News.

By Victoria Knight

Last week, Sen. Rand Paul (R-Ky.) posted a Twitter thread asserting that people who have survived a COVID-19 infection were unlikely to be reinfected and have better immunity against variants than those who have been vaccinated against — but not infected by — SARS-CoV-2, the virus that causes COVID.

The social media communication represented his latest salvo in the ongoing debate over whether natural immunity is equivalent or even better than vaccination.

While the science on the subject is still evolving, a look at the evidence behind Paul's series of tweets seemed in order. After all, though almost 65% of Americans have received at least one dose of a COVID vaccine, some people who have recovered from COVID may not feel a need to get shot. Paul, who was the first senator to be diagnosed with the virus, is among them. Here's a deeper look at what Paul said on Twitter, the studies he cited and how researchers characterized his comments.

Breaking Down the Twitter Thread

In his first tweet, Paul referenced a recent Cleveland Clinic study finding that among subjects who were unvaccinated but had already had COVID-19, there were no re-infections in a five-month observation period: "Great news! Cleveland clinic study of 52,238 employees shows unvaccinated people who have had COVID 19 have no difference in re-infection rate than people who had COVID 19 and who took the vaccine."

In subsequent tweets, the senator said: "The immune response to natural infection is highly likely to provide protective immunity even against the SARS-CoV-2 variants. … Thus, recovered COVID-19 patients are likely to better defend against the variants than persons who have not been infected but have been immunized with spike-containing vaccines only." All three vaccines authorized for emergency use in the U.S. (Pfizer-BioNTech, Moderna and Johnson & Johnson) contain genetic instructions that tell our cells how to make a spike protein associated with the coronavirus. The presence of that spike protein then causes our bodies to make antibodies to protect against COVID.

At the end of his final tweet, Rand then linked to a second study led by scientists at the Fred Hutchinson Cancer Research Center in Seattle to support his assertions.

Digesting the Scientific Papers

Paul referenced two scientific papers in his tweet thread — both of which are preprints, meaning they have not yet been published in scientific journals or been peer-reviewed.

One was a study from the Cleveland Clinic following four categories of healthcare workers: unvaccinated but previously infected; unvaccinated but not previously infected; vaccinated and previously infected; and vaccinated but not previously infected. The workers were followed for five months.

The researchers found that no one who was unvaccinated but had previously been infected with COVID became infected again during the five-month study period. Infections were almost zero among those who were vaccinated, while there was a steady increase in infections among those who were unvaccinated and previously uninfected.

When asked whether he believed Paul's tweet had interpreted his study results correctly, the study's lead author, Dr. Nabin Shrestha, an infectious diseases specialist at Cleveland Clinic, said "it was an accurate interpretation of the study's findings."

However, Dr. George Rutherford, an epidemiologist at the University of California-San Francisco, wrote in an email that he would add one caveat to the wording of Paul's tweet: "Note that in his tweet Senator Paul seems to suggest that the denominator of previously infected healthcare workers at the Cleveland Clinic was 52,238 — that was the total number in the whole study. There were 1,359 that were previously infected and never vaccinated, and there were no reinfections noted over a median follow up of 143 days. So, the tweet itself is accurate if read literally but the denominator is really 1,359."

As for the other study Paul mentioned, researchers analyzed COVID-19 immunity in those who had been infected with the COVID virus and those who hadn't and found that infection activated a range of immune cells and immunity lasted at least eight months.

In his last two tweets in the thread, Paul quotes directly from the study's "discussion" section: "The immune response to natural infection is highly likely to provide protective immunity even against the SARS-CoV-2 variants. … Thus, recovered COVID-19 patients are likely to better defend against the variants than persons who have not been infected but have been immunized with spike-containing vaccines only."

The lead study author, Kristen Cohen, a senior staff scientist in the Vaccine and Infectious Disease Division at the Fred Hutchinson Cancer Research Center in Seattle, acknowledged that Paul's tweet was a direct quote from the study. Still, she said, in her view, the quote was taken out of context and presented to suit Paul's objective — but does not accurately reflect the overall take-home message from the study's findings.

That's because, she said, Paul was quoting from the discussion section of the paper. The discussion is the final section of a scientific paper, and Cohen said its purpose here was to project what the study's findings could imply for a broader scientific significance.

"We wrote that recovering COVID patients are "likely" to better defend against variants than those who have just been immunized, but it's not saying they do," said Cohen. "It's not saying they have been known to. It's making a hypothesis or basically saying this could be the case."

In fact, Cohen's study did not include any subjects who had been vaccinated. The researchers were merely reasoning in the sentence Paul quoted that, based on the data showing the immune system's broad natural response, those who recover from COVID-19 and then receive a vaccine may be better protected against COVID variants than those who had only vaccine-induced immunity.

"We did not intend to argue that infected people do not need to get vaccinated or that their immune responses are superior," Cohen wrote in an email.

However, Cohen recognized the sentence was confusing when taken out of context and said she will eliminate it from the paper when it gets submitted for publication.

Cohen pointed us to another Fred Hutchinson-led study with which she was involved. It did show that people who previously had COVID-19 benefited from also getting vaccinated, because there was a significant boost in immune response, especially against variants.

The Conventional Wisdom on Natural Immunity

So, what's known from these two studies is that surviving a COVID infection confers a significant amount of immunity against the virus. Other studies also support this assertion.

"Existing literature does show natural immunity provides protection against COVID-19," said Shane Crotty, a professor at the Center for Infectious Disease and Vaccine Research at the La Jolla Institute for Immunology who has published numerous peer-reviewed studies on natural immunity against COVID-19. He said such immunity particularly protects against hospitalizations and severe illness.

In Crotty's own recent study, the largest yet to measure the molecules and cells involved in immune protection, his team found that natural immunity against COVID lasted at least eight months. Based on projections, it could last up to a couple of years.

While that is good news, Crotty said, there are three points of caution.

First, though natural immunity appears to be very effective against the current dominant U.S. variant (known as alpha), it also appears weaker than vaccine immunity against some of the variants circulating, such as the delta variant, first detected in India. That means if those variants eventually become dominant in the U.S., people relying on natural immunity would be less protected than those who are vaccinated.

Second, there is a lack of data about whether natural immunity prevents asymptomatic transmission and infection. Several other studies, though, show vaccines do.

Third, Crotty said his studies have shown that levels of natural immunity can vary widely in individuals. His team even found a hundredfold difference in the number of immune cells among people.

"If you thought about the immune system as a basketball game and you thought about that as a team scoring 1 point, and another team scoring 100 points, that's a big difference," said Crotty. "We're not so confident that people at the low end of immunity levels would be as protected against COVID-19."

But those who receive a vaccine shot have a much more consistent number of immune cells, since everyone receives the same dose amount, said Crotty.

With all that in mind, the Centers for Disease Control and Prevention recommends that those who previously had COVID-19 should get vaccinated and receive both doses of a vaccine, whether it's the Pfizer-BioNTech or Moderna vaccine. Fauci, the nation's leading infectious disease expert, reiterated this message during a White House COVID-19 briefing last month.

Victoria Knight: vknight@kff.org, @victoriaregisk  

Hospitals, Insurers Invest Big Dollars to Tackle Patients' Social Needs

KFF Health News, June 22, 2021

After years of testing, the evidence is mixed that these efforts work.

This article was published on Tuesday, June 22, 2021 in Kaiser Health News.

By Phil Galewitz

PHILADELPHIA — When doctors at a primary care clinic here noticed many of its poorest patients were failing to show up for appointments, they hoped giving out free rides would help.

But the one-time complimentary ride didn't reduce these patients' 36% no-show rate at the University of Pennsylvania Health System clinics.

"I was super surprised it did not have any effect," said Dr. Krisda Chaiyachati, the Penn researcher who led the 2018 study of 786 Medicaid patients.

Many of the patients did not take advantage of the ride because they were either saving it for a more important medical appointment or preferred their regular travel method, such as catching a ride from a friend, a subsequent study found.

It was not the first time that efforts by a healthcare provider to address patients' social needs — such as food, housing and transportation — failed to work.

In the past decade, dozens of studies funded by state and federal governments, private hospitals, insurers and philanthropic organizations have looked into whether addressing patients' social needs improves health and lowers medical costs.

But so far it's unclear which of these strategies, focused on so-called social determinants of health, are most effective or feasible, according to several recent academic reports by experts at Columbia, Duke and the University of California-San Francisco that evaluated existing research.

And even when such interventions show promising results, they usually serve only a small number of patients. Another challenge is that several studies did not go on long enough to detect an impact, or they did not evaluate health outcomes or health costs.

"We are probably at a peak of inflated expectations, and it is incumbent on us to find the innovations that really work," said Dr. Laura Gottlieb, director of the UCSF Social Interventions Research and Evaluation Network. "Yes, there's a lot of hype, and not all of these interventions will have staying power."

With healthcare providers and insurers eager to find ways to lower costs, the limited success of social-need interventions has done little to slow the surge of pilot programs — fueled by billions of private and government dollars.Bottom of Form

Paying for Health, Not Just Healthcare

Across the country, both public and private health insurance programs are launching large initiatives aimed at improving health by helping patients with unmet social needs. One of the biggest efforts kicks off next year in North Carolina, which is spending $650 million over five years to test the effect of giving Medicaid enrollees assistance with housing, food and transportation.

California is redesigning its Medicaid program, which covers nearly 14 million residents, to dramatically increase social services to enrollees.

These moves mark a major turning point for Medicaid, which, since its inception in 1965, largely has prohibited government spending on most nonmedical services. To get around this, states have in recent years sought waivers from the federal government and pushed private Medicaid health plans to address enrollees' social needs.

The move to address social needs is gaining steam nationally because, after nearly a dozen years focused on expanding insurance under the Affordable Care Act, many experts and policymakers agree that simply increasing access to healthcare is not nearly enough to improve patients' health.

That's because people don't just need access to doctors, hospitals and drugs to be healthy, they also need healthy homes, healthy food, adequate transportation and education, a steady income, safe neighborhoods and a home life free from domestic violence — things hospitals and doctors can't provide, but that in the long run are as meaningful as an antibiotic or an annual physical.

Researchers have known for decades that social problems such as unstable housing and lack of access to healthy foods can significantly affect a patient's health, but efforts by the health industry to take on these challenges didn't really take off until 2010 with the passage of the ACA. The law spurred changes in how insurers pay health providers — moving them away from receiving a set fee for each service to payments based on value and patient outcomes.

As a result, hospitals now have a financial incentive to help patients with nonclinical problems — such as housing and food insecurity — that can affect health.

Temple University Health System in Philadelphia launched a two-year program last year to help 25 homeless Medicaid patients who frequently use its emergency room and other ERs in the city by providing them free housing, and caseworkers to help them access other health and social services. It helps them furnish their apartments, connects them to healthy delivered meals and assists with applications for income assistance such as Social Security.

To qualify, participants had to have used the ER at least four times in the previous year and had at least $10,000 in medical claims that year.

Temple has seen promising results when comparing patients' experiences before the study to the first five months they were all housed. In that time, the participants' average number of monthly ER visits fell 75% and inpatient hospital admissions dropped 79%.

At the same time, their use of outpatient services jumped by 50% — an indication that patients are seeking more appropriate and lower-cost settings for care.

Living Life as 'Normal People Do'

One participant is Rita Stewart, 53, who now lives in a one-bedroom apartment in Philadelphia's Squirrel Hill neighborhood, home to many college students and young families.

"Everyone knows everyone," Stewart said excitedly from her second-floor walk-up. It's "a very calm area, clean environment. And I really like it."

Before joining the Temple program in July and getting housing assistance, Stewart was living in a substance abuse recovery home. She had spent a few years bouncing among friends' homes and other recovery centers. Once she slept in the city bus terminal.

In 2019, Stewart had visited the Temple ER four times for various health concerns, including anxiety, a heart condition and flu.

Stewart meets with her caseworkers at least once a week for help scheduling doctor appointments, arranging group counseling sessions and managing household needs.

"It's a blessing," she said from her apartment with its small kitchen and comfy couch.

"I have peace of mind that I am able to walk into my own place, leave when I want to, sleep when I want to," Stewart said. "I love my privacy. I just look around and just wow. I am grateful."

Stewart has sometimes worked as a nursing assistant and has gotten her healthcare through Medicaid for years. She still deals with depression, she said, but having her own home has improved her mood. And the program has helped keep her out of the hospital.

"This is a chance for me to take care of myself better," she said.

Her housing assistance help is set to end next year when the Temple program ends, but administrators said they hope to find all the participants permanent housing and jobs.

"Hopefully that will work out and I can just live my life like normal people do and take care of my priorities and take care of my bills and things that a normal person would do," Stewart said.

"Housing is the second-most impactful social determinant of health after food security," said Steven Carson, a senior vice president at Temple University Health System. "Our goal is to help them bring meaningful and lasting health improvement to their lives."

Success Doesn't Come Cheap

Temple is helping pay for the program; other funding comes from two Medicaid health plans, a state grant and a Pittsburgh-based foundation. A nonprofit human services organization helps operate the program.

Program organizers hope the positive results will attract additional financing so they can expand to help many more homeless patients.

The effort is expensive. The "Housing Smart" program cost $700,000 to help 25 people for one year, or $28,000 per person. To put this in perspective, a single ER visit can cost a couple of thousands of dollars. And "frequent flyer" patients can tally up many times that in ER visits and follow-up care.

If Temple wants to help dozens more patients with housing, it will need tens of millions of dollars more per year.

Still, Temple officials said they expect the effort will save money over the long run by reducing expensive hospital visits — but they don't yet have the data to prove that.

The Temple program was partly inspired by a similar housing effort started at two Duke University clinics in Durham, North Carolina. That program, launched in 2016, has served 45 patients with unstable housing and has reduced their ER use. But it's been unable to grow because housing funding remains limited. And without data showing the intervention saves on healthcare costs, the organizers have been unable to attract more financing.

Often there is a need to demonstrate an overall reduction in healthcare spending to attract Medicaid funding.

"We know homelessness is bad for your health, but we are in the early stages of knowing how to address it," said Dr. Seth Berkowitz, a researcher at the University of North Carolina-Chapel Hill.

Results Remain to Be Seen

"We need to pay for health not just healthcare," said Elena Marks, CEO of the Houston-based Episcopal Health Foundation, which provides grants to community clinics and organizations to help address the social needs of vulnerable populations.

The nationwide push to spend more on social services is driven first by the recognition that social and economic forces have a greater impact on health than do clinical services like doctor visits, Marks said. A second factor is that the U.S. spends far less on social services per capita compared with other large, industrialized nations.

"This is a new and emerging field," Marks said when reviewing the evaluations of the many social determinants of health studies. "The evidence is weak for some, mixed for some, and strong for a few areas."

But despite incomplete evidence, Marks said, the status quo isn't working either: Americans generally have poorer health than their counterparts in other industrialized countries with more robust social services.

"At some point we keep paying you more and more, Mr. Hospital, and people keep getting less and less. So, let's go look for some other solutions" Marks said.

The COVID-19 pandemic has shined further light on the inequities in access to health services and sparked interest in Medicaid programs to address social issues. Over half of states are implementing or expanding Medicaid programs that address social needs, according to a KFF study in October 2020. (The KHN newsroom is an editorially independent program of KFF.)

The Medicaid interventions are not intense in many states: Often they involve simply screening patients for social needs problems or referring them to another agency for help. Only two states — Arizona and Oregon — require their Medicaid health plans to directly invest money into pilot programs to address the social problems that screening reveals, according to a survey by consulting firm Manatt.

The Centers for Medicare & Medicaid Services, which is funding a growing number of efforts to help Medicaid patients with social needs, said it "remains committed" to helping states meet enrollees' social challenges including education, employment and housing.

On Jan. 7, CMS officials under the Trump administration sent guidance to states to accelerate these interventions. In May, under President Joe Biden, a CMS spokesperson told KHN: "Evidence indicates that some social interventions targeted at Medicaid and CHIP beneficiaries can result in improved health outcomes and significant savings to the healthcare sector."

The agency cited a 2017 survey of 17 state Medicaid directors in which most reported they recognized the importance of social determinants of health. The directors also noted barriers to address them, such as cost and sustainability.

In Philadelphia, Temple officials now face the challenge of finding new financing to keep their housing program going.

"We are trying to find the magic sauce to keep this program running," said Patrick Vulgamore, project manager for Temple's Center for Population Health.

Sojourner Ahebee, health equity fellow at WHYY's health and science show, "The Pulse," contributed to this report.

This story is part of a partnership that includes WHYY, NPR and KHN.

Phil Galewitz: pgalewitz@kff.org, @philgalewitz  

Hemmed In at Home, Nonprofit Hospitals Look for Profits Abroad

KFF Health News, June 22, 2021

Around three dozen of America's elite health systems are searching with a missionary zeal for patients and insurers able to pay high prices that will preserve their financial successes.

This article was published on Tuesday, June 22, 2021 in Kaiser Health News.

By Jordan Rau

Across the street from the Buckingham Palace Garden and an ocean away from its Ohio headquarters, Cleveland Clinic is making a nearly $1 billion bet that Europeans will embrace a hospital run by one of America's marquee health systems.

Cleveland Clinic London, scheduled to open for outpatient visits later this year and for overnight stays in 2022, will primarily offer elective surgeries and other profitable treatments for the heart, brain, joints and digestive system. The London strategy attempts to attract a well-off, privately insured population: American expatriates, Europeans drawn by the clinic's reputation, and Britons impatient with the waits at their country's National Health Service facilities. The hospital won't offer less financially rewarding business lines, like emergency services.

"There are very few people out there in the world who would not choose to have Cleveland Clinic as their healthcare provider," said chief executive Dr. Tomislav Mihaljevic.

Facing the prospect of stagnant or declining revenues at home, around three dozen of America's elite hospitals and health systems are searching with a missionary zeal for patients and insurers able to pay high prices that will preserve their financial successes.

For years, a handful of hospitals have partnered with foreign companies or offered consulting services in places like Dubai, where Western-style healthcare was rare and money plentiful. Now a few, like the clinic, are taking on a bigger risk — and a potentially larger financial reward.

These foreign forays prompt questions about why American nonprofit health systems, which pay little or no taxes in their hometowns, are indulging in such nakedly commercial ventures overseas. The majority of U.S. hospitals are exempt from taxes because they provide charity care and other benefits to their communities. Nonprofit hospitals routinely tout these contributions, though studies have found they often amount to less than the tax breaks.

Despite their tax designation, nonprofit hospitals are as aggressive as commercial hospitals in seeking to dominate their healthcare markets and extract prices as high as possible from private insurers. Though they do not pay dividends, some nonprofits amass large surpluses most years even as more and more patients are covered by Medicare and Medicaid, the U.S. government's insurance programs for the elderly, disabled and poor, which pay less than commercial insurance. Cleveland Clinic, one of the wealthiest, ran an 11% margin in the first three months of this year and paid Mihaljevic $3.3 million in 2019, the most recent salary disclosed.

The advantages of international expansion for their local communities are tenuous. Venturing overseas does not provide Americans with the direct or trickle-down benefits that investing locally does, such as construction work and healthcare jobs. Even when hospitals abroad add to the bottom line, the profits funneled home are minimal, according to the few financial documents and tax returns that disclose details of the operations.

"It's a distraction from the local mission at a minimum," said Paul Levy, a former chief executive at Boston's Beth Israel Deaconess Medical Centerand now a consultant. "People get into them at the beginning, thinking this is easy money. The investment bankers get involved because they get the financing, and the senior faculty get on board and say, 'This is great; it means I can go to Italy for two years' — and there's not a real business plan."

There are financial hazards. For instance, Cleveland Clinic has warned bondholders that its performance could suffer if its London project does not launch as planned. There are also risks to a system's reputation if a foreign venture goes awry.

Finance experts temper expectations that operations of overseas hospitals will have a major bearing on a system's balance sheet. "Even though they do well, they're small hospitals — they're never part of the overall picture," said Olga Beck, a senior director at Fitch Ratings. "It does help [the U.S. operations] because it gives a global name and presence in other markets."

Hospital executives say their foreign ventures provide an additional source of revenue, thus adding stability, and benefit the care of their hometown patients.

"As we go to different areas around the world, we learn and we continuously improve for all our patients," said Dr. Brian Donley, CEO of Cleveland Clinic London. He said the clinic has learned from U.K. practices more efficient ways to sterilize surgical instruments and perform X-rays.

For decades, wealthy foreigners — who are willing to pay the list prices for specialized surgeries and cancer care that domestic insurers bargain down — have been appealing targets for U.S. hospitals. Hospitals like MedStar Health's Georgetown University Hospital in Washington, D.C., solicit and assist foreign patients with special offices staffed by people with job titles such as "international services coordinator" and "international services finance administrator."

Between July 2019 and June 2020, U.S. hospitals treated more than 53,000 foreign patients, charging them more than $2.8 billion, according to a survey of members by the Chicago-based U.S. Cooperative for International Patient Programs. In addition, instead of just importing patients, 37 of 51 health systems in the survey said they offer international advisory or consulting services abroad.

"'Send us your patients' is pretty much a dying approach," said Steven Thompson, a consultant who has spearheaded international programs for Baltimore's Johns Hopkins Medicine and Boston's Brigham and Women's Hospital. "People see it on both sides for what it is: a one-way relationship."

One of the oldest foreign ventures is the organ transplant program the Pittsburgh-based nonprofit system UPMC has run in Palermo, Italy, since 1997, when Sicily's government and Italian insurers realized it would be cheaper to perform those procedures there than continue to send patients to the U.S. Since then, UPMC's Palermo facility has performed more than 2,300 transplants.

In this initial expansion, the U.S. hospital was providing a highly specialized type of surgery — one that UPMC is renowned for — that was not available locally. But UPMC, one of the most entrepreneurial U.S. health systems, didn't stop there. In Ireland, UPMC owns a cancer center and provides care for concussions through sports medicine clinics. Since 2018, the system has acquired hospitals in Waterford, Clane and Kilkenny. They are staffed mostly by independent Irish physicians, but UPMC regularly sends over its leading U.S. specialists to lend expertise, according to Wendy Zellner, a UPMC spokesperson.

UPMC has company in Ireland: in 2019, Bon Secours Mercy Health, a Roman Catholic system with hospitals in Eastern states, merged with a five-hospital Catholic system there.

Over the past two decades, UPMC did advisory and consulting work in 15 countries but ultimately decided to narrow its involvement to four: Italy, Ireland, China and Kazakhstan, where UPMC is helping a university develop a medical teaching hospital. Charles Bogosta, president of UPMC International, said UPMC wanted to focus its efforts where it was confident it could improve the quality of care, bolster UPMC's reputation and earn profit margins greater than its U.S. hospitals do.

UPMC officials said the economics are favorable abroad because labor is cheaper and the mix of patients is heavily tilted toward those with commercial insurance, which pays better than government programs.

"What we've been doing overseas has been really helpful in addressing what everyone in the U.S. is trying to do, which is come up with diversified revenue sources," Bogosta said.

Even so, that extra revenue remains a small part of UPMC's earnings. The health system's foreign hospital business generated gross revenues of $96 million, or 1% of UPMC's $9.3 billion total hospital revenues in 2019, according to a KHN analysis of a UPMC financial disclosure. Since that figure is before accounting for the costs of running the hospitals, taxes and other expenses, the actual profits the foreign hospitals might send back to Pittsburgh are much smaller. In Ireland, where corporations are required to disclose audited financial statements, UPMC Investments Ltd., an umbrella group that owns the Waterford hospital operation and property, reported net profits of about a half-million dollars in 2019 on more than $47 million in gross revenues.

In an email, Zellner said the Ireland statements "do not give you the totality of the picture in Ireland or International, where our results are far better than these documents would suggest." UPMC declined to provide more detailed financial data.

Like other systems, UPMC has expanding ambitions in China. In 2019 it signed an agreement with the multinational corporation Wanda Group to help manage several "world-class" hospitals, starting with one opening in Chengdu next year.

But foreign ventures can misfire. "These partnerships can turn into nightmares, as Hopkins has learned," Thompson wrote in a 2012 article for the Harvard Business Review that described his observations as the founder and first CEO of Johns Hopkins Medicine International, a for-profit venture jointly owned by Johns Hopkins Medicine and Johns Hopkins University.

Anadolu Medical Center, which Hopkins helped establish in Istanbul in 2005, was "plagued by quality problems," including overbooked operating rooms and physicians who refused to follow evidence-based procedures and quality protocols, he wrote. Thompson attributed the problem to the Turkish mandate that the hospital be run by a Turkish citizen and wrote that the problems did not dissipate until Hopkins was allowed to install its own manager in the second-highest position and dissolve the top position to get around the citizenship requirement "while remaining in technical compliance with the law."

While "the project is now thriving," he warned that "lending the Hopkins name to a hospital that delivers unimpressive care could significantly damage our 135-year-old brand — and that's a real danger in developing areas, especially in a project's early days."

Hopkins has remained skittish about outright ownership or even management responsibilities. Instead, it has affiliations with hospitals and health systems in 13 countries, including Vietnam, China, Turkey, Lebanon, Brazil and Saudi Arabia. Hopkins does not run any of the hospitals but helps develop hospital master plans and clinical programs, trains doctors, and advises on patient safety and infection control.

Even so, in 2014 it created a joint venture with the oil and gas company Saudi Aramco to provide healthcare to 255,000 employees and their dependents and retirees. Hopkins, which owns a fifth of the venture, said all foreign net revenue is returned to the system's parent organizations to fund research, expansion of care and scholarships. But its public records report meager income from its foreign subsidiary, just $7 million in 2018 — a tenth of a percent of the health system's $7 billion revenues.

Charles Wiener, the current president of Johns Hopkins Medicine International, focused on other benefits. "If we can put in robust quality and safety at one of our affiliates, their patients do better," he said. "If we can export our education and training models, we believe that allows our people to benefit from learning from other cultures, and some of their people come here to train."

Cleveland Clinic London is unusual in that U.S. health systems rarely build a hospital abroad from scratch without a local partner. The clinic chose that more cautious approach with Cleveland Clinic Abu Dhabi, a 364-bed hospital owned by the Mubadala Investment Co. that the clinic manages. It also has a consulting practice that is helping a Singapore healthcare company build a hospital in Shanghai.

Foreign enterprises appeal to the clinic because it has limited growth opportunities in Ohio, where the population is growing slowly and aging, meaning more patients are leaving high-paying commercial insurers for lower-paying Medicare. The clinic has expanded in Florida, acquiring five hospitals to take advantage of population increases and wealthier patients there.

The London project will have 184 beds and eight operating rooms. Donley said it will be staffed primarily by U.K. physicians, including ones who also work for the National Health Service.

"The clinic has a long track record of being able to execute on its strategies," said Lisa Martin, an analyst at the bond rating agency Moody's Investors Service. "The London project is obviously the biggest venture and the biggest financial risk that they've made abroad."

Jordan Rau: jrau@kff.org, @JordanRau

Montana Tribe Welcomes Back Tourists After Risky Shutdown Pays Off

KFF Health News, June 21, 2021

Last year, the number of Glacier visitors plunged to 1.7 million after a record 3 million people visited in 2019. 

This article was published on Monday, June 21, 2021 in Kaiser Health News.

By Aaron Bolton

Millions of people will flock to Montana’s Glacier National Park this summer after last year’s pandemic-caused tourism skid, and they will once more be able sightsee and camp nearby on the recently reopened Blackfeet Indian Reservation.

The tourists’ return is a relief to the owners of the restaurants, campgrounds and hotels forced to shut down last summer when Blackfeet tribal leaders closed the roads leading to the eastern side of the popular park.

Those closures fed worries that a major economic driver for residents on the reservation would be crippled. But the tribe’s priority was protecting its elders and stemming the spread of the coronavirus. It worked: The closures and the tribe’s strictly enforced stay-at-home orders and mask mandate led to a low daily case rate held up as an example by federal health officials. Now, boasting one of the highest vaccination rates in the nation, the reservation is back open for business.

On a recent day at the Two Sisters Café, a stone’s throw from Glacier National Park’s eastern boundary, workers stacked dishes and stocked freezers in preparation for a busy season as demand soars for the wide-open spaces national parks can offer during the lingering pandemic.

Susan Higgins, co-owner of the cafe, said she’s seen more traffic whiz past her door than she’s seen at this time of year in nearly three decades. Some passersby stopped and poked their heads through the front door of the restaurant known for fresh huckleberry pies, only to leave disappointed because the restaurant didn’t open for the season until mid-June.

The situation is nothing like last year, when Higgins and sister Beth worried they would rack up massive debt just to survive. With the help of government loans and other grants, they were able to cover their bills and maintain their savings to expand the business.

“When everything happened, we were initially, of course, just concerned about just making it to this year,” Susan Higgins said.

Despite the uncertainty of the past year, Higgins said she supported the stringent measures taken by Blackfeet tribal leaders. The pandemic has disproportionately affected Native Americans, something Higgins is keenly aware of.

“With such a vulnerable population, I would have hated to see what would have happened last year if we had been open, especially with the issue of getting people to mask up,” Higgins said.

Last year, the number of Glacier visitors plunged to 1.7 million after a record 3 million people visited in 2019. Those who did come stayed and spent their money in non-Blackfeet communities on the western side of the Continental Divide.

The measures the tribe took slowed but didn’t stop the spread of covid. Daily cases surged in September, after the Northwest Montana Fair and Rodeo in August and Labor Day weekend, leading to a strictly enforced stay-at-home order, the tribe’s third, issued Sept. 28.

Daily cases then dropped from a peak of 6.4 per 1,000 per day on Oct. 5 to 0.19 on Nov. 7, a 33-fold drop that the Centers for Disease Control and Prevention held up as an example that such restrictions work.

Out of roughly 10,000 reservation residents, fewer than 50 Blackfeet tribal members have died of covid to date. Kimberly Boy, Blackfeet department of revenue director and a member of the incident command team that leads the tribe’s pandemic response, said she is certain their actions saved lives.

“It was the toughest job I’ve had so far in my life,” Boy said. “We had moved aggressively and extremely restrictive[ly] only due to the fact that our primary goal was to save as many lives as we can.”

The efforts bought time until the covid vaccines became available. Then, the tribe mounted a serious campaign that has resulted in about 85% of the total population — over 90% of adults — being fully vaccinated, according to tribal officials. The national average is about 44%, according to the CDC.

The Blackfeet’s vaccination campaign then stretched into Canada when tribal officials set up a clinic at the border for their counterparts in the Blackfoot Confederacy. The Blackfoot Confederacy, of which the Montana Blackfeet nation is a part, includes affiliated First Nations tribes who live on the Canadian side of the border.

The idea for the makeshift clinic was conceived after U.S. and Canadian officials denied requests to ship vaccines over the border, Blackfoot Confederacy Health Director Bonnie Healy said.

“We were joking, and I said that we’ll just have the Canadians from the confederacy stand on one side of the border and you guys vaccinate us over the fence and we’ll get it done,” Healy said.

Healy said that’s exactly happened in a sense, and the clinic was aptly named the “medicine line vaccine clinic,” referencing what the Blackfeet and Blackfoot call the U.S.-Canadian border that separates the different bands of the tribe.

Mark Pollock, a member of the Blackfeet Tribal Business Council, and others said the strong vaccination rate on the reservation in Montana is giving the tribe the confidence to open to tourists this summer.

Pollock hopes the season will go smoothly and covid can be eliminated among tribal members or cases remain very low. However, if cases rise, he said, the tribe could reduce the current 75% capacity limit on dine-in restaurants and bars, as well as reintroduce restrictive measures like curfews and limits on gatherings.

“Whatever it takes to get that number back down, get a handle on it,” Pollock said.

Jackie Conway owns the Heart of Glacier Campground near Glacier’s east gate with her husband, Steve, a tribal member. Conway said even with all 40 of her RV and camping sites booked for the season, she still can’t make up for last year’s 100% loss. Government relief helped the business survive over the past year.

She’s happy there will be a tourism season this summer but knows in the back of her mind that tribal leaders could shut things down anytime.

“The tribe gets spooked pretty easy. So, you just don’t know,” she said.

Angelika Harden-Norman owns the Lodgepole Gallery & Tipi Village just outside Browning, the reservation’s largest city. Standing in the gallery full of artwork by her late husband, Darrell Norman, and other Blackfeet tribal members, she said it’s up to business owners to keep guests safe and make sure this pandemic tourist season goes smoothly.

She used grant money to move her art gallery from the center of her home to another room with better ventilation. She’s also renovated the bathrooms of the two cabins for overnight guests so they are no longer shared.

“I will do my best to take the responsibility … by asking people to wear a mask when they come indoors to check in, to have hand sanitizers,” she explained.

At Two Sisters Café, Susan Higgins stood inside an unfinished drive-thru coffee stand just outside the restaurant. Higgins said she and her sister had thought about building a coffee stand in the past, but it was the uncertainty of how this season would go that pushed them to do it.

Higgins added she is requiring her workers to be vaccinated and hopes that will allow her to avoid shutting down her business this summer. So, for now, the coffee stand will serve as an addition to her business, but it’s also a Plan B should there be another shutdown.

“Primarily it is to assure ourselves of a continued cash flow should we get shut down again,” she explained.

What It Means When Celebrities Stay Coy About Their Vaccine Status

KFF Health News, June 21, 2021

While fans often know intricate details about athletes' knee joints and concussions, COVID vaccinations are another story.

This article was published on Monday, June 21, 2021 in Kaiser Health News.

By Eric Berger

When two St. Louis Blues hockey players were sidelined because of COVID-19 just days before this year's NHL playoffs, the team said young defenseman Jake Walman had been vaccinated against the deadly illness. But it was mum about the vaccination status of a more well-known player: star forward David Perron.

It wasn't until 10 days later — and after the Colorado Avalanche buried the team, without Perron touching the ice in any of the series' four games — that he begrudgingly acknowledged he had been vaccinated.

"I don't want to talk about that anymore," Perron, the team's leading scorer, said at a press conference.

While fans often know intricate details about athletes' knee joints and concussions, COVID vaccinations are another story. Reticence is common among professional athletes. Vaccination status is also a point of secrecy among some Republican lawmakers, other public figures and even many regular people.

Public health leaders say that people in the limelight do not have an obligation to announce or answer media questions about their vaccination status, but many add that they hoped more well-known names would become role models for getting the vaccines.

Instead, they say, the politicization of the shots, misinformation and flawed public messaging from the federal government have made the vaccines controversial and something some public figures are reluctant to endorse, which then ripples across society.

President Joe Biden is trying to get at least 70% of the nation vaccinated by July 4. So far, according to the Centers for Disease Control and Prevention, 53% of Americans have received at least one dose.

"I continue to be hopeful that celebrities will share their vaccination status and use their platform to encourage people to get vaccinated," said Thomas LaVeist, a sociologist and the dean of the School of Public Health and Tropical Medicine at Tulane University. "But I haven't seen a lot of celebrities really embrace that role."

LaVeist and others in public health hoped someone would step up as Elvis Presley did in 1956 to help increase the low rate of polio vaccinations. He received his shot on "The Ed Sullivan Show."

But that occurred years after the polio vaccine was developed, whereas the COVID vaccines became available less than a year after the onset of the pandemic.

"We still have not done a good enough job of explaining to people how and why it is that we were able to have a vaccine developed so quickly, and a lot of people have questions about whether corners were cut," said LaVeist, who criticized the Trump administration's decision to call its vaccine development program Operation Warp Speed.

Former President Donald Trump also hurt vaccination efforts among Republicans when he received his vaccine privately rather than in a public setting like Biden and other former presidents, said Gregory Zimet, a behavioral scientist who studies vaccination at Indiana University School of Medicine.

When CNN conducted a survey of congressional lawmakers in May, 95 of the 212 Republican House members said they had received the vaccines and 112 Republican offices did not respond at all. (All congressional Democrats said they had received the vaccines.)

"For some individuals, particularly if their social circle is very anti-vaccine or skeptical of the vaccine, it can feel very uncomfortable to come out and say, 'I got vaccinated,'" Zimet said.

Sports stars, who are often asked about their health, could change public perceptions of the vaccines, said Nancy Berlinger, a bioethicist at the Hastings Center, a research institute in Garrison, New York.

"In the worst days of HIV-AIDS, the fact that Magic Johnson was willing to talk about being HIV-positive changed public conversation in this country," Berlinger said. "Not everyone is able to step into that role."

Basketball king LeBron James, when asked if he planned to get a COVID vaccine, told reporters in March, "That's a conversation that my family and I will have. Pretty much keep that to a private thing."

Jennifer Reich, a sociologist at the University of Colorado-Denver who has studied vaccine hesitancy, thinks that James and other NBA stars could be reluctant to promote the vaccines because of the way athletes have been castigated in recent years for taking stands on hot-button issues.

But James has expressed support for the Black Lives Matter movement and called for the prosecution of police officers who shot and killed Breonna Taylor, a Black medical worker, in her Kentucky apartment.

"It's not like he is someone who has been a shrinking violet and has not stepped into the public arena to make very strong statements about inequities and problems in our society," Zimet said. "So, it's a little hypocritical that he would now say, 'This is a private issue.'"

Not everyone in public health is convinced, though, that what James, Perron and other celebrities say is crucial to vaccination efforts.

Sandra Crouse Quinn, a professor of family science at University of Maryland, studied the role of communication in vaccine acceptance during events such as the 2009 H1N1 pandemic. She found that while public figures' disclosures can make a difference, they are not as important as endorsements from "people we care about and people who care about us," she said.

"If Beyoncé came out with a vaccine video, would people watch it? Yes," Quinn said. "Is it entertainment? Yes. Does it move somebody? Not necessarily, because her life is so dramatically different" than that of an ordinary person.

But Timothy Caulfield, a law professor at the University of Alberta and the author of a book on vaccine myths, believes celebrities can make a big difference, pointing to actor Jenny McCarthy's role in the anti-vaccine movement.

"The role that pop culture can play in normalization is a constructive role," Caulfield said. "We are getting close to that hesitancy hurdle in jurisdictions where you are getting 60-65% of people vaccinated, so this messaging may seem trivial, but it matters when you are talking about trying to get another 2% or 3% of the population vaccinated."

During the time when Perron was quiet during the playoff series, sportswriters and fans speculated about his vaccination status. At the press conference where he revealed his vaccination after being questioned about it, Perron said, "I don't know why it's a big deal." He pointed out that he and two other players had gotten COVID despite being vaccinated.

"It's unfortunate and shows that it's not perfect," he said, adding that, among his teammates, "I can tell you that we support each individual to make their own decision."

Even if Perron had declined a vaccine or not revealed his status, some fans would likely not have held it against him.

Thomas Welch, who hosts a hockey podcast, "Locked On Blues," quickly decided to get vaccinated because his father and brother have Crohn's disease, which means they could face a greater risk from the coronavirus. But Welch said he understands that for some people the vaccines might not make sense for various reasons.

"As much as we love talking about these players and breaking down the analytics of the sport, at the end of the day, each of these players are people," said Welch, who lives in Jefferson County, outside St. Louis. "We lose sight of that a lot."

'It's a Mission': Volunteers Treat Refugees Massing at the Border

KFF Health News, June 21, 2021

New guidelines issued in February by the Biden administration require migrants seeking asylum to register online or via phone from their home countries.

This article was published on Monday, June 21, 2021 in Kaiser Health News.

By Heidi de Marco

TIJUANA, Mexico — El Chaparral Plaza once teemed with tourists, street vendors and idling taxis. But the plaza, just outside the San Ysidro port of entry on the Mexican side of the border, now serves as a sprawling refugee camp where migrants from Mexico, Central America and Haiti wait in limbo while they seek asylum in the U.S.

Dr. Hannah Janeway, an emergency medicine physician who works in a Los Angeles hospital but volunteers at the border, estimates at least 2,000 people are jammed into tents and repurposed tarps here, living without running water and electricity.

Survival is the pressing concern, not COVID.

"The encampment just keeps growing day by day," Janeway said.

A record number of migrants are making the often long and perilous journey to the border. U.S. Customs and Border Protection apprehended 180,034 people at the southern border in May, a 78% increase since February. By comparison, border agents apprehended about 144,000 people in May 2019.

New guidelines issued in February by the Biden administration require migrants seeking asylum to register online or via phone from their home countries, get tested for the coronavirus in Mexico and then come to a U.S. port of entry on a specific day for their asylum interviews. The goal is to reduce the number of people making the dangerous trek and alleviate the waiting in border towns like Tijuana — but people continue to show up without going through the process.Bottom of Form

"As I was driving here, I just saw two buses drop off a group of migrants," Janeway said. "Where are they going to go?"

Because migrant shelters were already at capacity before this year's influx of migrants, many end up at the El Chaparral camp, where food and medical care are scarce and there is little access to sanitation facilities — other than hand-washing stations and portable toilets.

Janeway, who co-directs the Refugee Health Alliance, a nonprofit organization that provides medical care to migrants at the U.S.-Mexico border in Tijuana, visits the camp two to three times a month to tend to patients and spread the word about the nearby clinic she opened in 2018, located a few blocks from the plaza.

The clinic, Resistencia en Salud, provides free care and depends on donations and a mostly volunteer staff to keep the doors open.

"I believe that the people that I'm serving deserve to have healthcare and a reduction to their suffering," Janeway said.

The clinic is small and basic, with two exam rooms. Staffers coordinate with Mexico's public health system to handle patients who need more specialized care, such as surgery or chemotherapy.

On a recent Thursday, Janeway made her way along the edge of the camp — lined with tents, tarps fashioned into makeshift shelters and mounds of trash — to check on the water tank supply her organization provides. She said the Mexican government is not providing much in the way of healthcare or essential provisions, like water.

The office of Baja California's secretary of health (Secretaría de Salud de Baja California) did not respond to multiple requests for comment.

"It's the government's responsibility, but I don't want to play a game of chicken with them about water," she said. "It's critical. There are all these kids here with [gastrointestinal] illnesses."

At the clinic, Janeway and her staff "see it all," she said: heart problems, back pain, cancer, assault injuries. In addition to medical treatment, Resistencia en Salud provides mental health services and support to the LGBTQ community.

By the time doors opened at 10:30 a.m., a line of people were waiting to sign up. Some were turned away because the clinic hit capacity. Octavio Alfaro and his 12-year-old son, whose knees had been hurting, were among the hopefuls.

The 53-year-old from Villanueva, Cortés, in Honduras, had been waiting for asylum for 2½ years.

"My story is cruel," he said.

Alfaro left Honduras with his three children, fleeing gang violence. "In Honduras, you cannot risk starting a business because if you don't pay what the gangs charge you, they will put you in the ground," he said. "They wanted to take my son and were ready to kidnap my daughter to do what they do to young girls."

Stories like his are common in the encampment, he said. "That's why we come. For a better life for these kids."

Alfaro met Janeway at the El Chaparral encampment in late May. She quickly wrote an advocacy letter in support of his 14-year-old daughter Brenda's asylum claim. Brenda has a cardiac murmur that requires immediate surgery in the U.S. "She needs to be seen by a specialist," Janeway said. "She can't get that type of care here."

Janeway said many patients like Alfaro and his family are just trying to survive in Tijuana's encampments and overcrowded shelters, where they fear being assaulted or robbed. Navigating the pandemic is secondary.

The clinic has seen only a handful of COVID patients, Janeway said, and, as far as she knows, no one is vaccinating migrants.

Nurse Luz Elena Esquivel said she tries to educate patients about maintaining distance and wearing masks, "but sometimes it seems impossible," she said. "It's not their priority. Their priority is crossing."

On this day, a dozen clinic staff members saw 55 people in about six hours. They moved in synchrony from patient to patient, attempting to treat as many as possible, including a 3-year-old child from Honduras who was so small he appeared 6 months old, a Mexican transgender woman in need of hormone therapy and a Haitian man complaining of chest pain. In the middle of it all, they rushed to treat a man who collapsed in the waiting area.

The latest wave of migrants has put a strain on the clinic, which needs more money, more volunteers and another doctor. "The working conditions aren't that good. And the salaries we can offer aren't either," Janeway said. "But the people who are here are here because they are very dedicated to helping this population. It's a mission."

Dr. Christian Armenta, a family physician at the clinic, was born and raised in Tijuana. He started working at the clinic in the midst of the pandemic. "It was very scary in the beginning, but I adapted quickly," he said. "As a doctor and a Tijuanense, I have to generate some sort of impact to better my city."

About 95% of the patients are migrants, he said. The rest are people from Tijuana who live on the streets or in shelters. "The environment in which they are living creates the perfect storm to generate health problems," he said.

Alfaro, a construction worker by trade, was robbed more than once. "I've been mistreated here," he said. "My tools have been stolen twice."

Even so, Alfaro said he feels like a child of Tijuana. "The people I have met here are like my family."

In the middle of her shift, Janeway stepped out of the clinic to deliver some good news to Alfaro.

"I just talked to the lawyers and they told me that you have a date to cross on June 8," she said.

"Glory to God," Alfaro said. "I'm so happy. If I've learned one thing here, it's to have patience."

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

Heidi de Marco: heidid@kff.org, @Heidi_deMarco

Nurses and Docs at Long Beach Center 'Consider It an Honor' to Care for Migrant Children

KFF Health News, June 21, 2021

The city provides one of more than a dozen temporary homes the federal government has set up for a massive influx of children.

This article was published on Monday, June 21, 2021 in Kaiser Health News.

By Stephanie Stephens

The 5-year-old had nodded off while waiting for her 10-year-old brother to be treated for scabies at the clinic in the Long Beach Convention & Entertainment Center, which she currently calls home. Nurse Chai-Chih Huang asked if she wanted to be taken back to her dormitory to sleep.

"She looked so sad and didn't say anything," Huang recalled. The girl's brother explained that they had been separated for a week during their journey. His sister cried every day without him, he said. Now, she wanted to stick close at all times.

"This has been pretty hard," Huang told KHN later. She knew few details of the siblings' story, but many of the children at the center had trekked across hundreds of miles of dangerous lands guided by a smuggler.

The siblings, not named for privacy reasons, are among the hundreds of children, mostly from Central America, attempting to cross the U.S. border alone from Mexico each day. After brief detention by the Border Patrol, they are sent to shelters run by the Department of Health and Human Services while officials seek to unite them with relatives or other sponsors in the United States.

Long Beach offered housing at its convention center as part of a Biden administration effort to move children more quickly from the forbidding border housing where they are held initially. Those harsh settings, where at least five children died in 2018 and 2019, provoked a backlash against the Trump administration's immigration policies.

The Long Beach location is one of more than a dozen temporary homes the federal government has set up for a massive influx of children. On June 14, it housed 115 children — a mix of girls up to age 17 and boys up to 12, out of consideration for their privacy and safety, an HHS official said — and had connected 755 others with relatives or sponsors since the first children arrived on April 22. Federal officials, citing the safety and privacy of the children, have not allowed KHN or other news media to enter the facility currently.

The children arrive at the Long Beach facility by bus, scared and timid but "very well behaved," said Huang, director of pediatric nursing at Mattel Children's Hospital of UCLA Health, who is doing temporary duty at the shelter. "They warm up to the staff here and when they get to know you and start talking to you, it melts your heart."

DRC Emergency Services, a government contractor that typically performs jobs like debris removal after hurricanes, subcontracted with UCLA Health, UCI Health, Children's Hospital of Orange County and other providers to care for the children.

"We can imagine they have been through a lot," said Jennie Sierra, nursing director in the neonatal intensive care unit at the Orange County hospital. "They're very grateful, and they're an amazing, resilient group."

"Most of my nurses here come from immigrant families, and we consider it an honor and privilege to serve in this capacity," she said.

Before this year's surge of migrants at the U.S. border, HHS ran about 200 such facilities in 22 states and has announced plans to double capacity by adding about 18,500 emergency beds this year. It has signed $400 million in contracts to provide services for unaccompanied children. The federal government is paying about $35 million to house and care for the children at the Long Beach convention center through Aug. 2.

"Border Patrol stations were never designed to be places for minors to be held for any period of time," said Border Patrol spokesperson Matthew Dyman. The cells were intended for "single adult males to be quickly turned around — and not for families or children."

The Border Patrol can legally hold the children 72 hours before putting them in the custody of HHS' Office of Refugee Resettlement, which looks for relatives or sponsors in the U.S. pending immigration hearings.

On a recent day, June 14, HHS was caring for 15,365 children at facilities around the country and discharged 412 into communities. HHS Secretary Xavier Becerra said in May that the agency had reduced time spent in the emergency shelters to an average of 29 days, down from 40 days in late January.

Within two days of their arrival at Long Beach, the children get a health assessment at a pediatric clinic set up by UCLA Health.

Many come with chronic headaches and stomachaches. Some have rough or broken skin, swollen and infected feet, or rashes caused by filth and clothes rubbing against skin on long marches. Some have colds — or COVID; as of Monday, two cases were recorded among children at the convention center. The children stay in isolation and receive appropriate care.

While mental health therapy is limited, visibly sad or anxious children can get counseling and children can take part in weekly group discussions overseen by clinicians, said David Kosub, a federal spokesperson for the Long Beach site. Referrals are provided in the communities to which they are moving, he said.

Caring for the kids "has been very moving and meaningful, even life-changing," said Dr. Charles Golden, a pediatrician and executive medical director of Children's Hospital of Orange County's primary care network.

The doctors and nurses feel loved by their charges, he said. One day, Golden saw a group of children sitting in a circle, playing games. "They came over and gave me a big hug."

UCLA staffers painted murals for the children, who have access to classrooms, indoor and outdoor play spaces and TVs, soccer nets, hula hoops and ample board games.

They have books, and music from their homelands: punta, marimba, merengue, cumbia and bachata, said UCLA Health child life specialist Tracy Reyes Serrano. Performers have played for the children, too, she said.

"When the kids hear songs they recognize, it lifts their spirits; they're quick to get up and dance and sing, and we're happy to join them," she said.

The Long Beach Community Foundation launched a Migrant Children Support Fund that has raised $200,000, said foundation president and CEO Marcelle Epley. The money has gone to educational programs and toys, as well as gift cards that HHS can distribute once the children are settled with families. Long Beach residents have donated books, toys and personalized notes in Spanish.

Sierra recalled a girl who said she wanted to learn English and become a pediatrician.

"I told her, 'This is a great country with great opportunities. You're going to be an amazing doctor,'" Sierra said.

U.S. Rep. Nanette Diaz Barragán (D-Calif.), who represents North Long Beach and the Port of Los Angeles, visited the center May 6 and met children who "seemed to be in a state of hope, smiling and anxious to talk," including a young boy from Honduras.

"He was very happy until I asked about his home country and he looked like he wanted to cry," she said. "Someone in our group said, 'It's beautiful there,' and he said 'No, it's bad,' and talked about gangs and violence. He was willing to disagree with an adult."

The children's histories are mostly a mystery to their temporary caretakers, said Jennifer Sablan Panopio, a nurse manager in UCI Health's neonatal intensive care unit who has been the health system's lead nurse in Long Beach. "We can at least help give them a positive experience here, a good start."

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

Stephanie Stephens: @StephStephens

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