A Hospital Charged $722.50 to Push Medicine Through an IV. Twice.

KFF Health News, June 28, 2021

As hospitals disaggregate charges for services, there has been a proliferation of newfangled fees to increase billing. In the field, this is called "unbundling."

This article was published on Monday, June 28, 2021 in Kaiser Health News.

By Rae Ellen Bichell

Claire Lang-Ree was in a lab coat taking a college chemistry class remotely in the kitchen of her Colorado Springs, Colorado, home when a profound pain twisted into her lower abdomen. She called her mom, Jen Lang-Ree, a nurse practitioner who worried it was appendicitis and found a nearby hospital in the family's health insurance network.

After a long wait in the emergency room of Penrose Hospital, Claire received morphine and an anti-nausea medication delivered through an IV. She also underwent a CT scan of the abdomen and a series of tests.

Hospital staffers ruled out appendicitis and surmised Claire was suffering from a ruptured ovarian cyst, which can be a harmless part of the menstrual cycle but can also be problematic and painful. After a few days — and a chemistry exam taken through gritted teeth — the pain went away.

Then the bill came.

Patient: Claire Lang-Ree, a 21-year-old Stanford University student who was living in Colorado for a few months while taking classes remotely. She's insured by Anthem Blue Cross through her mom's work as a pediatric nurse practitioner in Northern California.

Total Bill: $18,735.93, including two $722.50 fees for a nurse to "push" drugs into her IV, a process that takes seconds. Anthem's negotiated charges were $6,999 for the total treatment. Anthem paid $5,578.30, and the Lang-Rees owed $1,270 to the hospital, plus additional bills for radiologists and other care. (Claire also anted up a $150 copay at the ER.)

Service Provider: Penrose Hospital in Colorado Springs, part of the regional healthcare network Centura Health.

What Gives: As hospitals disaggregate charges for services once included in an ER visit, a hospitalization or a surgical procedure, there has been a proliferation of newfangled fees to increase billing. In the field, this is called "unbundling." It's analogous to the airlines now charging extra for each checked bag or for an exit row seat. Over time, in the health industry, this has led to separate fees for ever-smaller components of care. A charge to put medicine into a patient's IV line — a "push fee" — is one of them.

Though the biggest charge on Claire's bill, $9,885.73, was for a CT scan, in many ways Claire and her mom found the push fees most galling. (Note to readers: Scans often are significantly more expensive when ordered in an ER than in other settings.)

"That was so ridiculous," said Claire, who added she had previously taken the anti-nausea drug they gave her; it's available in tablet form for the price of a soda, no IV necessary. "It works really well. Why wasn't that an option?"

In Colorado, the average charge for the code corresponding to Claire's first IV push has nearly tripled since 2014, and the dollars hospitals actually get for it has doubled. In Colorado Springs specifically, the cost for IV pushes rose even more sharply than it did statewide.

A typical nurse in Colorado Springs makes about $35 an hour. At that rate, it would take nearly 21 hours to earn the amount of money Penrose charged for a push of plunger that likely took seconds or at most minutes.

The hospital's charge for just one "IV push" was more than Claire's portion of the monthly rent in the home she shared with roommates. In the end, Anthem did not pay the push fees in its negotiated payment. But claims data shows that in 2020 Penrose typically received upward of $1,000 for the first IV push. And patients who didn't have an insurer to dismiss such charges would be stuck with them. Colorado hospitals on average received $723 for the same code, according to the claims database.

"It's insane the variation that we see in prices, and there's no rhyme or reason," said Cari Frank with the Center for Improving Value in Healthcare, a Colorado nonprofit that runs a statewide healthcare claims database. "It's just that they've been able to negotiate those prices with the insurance company and the insurance company has decided to pay it."

Penrose initially charged more money for Claire's visit than the typical Colorado hospital would have charged for live birth, according to data published by the Colorado Division of Insurance.

Even with the negotiated rate, "it was only $1,000 less than an average payment for having a baby," Frank said.

In an emailed statement, Centura said it had "conducted a thorough review and determined all charges were accurate" and went on to explain that "an Emergency Room (ER) must be prepared for anything and everything that comes through the doors," requiring highly trained staff, plus equipment and supplies. "All of this adds up to large operating costs and can translate into patient responsibility."

Do you have an exorbitant or baffling medical bill? Join the KHN and NPR 'Bill of the Month' Club and tell us about your experience. We'll feature a new one each month.

As researchers have found, little stands in the way of hospitals charging through the roof, especially in a place like an emergency room, where a patient has no choice. A report from National Nurses United found that hospital markups have more than doubled since 1999, according to data from the United States Bureau of Labor Statistics. In an email, Anthem called the trend of increasing hospital prices "alarming" and "unsustainable."

But Ge Bai, an associate professor of accounting and health policy at Johns Hopkins University, said that when patients see big bills it isn't only the hospital's doing — a lot depends on the insurer, too. For one, the negotiated price depends on the negotiating power of the payer, in this case, Anthem.

"Most insurance companies don't have comparable negotiating or bargaining power with the hospital," said Bai. Prices in a state like Michigan, where Bai said the autoworkers union covers a big portion of patients, will look very different from those in Colorado.

 Also, insurers are not the wallet defenders patients might assume them to be.

"In many cases, insurance companies don't negotiate as aggressively as they can, because they earn profit from the percentage of the claims," she said. The more expensive the actual payment is, the more money they get to extract.

Though Anthem negotiated away the push fees, it paid the hospital 30% more than the average Level IV emergency department visit in Colorado that year, and it paid quadruple what Medicare would allow for her CT scan.

Resolution: Claire and her mom decided to fight the bill, writing letters to the hospital and searching for information on what the procedures should have cost. The prices of the IV pushes and the CT scan infuriated them — the hospital wanted more than double what top-rated hospitals typically charged in 2019.

But the threat of collections wore them out and ultimately they paid their assigned share of the bill, $1,420.45, which was mostly coinsurance.

"Eventually it got to the point where I was like, 'I don't really want to go to collections, because this might ruin my credit score,'" said Claire, who didn't want to graduate from college with dinged credit.

Bai and Frank said Maryland can be a useful benchmark for medical bills, since the state sets the prices that hospitals can charge for each procedure. Data provided by the Maryland Healthcare Commission shows that Anthem and Claire paid seven times what she likely would have paid for the CT scan there, and nearly 10 times what they likely would have paid for the Level IV ER visit. In Maryland, IV pushes typically cost about $200 apiece in 2019. A typical Maryland hospital would have received only about $1,350 from a visit like Claire's, and the Lang-Rees would have been on the hook for about $270.

Claire's pain has come back a few times but never as bad as that night in Colorado. After visiting multiple specialists back home in California, she learned it might have been a condition called ovarian torsion. Claire has avoided reentering an emergency room.

The Takeaway: Even at an in-network facility and with good insurance, patients can get hurt financially by visiting the ER. A few helpful documents can help guide the way to fighting such charges. The first is an itemized bill.

"I just think it's wrong in the U.S. to charge so much," said Jen Lang-Ree. "It's just a little side passion of mine to look at those and make sure I'm not being scammed."

Bai, of Johns Hopkins, suggests asking for an itemized explanation of benefits from the insurance company, too. That will show what the hospital actually received for each procedure.

Find out if the hospital massively overcharged. The Medicare price lookup tool can be useful for getting a benchmark. And publicly available data on health claims in Colorado and at least 17 other states can help, too.

Vincent Plymell with the Colorado Division of Insurance encourages patients to reach out if something looks sketchy. "Even if it's not a plan we regulate," he wrote in an email, such departments "can always arm the consumer with info."

Finally, make it fun. Claire and Jen made bill-fighting their mother-daughter hobby for the winter. They recommend pretzel chips and cocktails to boost the mood.

Bill of the Month is a crowdsourced investigation by KHN and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!

Rae Ellen Bichell: rbichell@kff.org, @raelnb

COVID's Lingering Effects Can Put the Brakes on Elective Surgeries

KFF Health News, June 28, 2021

As the number of people who have had COVID grows, medical experts are trying to determine when it's safe for them to have elective surgery.

This article was published on Monday, June 28, 2021 in Kaiser Health News.

By Michelle Andrew

The week before Brian Colvin was scheduled for shoulder surgery in November, he tested positive for COVID-19. What he thought at first was a head cold had morphed into shortness of breath and chest congestion coupled with profound fatigue and loss of balance.

Now, seven months have passed and Colvin, 44, is still waiting to feel well enough for surgery. His surgeon is concerned about risking anesthesia with his ongoing respiratory problems, while Colvin worries he'll lose his balance and fall on his shoulder before it heals.

"When I last spoke with the surgeon, he said to let him know when I'm ready," Colvin said. "But with all the symptoms, I've never felt ready for surgery."

As the number of people who have had COVID grows, medical experts are trying to determine when it's safe for them to have elective surgery. In addition to concerns about respiratory complications from anesthesia, COVID may affect multiple organs and systems, and clinicians are still learning the implications for surgery. A recent study compared the mortality rate in the 30 days following surgery in patients who had a COVID infection and in those who did not. It found that waiting to undergo surgery for at least seven weeks after a COVID infection reduced the risk of death to that of people who hadn't been infected in the first place. Patients with lingering COVID symptoms should wait even longer, the study suggested.

But, as Colvin's experience illustrates, such guideposts may be of limited use with a virus whose effect on individual patients is so unpredictable.

"We know that COVID has lingering effects even in people who had relatively mild disease," said Dr. Don Goldmann, a professor at Harvard Medical School who is a senior fellow and chief scientific officer emeritus at the Institute for Healthcare Improvement. "We don't know why that is. But it's reasonable to assume, when we decide how long we should wait before performing elective surgery, that someone's respiratory or other systems may still be affected."

The study, published in the journal Anaesthesia in March, examined the 30-day postoperative mortality rate of more than 140,000 patients in 116 countries who had elective or emergency surgery in October. Researchers found that patients who had surgery within two weeks of their COVID diagnosis had a 4.1% adjusted mortality rate at 30 days; the rate decreased to 3.9% in those diagnosed three to four weeks before surgery, and dropped again, to 3.6%, in those who had surgery five to six weeks after their diagnosis. Patients whose surgery occurred at least seven weeks after their COVID diagnosis had a mortality rate of 1.5% 30 days after surgery, the same as for patients who were never diagnosed with the virus.

Even after seven weeks, however, patients who still had COVID symptoms were more than twice as likely to die after surgery than people whose symptoms had resolved or who never had symptoms.

Some experts said seven weeks is too arbitrary a threshold for scheduling surgery for patients who have had COVID. In addition to patients' recovery status from the virus, the calculus will be different for an older patient with chronic conditions who needs major heart surgery, for example, than for a generally healthy person in their 20s who needs a straightforward hernia repair.

"COVID is just one of the things to be taken into account," said Dr. Kenneth Sharp, a member of the Board of Regents of the American College of Surgeons and vice chair of the Department of Surgery at Vanderbilt University Medical Center.

In December, the American Society of Anesthesiologists and the Anesthesia Patient Safety Foundation issued these guidelines for timing surgery for former COVID patients:

• Four weeks if a patient was asymptomatic or had mild, non-respiratory symptoms.

• Six weeks for a symptomatic patient who wasn't hospitalized.

• Eight to 10 weeks for a symptomatic patient who has diabetes, is immunocompromised or was hospitalized.

• Twelve weeks for a patient who spent time in an intensive care unit.

Those guidelines are not definitive, according to the groups. The operation to be performed, patients' medical conditions and the risk of delaying surgery should all be factored in.

"Long COVID" patients like Colvin who continue to have debilitating symptoms months after 12 weeks have passed require a more thorough evaluation before surgery, said Dr. Beverly Philip, president of the society.

Now that COVID has been brought to heel in many areas and vaccines are widely available, hospital operating rooms are bustling again.

"In talking to surgical colleagues, hospitals are really busy now," said Dr. Avital O'Glasser, medical director of the outpatient preoperative clinic at Oregon Health and Sciences University in Portland. "I've seen patients with delayed knee replacements, bariatric surgery, more advanced cancer."

At the beginning of the pandemic, surgical volumes dropped dramatically as many hospitals canceled nonessential procedures and patients avoided facilities packed with COVID patients.

From March to June 2020, the number of inpatient and outpatient surgeries at U.S. hospitals was 30% lower than in the same period the year before, according to McKinsey & Company's quarterly Health System Volumes Survey. By May 2021, surgical volumes had mostly rebounded, and were just 2% lower than their May 2019 totals, according to the May survey.

Oregon Health and Sciences University clinicians developed a protocol a year ago for clearing any patient who had COVID for elective surgery. When obtaining patients' medical history and conducting physical exams, clinicians look for signs of COVID complications that aren't readily identifiable and determine whether patients have returned to their pre-COVID level of health.

The pre-op exam also includes lab and other tests that evaluate cardiopulmonary function, coagulation status, inflammation markers and nutrition, all of which can be disrupted by COVID.

If the assessment raises no red flags, patients can be cleared for surgery once they have waited the minimum seven weeks since their COVID diagnosis.

Originally, the minimum wait for surgery was four weeks, but clinicians pushed it back to seven after the international study was published, O'Glasser said.

"We are still learning about COVID, and uncertainty in medicine is one of the biggest challenges we face," said O'Glasser. "Right now, our team is erring on the side of caution."

At Memorial Sloan Kettering Cancer Center in New York, doctors don't follow a specific protocol. "We're taking every patient one at a time. There are no hard-and-fast rules at this institution," said Dr. Jeffrey Drebin, chair of surgery.

Clinicians work to find a balance between the urgency of the cancer surgery and the need to allow enough time to ensure COVID recovery, he said.

For Brian Colvin, whose right rotator cuff is torn, delaying surgery is painful and may worsen the tear. But the rest of his life is on hold, too. A sales representative for an auto parts company, he hasn't been able to work since he got sick. His balance problems make him reluctant to stray far from his home in Crest Hill, Illinois, the Chicago suburb where he lives with his wife and 15-year-old son.

Some days he has more energy and isn't as short of breath as others. Colvin hopes it's a sign he's slowly improving. But at this point, it's hard to be optimistic about the virus.

"It's always something," he said.

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

Doctors' Lobby Scores 'Major Victory' on Bill to Hold Physicians Accountable

KFF Health News, June 28, 2021

This year's bill was approved by the state Senate after it was amended under pressure from the doctors' group. 

This article was first published on Monday, June 28, 2021 in Kaiser Health News.

By Samantha Young

SACRAMENTO, Calif. — The board that licenses and disciplines doctors in California is failing to hold bad actors accountable, endangering patients in the process.

That's the verdict of state lawmakers and patient advocates who have been working for years to reform the Medical Board of California.

But an attempt this year to give the board more money and power to investigate complaints of fraud, gross negligence, sexual misconduct and other misbehavior is under attack from one of the most politically potent forces in California's Capitol: doctors themselves.

And so far, it seems, the doctors are winning.

The California Medical Association (CMA), whose top lobbyist sat next to Gov. Gavin Newsom at the infamous French Laundry dinner last fall, swooped in to slash a proposed hike on physicians' licensing fees even though the board, which relies on those fees, is teetering on insolvency. It also beat back a proposal to put more non-physician members of the public on the board, which would have diminished the influence of the doctors who represent a majority.

"The strength and the power of the CMA is that they are able to deflect and obstruct the beneficial and necessary legislation to protect the consumer and to ensure the success of the medical board," said former state Sen. Jerry Hill, who four years ago lost his push to overhaul the board. "That's what I found, and that's what I see occurring this year."

This year's bill was approved by the state Senate after it was amended under pressure from the doctors' group. The measure is now before the state Assembly, where it remains a target of the California Medical Association. As currently written, SB 806 would authorize a smaller licensing fee increase, restore the board's authority to recoup investigative costs from doctors who have been disciplined and create an independent monitor to evaluate the board's complaint and disciplinary processes.

The mission of the medical board, composed of eight physicians and seven members of the public, is to license and discipline doctors. But critics say the board has allowed some doctors who have committed wrongdoing to keep their licenses, despite reports of egregious behavior, while families complain they've been left in the dark for years.

The board received 10,868 complaints in the 2019-20 fiscal year. During that period, it initiated 1,956 investigations, revoked 35 physician licenses, put 170 doctors on probation and reprimanded 108 doctors, according to the board's 2019-2020 Annual Report. An additional 96 physicians surrendered their licenses.

In his independent review of cases that came before the panel last year, board member Eserick "TJ" Watkins told lawmakers the board had settled 84% of complaints, with a bias toward allowing doctors to continue to practice without real rehabilitation.

"This board's value is we protect the doctors, and we'll go over and above in order to do so," said Watkins, one of the board's members representing the public.

Earlier this year, the board's executive director told lawmakers the board is taking longer to investigate complex cases than it did six years ago, in part because of more complaints and vacancies among the board's support staff. In fiscal year 2019-20, those cases took an average of 548 days from start to end, he said, compared with 310 in fiscal year 2013-14.

Patients and their families who have testified at legislative hearings describe an unresponsive and uncommunicative board that usually allows doctors accused of negligence or malpractice to continue to practice.

"I thought there would be a lot of integrity and thoroughness to the investigation process, and I didn't get a sense that the medical board really looked at the matter," said Alka Airy, who in 2019 filed a complaint of unprofessional conduct and potential negligence against the University of California-San Francisco's Lung Transplant Program after her sister, Shilpa Airy, died the year before.

According to the complaint, doctors who treated Shilpa Airy between 2015 and 2018 failed to evaluate how her lung failure affected her heart or refer her to a cardiologist. She died of end-stage heart failure while waiting for a lung transplant. Airy said the board closed the complaint without taking action. The board declined to comment.

By comparison, when Alka Airy filed a complaint with the California Board of Registered Nursing, she said, she was interviewed by an investigator who requested additional records beyond what the doctors or hospital may have provided. Airy said she is still waiting to learn the outcome of the case.

A UCSF spokesperson said its clinicians have fully cooperated with all investigators and could not comment on pending investigations.

"I think my experience was very similar to thousands of other folks who sent in complaints to the medical board," Airy said. "It's not a transparent process. So much happens behind closed doors."

Board spokesperson Carlos Villatoro said the board bases its disciplinary decisions "on the facts and circumstances of each case" to determine whether revoking a physician's license is necessary.

"The board does not have the authority to punish a licensee by imposing a level of discipline that goes beyond what is necessary to protect the public," Villatoro said via email.

Advocates for patients and even some board members believe that tipping the board's balance of power to public members could regain some of the public's trust. But that provision was removed from this year's bill after the California Medical Association argued the panel — like other comparable state boards — needed the expertise of people in the profession it regulates.

Dr. Howard Krauss, himself a former trustee of the CMA, has been on the board for eight years. In that time, he said, he's never witnessed a decision that pitted physicians on the board against public members.

"The optics of having a board with one more public member than a physician might be of benefit," Krauss said at an emergency hearing this month.

Critics say the board also lacks the resources and the ability to pursue timely investigations, hamstrung by a legislature beholden to the CMA, whose 50,000 pediatricians, surgeons and other physicians are influential members of every lawmaker's district.

The California Medical Association is one of the most prolific campaign contributors in Sacramento and has given to Newsom and all but one of the 119 lawmakers currently serving in the state legislature.

In addition to making campaign contributions directly to lawmakers, the association spent $18.6 million between Jan. 1, 2011, and March 30, 2021, lobbying lawmakers and state agencies on a variety of issues, from flavored tobacco to medical malpractice caps, according to records filed with the California secretary of state's office. It employs its own lobbyists and hires outside lobbying firms.

The group routinely scores access to the state's top leaders. Among the movers and shakers at the French Laundry dinner party in Napa Valley in November were the association's top lobbyist, Janus Norman, and CEO, Dustin Corcoran.

CMA spokesperson Anthony York said the organization is "like any other group in the Capitol" that advocates for its members. He said the $367 increase in licensing fees that lawmakers initially proposed — from $783 to $1,150 — would have been too big a burden on doctors who fought to stay open during the pandemic.

Family medicine physicians in California earned an average annual wage of $220,240 as of the first quarter of this year, according to the state Employment Development Department. "A lot of physician practices are struggling to keep their doors open," York said. "Now is not the time for a fee increase."

After state Sen. Richard Roth (D-Riverside) introduced the legislature's must-pass bill to reauthorize the medical board in May, the CMA issued an "action alert" to its members, urging doctors to call, text and email their senators to voice their opposition. Eight days later, it declared a partial victory when Roth amended his bill to lower the fee increase to $863 and eliminate a requirement that the board be controlled by public members, a provision that had been backed by Senate leader Toni Atkins.

"While the bill is not perfect," the association wrote on its website, the removal of those provisions "was a major victory."

Despite repeated requests from the medical board, lawmakers haven't approved a licensing fee increase in 16 years, even though the fees are the board's primary source of income. The CMA agreed to the last fee increase in 2005 as part of a deal that also took away the board's ability to recover legal and investigative costs for cases in which doctors had been disciplined.

York said the association remains opposed to the provision that would restore the board's ability to recoup investigative costs and has concerns about the role of the independent monitor.

In its report to the legislature, the medical board projected it would be insolvent by the end of 2021-22 without an increase in licensing fees.

Doctors "just don't want to pay for it," said Bridget Gramme, an attorney at the Center for Public Interest Law at the University of San Diego School of Law. "What is the money going for? It's going for a stronger discipline system, which they don't want."

Roth, who chairs the Senate Business, Professions and Economic Development Committee, said the CMA's influence wasn't the reason he amended the bill to reduce the fee increase. Rather, he said the board hadn't justified the large fee increase — even though he included it in the original version of the bill — and could make do with a modest fee increase combined with better money management.

"Everybody had an opportunity to voice their perspective," Roth said, pointing out that the bill still includes provisions that doctors oppose. "The goal is to make sure that we have a medical board that is functioning effectively and efficiently, that the enforcement process does the right thing at the right time for the right reasons, and that we squeeze every bit of operational efficiency that we can afford."

As he watches from afar, Hill, the former legislator, said he doesn't think the California Medical Association will give up until it kills every provision it opposes.

"This whole thing is part of CMA's playbook. It's how they operate," Hill said. "They hire just about every available lobbyist in Sacramento to remove the rest of what was in the bill."

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

Samantha Young: syoung@kff.org, @youngsamantha

No Vacancy: How a Shortage of Mental Health Beds Keeps Kids Trapped Inside ERs

KFF Health News, June 25, 2021

Parents and advocates for kids' mental health say that the ER can't provide appropriate care and that the warehousing of kids in crisis can become an emergency itself.

This article was published on Friday, June 25, 2021 in Kaiser Health News.

By Martha Bebinger, WBUR

One evening in late March, a mom called 911. Her daughter, she said, was threatening to kill herself. EMTs arrived at the home north of Boston, helped calm the 13-year-old, and took her to an emergency room.

Melinda, like a growing number of children during the COVID-19 pandemic, had become increasingly anxious and depressed as she spent more time away from in-person contact at school, church and her singing lessons.

KHN and NPR have agreed to use only the first names of this teenager and her mother, Pam, to avoid having this story trail the family online. Right now in Massachusetts and in many parts of the U.S. and the world, demand for mental healthcare overwhelms supply, creating bottlenecks like Melinda's 17-day saga.

Emergency rooms are not typically places you check in for the night. If you break an arm, it gets set, and you leave. If you have a heart attack, you won't wait long for a hospital bed. But sometimes if your brain is not well, and you end up in an ER, there's a good chance you will get stuck there. Parents and advocates for kids' mental health say that the ER can't provide appropriate care and that the warehousing of kids in crisis can become an emergency itself.

What's known as emergency room boarding of psychiatric patients has risen between 200% and 400% monthly in Massachusetts during the pandemic. The CDC says emergency room visits after suicide attempts among teen girls were up 51% earlier this year as compared with 2019. There are no current nationwide mental health boarding numbers.

"This is really unlike anything we've ever seen before, and it doesn't show any signs of abating," said Lisa Lambert, executive director of Parent/Professional Advocacy League, which pushes for more mental healthcare for children.

Melinda spent her first 10 days in a hospital lecture hall with a dozen other children, on gurneys, separated by curtains because the emergency room had run out of space. At one point, Melinda, who was overwhelmed, tried to escape, was restrained, injected with drugs to calm her and moved to a small, windowless room.

Day 12: Cameras Track Her Movements

I met Melinda in early April, on her 12th day in the ER. Doctors were keeping her there because they were concerned she would harm herself if she left. Many parents report spending weeks with their children in hospital hallways or overflow rooms, in various states of distress, because hospital psychiatric units are full. While demand is up, supply is down. COVID precautions turned double rooms into singles or psych units into COVID units. While those precautions are beginning to ease, demand for beds is not.

Inside her small room, Melinda was disturbed by cameras that tracked her movement, and security guards in the hallways who were there, in part, for her safety.

"It's kinda like prison," she said. "It feels like I'm desperate for help."

"Desperate" is a word both Melinda and Pam use often to describe the prolonged wait for care in a place that feels alien.

"We occasionally hear screaming, yelling, monitors beeping," said Pam. "Even as the parent — it's very scary."

But this experience is not new. This was Melinda's fourth trip to a hospital emergency room since late November. Pam said Melinda spiraled downward after a falling out with a close family member last summer. She has therapists, but some of them changed during the pandemic, the visits were virtual, and she hasn't made good connections between crises.

"Each time, it's the same routine," Pam said. Melinda is rushed to an ER, where she waits. She's admitted to a psych hospital for a week to 10 days and goes home. "It's not enough time."

Pam said each facility has suggested a different diagnosis and adjusted Melinda's medication.

"We've never really gotten a good, true diagnosis as to what's going on with her," Pam said. "She's out of control; she feels out of control in her own skin."

Melinda waited six months for a neuropsychiatric exam to help clarify what she needs. She finally had the exam in May, after being discharged from the psychiatric hospital, but still doesn't have the results. Some psychiatrists say observing a patient's behavior is often a better way to reach a diagnosis.

Lambert, the mental health advocate, said there are delays for every type of psychiatric care — both residential and outpatient.

"We've heard of waits as long as five weeks or more for outpatient therapy," Lambert said. "If your child is saying they don't want to live or don't want to ever get out of bed again, you don't want to wait five weeks."

Day 13: 'The Longer She's Here, the More She's Going to Decline'

As her stay dragged on, Melinda bounced from manic highs to deep emotional lows. The emergency room is a holding area; it isn't set up to offer treatment or psychiatric therapy.

On this day Melinda was agitated.

"I just really want to get out of here," she said in an audio diary she was keeping at the time for this story. "I feel kind of helpless. I miss my pets and my bed and real food." She'd had a panic attack the night before and had to be sedated. Her mom, Pam, wasn't there.

"The longer she's here, the more she's going to decline," Pam recorded in her own audio diary. "She has self-harmed three times since she's been here."

The hospital and its parent network, Beth Israel Lahey Health, declined requests to speak about Melinda's care. But Dr. Nalan Ward, the network's chief medical officer for behavioral health services, hosts a daily call to discuss the best place for inpatient psychiatric treatment for each patient. Some may have unique medical or insurance constraints, she said. Many insurers require prior approval before they'll agree to pay for a placement, and that, too, can add delays.

"It takes a case-by-case approach," said Ward. "It's really hands-on."

Day 14: Increasingly Isolated From School and Friends

For Melinda, the issue keeping her from moving out of the ER and into an effective treatment program could have been her behavior. Pam was told her daughter may be harder to place than children who don't act out. Hospitals equipped to provide inpatient mental healthcare say they look for patients who will be a good fit for their programs and participants. Melinda's chart included the attempted escape as well as some fights while she was housed in the lecture hall.

"She's having behaviors because she has a mental illness, which they're supposed to help her with," Pam said, "but yet they're saying no to her because she's having behaviors."

Secluding Melinda in the ER didn't help, Pam said. "She's, at times, unrecognizable to me. She just is so sure that she's never going to get better."

Melinda described feeling increasingly isolated. She lost touch with friends and most family members. She'd stopped doing schoolwork weeks earlier. The noise and commotion of a 24/7 ER was getting to Melinda.

"I'm not sleeping well," she noted in her diary. "It's tough here. I keep waking up in the middle of the night."

Day 15: Mom Retreats to Her Car to Cry

Boarding is difficult for parents as well. Pam works two jobs, but she visited Melinda every day, bringing a change of clothes, a new book or something special to eat.

"Some days I sit and cry before I get out of the car, just to get it out of my system, so I don't cry in front of her," Pam said in her diary entry that day.

Some hospitals say they can't afford to care for patients with acute mental health problems because insurance reimbursements don't cover costs. Massachusetts is spending $40 million this year on financial incentives to create more inpatient psychiatric care. But emergency rooms are still flooded with psychiatric patients who are in limbo, boarding there.

Day 16: 'I Wish Someone Would Just Understand Me'

"I never thought we'd be here this long," said Pam.

At the nurses' station, Pam was told it could be two more weeks before there would be an opening at an appropriate hospital.

In Massachusetts, Gov. Charlie Baker's administration says it has a plan that will keep children out of ERs and reduce the need for inpatient care by providing more preventive and community-based services. Parents and providers say they are hopeful but question whether there are enough counselors and psychiatrists to staff proposed community clinics, therapy programs and more psychiatric hospital beds.

Meanwhile, in the ER, Melinda was growing listless.

"Life is really hard because things that should be easy for everyone are just hard for me," she said. "When I ask for help, sometimes I picture going to the hospital. Other times I wish someone would just understand me."

Then, in the late evening on Day 16, the family got word that Melinda's wait would soon end.

Day 17: Limbo Ends and Real Treatment Begins

On Day 17, Melinda was taken by ambulance to a Boston-area hospital that had added child psychiatric beds during the pandemic. She was lucky to get a spot. The day she arrived, there were 50 to 60 children on the waiting list.

"That's dramatically higher" than before the pandemic, said Dr. Linsey Koruthu, one of Melinda's doctors and a pediatric psychiatrist at Cambridge Health Alliance. "About double what we would have seen in 2019."

Doctors there adjusted Melinda's medications. She met with a psychiatrist and social worker daily and had group therapy and time for schoolwork, yoga and pet therapy. Hospital staff members met with Melinda and her family. She stayed two weeks, a bit longer than the average stay.

Doctors recommended that Melinda move from inpatient care to a community-based residential treatment program — a bridge between being in the hospital and returning home. But those programs were full and had weeks-long delays. So, Melinda went straight home.

She now has three therapists helping her make the transition and use what she's learned. And as COVID restrictions have begun to ease, some sessions are in person — which Koruthu said should be more effective for Melinda.

Pam said the transition has been rough. Police came to the house once and suggested Melinda go to an ER, but she was able to calm down before it came to that. Melinda has developed an eating disorder.

The first available appointment with a specialist is in August. But, by mid-June, Melinda was able to graduate from middle school, after finishing a backlog of schoolwork.

"If you had asked me two months ago, I would have said I don't think she'll make it," Pam said. "We're getting there."

If you or someone you know are in mental health crisis or may be considering suicide, contact the National Suicide Prevention Lifeline at 1-800-273-8255 (en Español: 1-888-628-9454; for the deaf and hard of hearing: Dial 711 then 1-800-273-8255) or the Crisis Text Line by texting HOME to 741741.

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

Martha Bebinger, WBUR: marthab@wbur.org, @mbebinger

The WHO Didn't Reverse Its Position on Kids and COVID Vaccines

KFF Health News, June 25, 2021

Social media posts falsely claimed that WHO reversed its stance on children receiving a COVID vaccine.

This article was published on Friday, June 25, 2021 in Kaiser Health News.

By Victoria Knight

A social media post circulating on Facebook and Instagram claims that the World Health Organization recently flipped its policy recommendation about children receiving a COVID-19 vaccine.

"The WORLD HEALTH ORGANIZATION recently reversed its stance on children getting the COVID vaccine. Sorry to all those dumb parents who rushed out to get their 12 year olds vaccinated. Oops you injected your kids with poison and it's no longer recommended. Personally no one should but at least save the children!," the post reads.

A photo posted alongside the caption is a screenshot from the World Health Organization's website, with the words circled in red: "Children should not be vaccinated for the moment."

The screen grab also shows the following paragraph with the words underlined in red: "There is not yet enough evidence on the use of vaccines against COVID-19 in children to make recommendations for children to be vaccinated against COVID-19."

The post was flagged as part of Facebook's efforts to combat false news and misinformation on its news feed. (Read more about PolitiFact's partnership with Facebook.)

Others have been spreading similar messages on social media about this alleged change in the WHO's stance on COVID vaccines for children, including Rep. Marjorie Taylor Greene (R-Ga.). The topic also dominated vaccine-related Google searches on June 22, according to Google Trends data.

Mining the Webpage

The screen grab posted on Instagram was indeed taken directly from the WHO's webpage and the text had not been altered. The purpose of that specific webpage is to give the public advice on who should receive a COVID vaccine.

The webpage stated, "Children should not be vaccinated for the moment."

However, this was not new guidance from the WHO. The organization first posted this guidance on April 8, according to our analysis of the webpage through the Wayback Machine, an internet archive service, and First Draft, a nonprofit group that analyzes misinformation on the web.

When we reached out to the WHO on June 22 to ask officials about the webpage's wording and whether they had reversed their stance, a spokesperson sent the following statement:

"Children and adolescents tend to have milder disease compared to adults, so unless they are part of a group at higher risk of severe COVID-19, it is less urgent to vaccinate them than older people, those with chronic health conditions and health workers.

"More evidence is needed on the use of the different COVID-19 vaccines in children to be able to make general recommendations on vaccinating children against COVID-19.

"WHO's Strategic Advisory Group of Experts (SAGE) has concluded that the Pfizer/BioNTech vaccine is suitable for use by people aged 12 years and above. Children aged between 12 and 15 who are at high risk may be offered this vaccine alongside other priority groups. Vaccine trials for children are ongoing and WHO will update its recommendations when the evidence or epidemiological situation warrants a change in policy.

"It's important for children to continue to have the recommended childhood vaccines."

The WHO updated its webpage June 23, replacing the language "children should not be vaccinated for the moment" with the precise language sent in the statement above.

Jen Kates, director of global health and HIV policy at KFF, said she reached out to a WHO contact who told her this updated language was added to reflect the latest advice from the WHO's June 15 meeting of the Strategic Advisory Group of Experts, which said the Pfizer-BioNTech vaccine can be given to those age 12 and older.

The WHO's Stance

The WHO's chief scientist, Dr. Soumya Swaminathan, explained in a June 11 video why the WHO was not prioritizing COVID vaccines for children.

"So, the reason that today, in June 2021, WHO is saying that vaccinating children is not a priority is because children, though they can get infected with COVID-19 and they can transmit the infection to others, they are at much lower risk of getting severe disease compared to older adults," Swaminathan said. "And that is why, when we started prioritizing people who should get the vaccination when there are limited supplies of vaccines available in the country, we recommend that we start with healthcare workers and front-line workers who are at very high risk of exposure to the infection. Also elderly, the people who have underlying illnesses that make them at high risk to develop severe disease."

Dr. Rachel Vreeman, director of the Arnhold Institute for Global Health at the Icahn School of Medicine at Mount Sinai Hospital, confirmed that the statements on the WHO's webpage were focused on whom to prioritize most urgently in getting COVID vaccines.

"They are not saying that children should not be vaccinated against COVID or that the vaccines currently approved for use in children 12 years old and above are not safe," Vreeman wrote in an email. "The WHO is saying that the global priority should be on getting more adults vaccinated, since older adults are at the highest risk of serious complications and death from COVID-19."

"In the face of massive inequities in who has access to COVID-19 vaccines globally, the WHO advises that those at highest risk — older adults — be prioritized first," Vreeman wrote.

Recommendations of COVID Vaccines for Children in the U.S.

It's also important to consider that supplies of the COVID vaccines are no longer limited in the U.S., as they are in other parts of the world. So, having to ration the vaccine for only healthcare workers or those who are older or at higher risk for severe disease does not apply here. Remember, the WHO is a global organization, so its recommendations need to be applicable worldwide.

In the U.S., the Centers for Disease Control and Prevention recommends that everyone age 12 and over receive a COVID vaccine. The Pfizer-BioNTech vaccine has been authorized for emergency use in the U.S. in children ages 12 to 18 and adults of all ages.

The American Academy of Pediatrics also recommends that children 12 and up receive a COVID vaccine.

So does Vreeman, who is a pediatrician.

"As a pediatrician in the United States, in a setting where the COVID-19 vaccine is widely available, I whole-heartedly recommend that children 12 years old and up receive the COVID-19 vaccination as soon as possible," Vreeman wrote in an email. "The data show that the vaccines are safe and effective for this age group, and we want to prevent the risks that COVID-19 does present to children."

Our Ruling

An Instagram post and other posts across social media falsely claimed that the WHO recently reversed its stance on children receiving a COVID vaccine because the vaccines were "poison" and would be dangerous for children.

The WHO first posted its guidance for children and COVID vaccinations on April 8. That guidance did include the wording, "Children should not be vaccinated for the moment." But that wording was a reflection of the WHO saying that children should not be prioritized for vaccinations over other groups because in many countries supplies of vaccine are limited and healthcare workers, front-line workers, the elderly and those with high-risk medical conditions should have first dibs.

There's no evidence the WHO "reversed" its position on childhood COVID vaccination in the way the viral social media posts allege. The WHO updated its guidance on June 23 to reflect a meeting of one of its scientific advisory groups, which said the Pfizer-BioNTech vaccine could be safely given to children 12 and up. But this came after those misleading posts first appeared.

We rate this claim False.

Sources:

American Academy for Pediatrics, "AAP, CDC Recommend COVID-19 Vaccine for Ages 12 and Older," May 12, 2021

Centers for Disease Control and Prevention, "COVID-19 Vaccines for Children and Teens," updated May 27, 2021

Email interview with Dr. Rachel Vreeman, director of the Arnhold Institute for Global Health at the Icahn School of Medicine at Mount Sinai, June 22, 2021

Email interview with Jen Kates, director of global health and HIV policy at KFF, June 22, 2021

Email exchange with World Health Organization Media Relations, June 22, 2021

First Draft News, "Misleading Information About Vaccinating Children Is Linked to Old WHO Advice," June 23, 2021

Google Trends, "World Health Organization COVID Vaccine," accessed June 23, 2021

Twitter, Marjorie Taylor Greene status, June 22, 2021

Wayback Machine, Robert F. Kennedy Jr. Twitter status, June 22, 2021, accessed June 23, 2021

Wayback Machine, World Health Organization — COVID-19 Advice for the Public: Getting Vaccinated, April 8, 2021, accessed June 23, 2021

Wayback Machine, World Health Organization — "COVID-19 Advice for the Public: Getting Vaccinated, June 22, 2021," accessed June 23, 2021

Wayback Machine, World Health Organization — "COVID-19 Advice for the Public: Getting Vaccinated," June 23, 2021, accessed June 23, 2021

World Health Organization, "COVID-19 Advice for the Public: Getting Vaccinated," accessed June 23, 2021

World Health Organization, "Interim Recommendations for Use of the Pfizer-BioNTech COVID-19 Vaccine, BNT162b2, Under Emergency Use Listing," June 15, 2021

World Health Organization, "Science in 5 — Episode #42 — Vaccines and Children," June 11, 2021

Victoria Knight: vknight@kff.org, @victoriaregisk

Calming Computer Jitters: Help for Seniors Who Aren't Tech-Savvy

KFF Health News, June 24, 2021

Millions of older adults are newly motivated to get online and participate in digital offerings after being shut inside, hoping to avoid the virus, for more than a year. But many need assistance and aren't sure where to get it.

By Judith Graham June 24, 2021

Six months ago, Cindy Sanders, 68, bought a computer so she could learn how to email and have Zoom chats with her great-grandchildren.

It's still sitting in a box, unopened.

"I didn't know how to set it up or how to get help," said Sanders, who lives in Philadelphia and has been extremely careful during the coronavirus pandemic.

Like Sanders, millions of older adults are newly motivated to get online and participate in digital offerings after being shut inside, hoping to avoid the virus, for more than a year. But many need assistance and aren't sure where to get it.

A recent survey from AARP, conducted in September and October, highlights the quandary. It found that older adults boosted technology purchases during the pandemic but more than half (54%) said they needed a better grasp of the devices they'd acquired. Nearly 4 in 10 people (37%) admitted they weren't confident about using these technologies.

Sanders, a retired hospital operating room attendant, is among them. "Computers put the fear in me," she told me, "but this pandemic, it's made me realize I have to make a change and get over that."

With a daughter's help, Sanders plans to turn on her new computer and figure out how to use it by consulting materials from Generations on Line. Founded in 1999, the Philadelphia organization specializes in teaching older adults about digital devices and navigating the internet. Sanders recently discovered it through a local publication for seniors.

Before the pandemic, Generations on Line provided free in-person training sessions at senior centers, public housing complexes, libraries and retirement centers. When those programs shut down, it created an online curriculum for smartphones and tablets (www.generationsonline.org/apps) and new tutorials on Zoom and telehealth as well as a "family coaching kit" to help older adults with technology. All are free and available to people across the country.

Demand for Generations on Line's services rose tenfold during the pandemic as many older adults became dangerously isolated and cut off from needed services.

Those who had digital devices and knew how to use them could do all kinds of activities online: connect with family and friends, shop for groceries, order prescriptions, take classes, participate in telehealth sessions and make appointments to get COVID vaccines. Those without were often at a loss — with potentially serious consequences.

"I have never described my work as a matter of life or death before," said Angela Siefer, executive director of the National Digital Inclusion Alliance, an advocacy group for expanding broadband access. "But that's what happened during the pandemic, especially when it came to vaccines."

Other organizations specializing in digital literacy for older adults are similarly seeing a surge of interest. Cyber-Seniors, which pairs older adults with high school or college students who serve as technology mentors, has trained more than 10,000 seniors since April 2020 — three times the average of the past several years. (Services are free and grants and partnerships with government agencies and nonprofit organizations supply funding, as is true for several of the organizations discussed here.)

Older adults using digital devices for the first time can call 1-844-217-3057 and be coached over the phone until they're comfortable pursuing online training. "A lot of organizations are giving out tablets to seniors, which is fantastic, but they don't even know the basics, and that's where we come in," said Brenda Rusnak, Cyber-Seniors' managing director. One-on-one coaching is also available.

Lyla Panichas, 78, who lives in Pawtucket, Rhode Island, got an iPad from Rhode Island's digiAGE program three months ago — among many local technology programs for older adults started during the pandemic. She is getting help from the University of Rhode Island's Cyber-Seniors program, which plans to offer digital training to 200 digiAGE participants in communities hardest hit by COVID-19 by the end of this year.

"The first time my tutor called me, I mean, the kids rattle things off so fast. I said, Wait a minute. You have a little old lady here. Let me keep up with you," Panichas said. "I couldn't keep up and I ended up crying."

Panichas persisted, however, and when her tutor called again the next week she began "being able to grasp things." Now, she plays games online, streams movies and has Zoom get-togethers with her son, in Arizona, and her sister, in Virginia. "It's kind of lifted my fears of being isolated," she told me.

OATS (Older Adults Technology Services) is set to expand the reach of its digital literacy programs significantly after a recent affiliation with AARP. It runs a national hotline for people seeking technical support, 1-920-666-1959, and operates Senior Planet technology training centers in six cities (New York; Denver; Rockville, Maryland; Plattsburgh, New York; San Antonio, Texas; and Palo Alto, California). All in-person classes converted to digital programming once the pandemic closed down much of the country.

Germaine St. John, 86, a former mayor of Laramie, Wyoming, found an online community of seniors and made dear friends after signing up with Senior Planet Colorado during the pandemic. "I have a great support system here in Laramie, but I was very cautious about going out because I was in the over-80 group," she told me. "I don't know what I would have done without these activities."

Older adults anywhere in the country can take Senior Planet virtual classes for free. (A weekly schedule is available at https://seniorplanet.org/get-involved/online/.) Through its AARP partnership, OATS is offering another set of popular classes at AARP's Virtual Community Center. Tens of thousands of older adults now participate.

Aging Connected (https://agingconnected.org/), another new OATS initiative, is focusing on bringing 1 million older adults online by the end of 2022.

An immediate priority is to educate older adults about the government's new $32 billion Emergency Broadband Benefit for low-income individuals, which was funded by a coronavirus relief package and became available last month. That short-term program provides $50 monthly discounts on high-speed internet services and a one-time discount of up to $100 for the purchase of a computer or tablet. But the benefit isn't automatic. People must apply to get funding.

"We are calling on anybody over the age of 50 to try the internet and learn what the value can be," said Thomas Kamber, OATS' executive director. Nearly 22 million seniors don't have access to high-speed internet services, largely because these services are unaffordable or unavailable, according to a January report co-sponsored by OATS and the Humana Foundation, its Aging Connected partner.

Other new ventures are also helping older adults with technology. Candoo Tech, which launched in February 2019, works with seniors directly in 32 states as well as organizations such as libraries, senior centers and retirement centers.

For various fees, Candoo Tech provides technology training by phone or virtually, as-needed support from "tech concierges," advice about what technology to buy and help preparing devices for out-of-the-box use.

"You can give an older adult a device, access to the internet and amazing content, but if they don't have someone showing them what to do, it's going to sit there unused," said Liz Hamburg, Candoo's president and chief executive.

GetSetUp's model relies on older adults to teach skills to their peers in small, interactive classes. It started in February 2020 with a focus on tech training, realizing that "fear of technology" was preventing older adults from exploring "a whole world of experiences online," said Neil Dsouza, founder and chief executive.

For older adults who've never used digital devices, retired teachers serve as tech counselors over the phone. "Someone can call in [1-888-559-1614] and we'll walk them through the whole process of downloading an app, usually Zoom, and taking our classes," Dsouza said. GetSetUp is offering about 80 hours of virtual technology instruction each week.

For more information about tech training for older adults in your area, contact your local library, senior center, department on aging or Area Agency on Aging. Also, each state has a National Assistive Technology Act training center for older adults and people with disabilities. These centers let people borrow devices and offer advice about financial assistance. Some started collecting and distributing used smartphones, tablets and computers during the pandemic.

For information about a program in your area, go to https://www.at3center.net/.

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

Black and Hispanic Americans Suffer Most in Biggest US Decline in Life Expectancy Since WWII

KFF Health News, June 24, 2021

The pandemic has exacerbated the discrepancies already seen in the country between the wealth and health of Black and Hispanic Americans and those of white Americans.

This article was published on Thursday, June 24, 2021 in Kaiser Health News.

By Liz Szabo

Although James Toussaint has never had COVID, the pandemic is taking a profound toll on his health.

First, the 57-year-old lost his job delivering parts for a New Orleans auto dealership in spring 2020, when the local economy shut down. Then, he fell behind on his rent. Last month, Toussaint was forced out of his apartment when his landlord — who refused to accept federally funded rental assistance — found a loophole in the federal ban on evictions.

Toussaint recently has had trouble controlling his blood pressure. Arthritis in his back and knees prevents him from lifting more than 20 pounds, a huge obstacle for a manual laborer.

Toussaint worries about what will happen when his pandemic unemployment benefits run out, which could happen as early as July 31.

"I've been homeless before," said Toussaint, who found a room to rent nearby after his eviction. "I don't want to be homeless again."

With coronavirus infections falling in the U.S., many people are eager to put the pandemic behind them. But it has inflicted wounds that won't easily heal. In addition to killing 600,000 in the United States and afflicting an estimated 3.4 million or more with persistent symptoms, the pandemic threatens the health of vulnerable people devastated by the loss of jobs, homes and opportunities for the future. It will, almost certainly, cast a long shadow on American health, leading millions of people to live sicker and die younger due to increasing rates of poverty, hunger and housing insecurity.

In particular, it will exacerbate the discrepancies already seen in the country between the wealth and health of Black and Hispanic Americans and those of white Americans. Indeed, new research published Wednesday in the BMJ shows just how wide that gap has grown. Life expectancy across the country plummeted by nearly two years from 2018 to 2020, the largest decline since 1943, when American troops were dying in World War II, according to the study. But while white Americans lost 1.36 years, Black Americans lost 3.25 years and Hispanic Americans lost 3.88 years. Given that life expectancy typically varies only by a month or two from year to year, losses of this magnitude are "pretty catastrophic," said Dr. Steven Woolf, a professor at Virginia Commonwealth University and lead author of the study.

Over the two years included in the study, the average loss of life expectancy in the U.S. was nearly nine times greater than the average in 16 other developed nations, whose residents can now expect to live 4.7 years longer than Americans. Compared with their peers in other countries, Americans died not only in greater numbers but at younger ages during this period.

The U.S. mortality rate spiked by nearly 23% in 2020, when there were roughly 522,000 more deaths than normally would be expected. Not all of these deaths were directly attributable to COVID-19. Fatal heart attacks and strokes both increased in 2020, at least partly fueled by delayed treatment or lack of access to medical care, Woolf said. More than 40% of Americans put off treatment during the early months of the pandemic, when hospitals were stretched thin and going into a medical facility seemed risky. Without prompt medical attention, heart attacks can cause congestive heart failure; delaying treatment of strokes raises the risk of long-term disability.

Much of the devastating public health impact during the pandemic can be chalked up to economic disparity. Although stock prices have recovered from last year's decline — and have recently hit all-time highs — many people are still suffering financially, especially Black and Hispanic Americans. In a February report, economic analysts at McKinsey & Co. predicted that, on average, Black and Hispanic workers won't recover their pre-pandemic employment and salaries until 2024. The lowest-paid workers and those with less than a high school education may not recover even by then.

And while federal and state relief programs have cushioned the impact of pandemic job losses, 11.3% of Americans today live in poverty — compared with 10.7% in January 2020. A federal eviction moratorium, which has helped an estimated 2.2 million people remain in their homes, expires June 30. Without protection from evictions, "millions of Americans could fall off the cliff," said Vangela Wade, president and CEO of the Mississippi Center for Justice, a nonprofit advocacy group.

Being evicted erodes a person's health in multiple ways. "Poverty causes a lot of cancer and chronic disease, and this pandemic has caused a lot more poverty," said Dr. Otis Brawley, a professor at Johns Hopkins University who studies health disparities. "The effect of this pandemic on chronic diseases, such as cardiovascular disease and diabetes, will be measured decades from now."

Twenty million adults recently have had trouble putting food on the table. The inability to afford healthy food — which is usually more expensive than salty, starchy fare — can cause both short-term and long-term harm. People with low incomes, for example, are more likely to be hospitalized for low blood sugar toward the end of the month, when they run out of money for food.

In the long term, food insecurity is associated with an increased risk of diabetes, high cholesterol, hypertension, depression, anxiety and other chronic diseases, especially in children.

"Once the acute phase of this crisis has passed, we will face an enormous wave of death and disability," said Dr. Robert Califf, former commissioner of the Food and Drug Administration, who wrote about post-pandemic health risks in an April editorial in Circulation, a medical journal. "These will be the aftershocks of COVID."

Less Wealth, Poorer Health

American health was poor even before the pandemic, with 60% of the population suffering from a chronic condition, such as obesity, diabetes, high blood pressure or heart failure. These four conditions were associated with nearly two-thirds of hospitalizations from COVID, according to a February study in the Journal of the American Heart Association.

Deaths from some chronic diseases began rising in lower-income Americans in the 1990s, Woolf said. That trend was exacerbated by the Great Recession of 2007-09, which undermined the health not just of those who lost their homes or jobs but the population as a whole. Still, the Great Recession, and its resultant health effects, did not affect all Americans equally. Black people in the U.S. today control less wealth than they did before that recession, while the gap in financial security between Black and white Americans has widened, according to a Nonprofit Quarterly article published last year. And the unemployment rate among Black workers did not recover to pre-recession levels until 2016.

Researchers have developed a better understanding in recent years of how chronic stress — such as that caused by poverty, job loss and homelessness — leads to disease. Unrelenting stress causes inflammation that can damage blood vessels, the heart and other organs.

Research shows that people with low incomes live an average of seven to eight years less than those who are financially secure. The richest 1% of Americans live nearly 15 years longer than the poorest 1%.

People who are poor tend to smoke more; have higher risks of chronic illnesses such as cardiovascular disease, diabetes, kidney disease and mental illness; and are more likely to become victims of violence.

The stress of the pandemic also has led many people to smoke, drink and gain weight, increasing the risk of chronic disease. Fatal drug overdoses spiked 30% from October 2019 to October 2020.

Jennifer Drury, 40, has struggled with substance abuse, particularly prescription painkillers, since her 20s. She blames the isolation and stress of the pandemic for causing her to relapse — and leading several of her friends to fatally overdose.

"Idle time is not good for addiction," said Drury, who fell behind on rent and was evicted from her previous home. She said drug dealers are never far away, especially at the New Orleans motel where she and her husband are now staying. "Drug dealers don't care about pandemics."

Women Losing Ground

The American Rescue Plan, which provides $1.9 trillion in pandemic relief, was designed to help displaced workers and cut child poverty rates in half. The actual benefits of the law may prove less sweeping.

Twenty-five states have opted to cut off additional federal unemployment payments, citing concerns that such generous benefits pay people more to stay home than they can earn by working.

Many women say they would like to return to work but have no one to take care of their children. Nearly half of child care centers have closed and others have reduced the number of children they serve.

The Federal Reserve Bank of Minneapolis concluded that "economic recovery depends on child care availability." A March report from the National Women's Law Center estimates "women have lost a generation of labor force participation gains," which could leave them and their children financially disadvantaged for years.

Ruth Bermudez is one of millions of women who have left the workforce in the past year. Bermudez, who was laid off from her job as a behavioral health caseworker in New Orleans last year, said her child care needs have prevented her from finding work. The care of her 6-year-old daughter became her full-time job after the pandemic closed schools.

Although her daughter has returned to class, Bermudez said school shutdowns due to COVID outbreaks have been frequent and unpredictable.

"I had to be the teacher, the lunch lady, the school bus driver, all at one time," said Bermudez, 27. "It is exhausting."

Life-Altering Evictions

James Toussaint had just two weeks to find a new place to live after a judge ordered him evicted. His family was unable to take him in.

"I've got family, but everybody has their own issues and problems," said Toussaint, who had to throw away all his clothes and furniture because they had become infested with bedbugs. "Everyone is trying their best to help themselves."

Toussaint is now renting a room in a boarding house with no kitchen and a shared bathroom for $160 a week. He's had to buy cleaning supplies with his own money in order to sanitize the bathroom, which he said is often too dirty to use.

Sharing communal space is often unsanitary and increases the risk of being exposed to the coronavirus, said Emily Benfer, a visiting professor at Wake Forest University School of Law. Even moving in with family poses risks, she said, because it's impossible to isolate or quarantine in crowded homes.

Benfer co-wrote a November study that found COVID infection rates grew twice as high in states that lifted moratoriums on evictions, compared with states that continued to ban them. About 14% of tenants have fallen behind on rent — double the rate before the pandemic.

Toussaint's annual lease expired during the pandemic, leaving him to rent on a month-to-month basis. While some states require landlords to show "just cause" for eviction, Louisiana landlords can evict tenants for any reason once their annual lease has expired.

Property owners have filed for more than 378,000 evictions during the pandemic in just the five states and 29 cities tracked by Princeton University's Eviction Lab. A growing body of evidence shows that eviction is toxic to health, causing immediate and long-term damage that increases the risk of death.  Studies show that evicted people are more likely to be in poor general health or have mental health concerns even years later.

"This singular event alters the course of one's life for the worse," Benfer said. "If we don't intervene" to prevent mass evictions when the moratorium ends, "it will be catastrophic for generations to come."

Eviction's harms can be measured at every stage of life:

When pregnant women are evicted, their newborns are more likely to be born early or very small and have a higher risk of dying in the first year. Women who are evicted are more likely to suffer sexual assault, Benfer said.

Kids who are evicted are at greater risk of lead poisoning from substandard housing, Benfer said. They're also more likely than others to be hospitalized.

Evicted adults report worse mental health and are more likely to be hospitalized for a mental health crisis, studies show. They also have higher mortality rates from suicide. Although the causes of addiction are complex, research shows that counties with higher eviction rates have significantly higher rates of drug- and alcohol-related deaths.

People who are evicted often move into substandard housing in neighborhoods with higher crime rates. These homes are sometimes plagued by mold and roaches, lack sufficient heating, or have plumbing that doesn't work. Landlords have no incentive to make repairs for tenants who are behind on their rent, Benfer said. In fact, tenants who request repairs or report safety hazards risk eviction.

Although middle-class Americans take their kitchens for granted — and rely on them to cook healthful meals — more than 1 million homes lack complete kitchens, according to the U.S. Census Bureau.

New Orleans doesn't require that rental units include stoves, said Hannah Adams, also a lawyer with Southeast Louisiana Legal Services. Toussaint's new room is equipped with a microwave and small refrigerator, but no sink, oven or stove. He washes dinner dishes in the bathroom. His landlord doesn't allow residents to have electric hot plates, so most of his meals involve cold cereal, deli sandwiches or meals he can heat in the microwave. His doctor has urged Toussaint, who is borderline diabetic, to lose weight, eat less salt and starch, and stop smoking.

Toussaint, who lived on the street for two years, said he's determined not to return there. He hopes to apply for disability insurance, which would provide him with an income if his arthritis prevents him from finding steady work.

Woolf said he hopes Americans won't forget about the suffering of people like Toussaint as cases of COVID decline. "My worry is that people will feel the crisis is behind us and it's all good," Woolf said. His research connecting four decades of declining economic opportunity with falling life expectancy shows "we are in really big trouble, and that was true before we knew a pandemic was coming."

The pandemic doesn't have to doom a generation of Americans to disease and early death, said Dr. Richard Besser, president and CEO of the Robert Wood Johnson Foundation. By addressing issues such as poverty, racial inequality and the lack of affordable housing, the country can improve American health and reverse the trends that caused communities of color to suffer. "How the pandemic will affect people's future health depends on what we do coming out of this," Besser said. "It will take an intentional effort to make up for the losses that have occurred over the past year."

Liz Szabo: lszabo@kff.org, @LizSzabo

Biden Quietly Transforms Medicaid Safety Net

KFF Health News, June 24, 2021

Biden's efforts — which have been largely overshadowed by other economic and health initiatives — represent an abrupt reversal of the Trump administration's moves to scale back the safety-net program.

This article was published on Thursday, June 24, 2021 in Kaiser Health News.

By Noam N. Levey and Phil Galewitz

The Biden administration is quietly engineering a series of expansions to Medicaid that may bolster protections for millions of low-income Americans and bring more people into the program.

Biden's efforts — which have been largely overshadowed by other economic and health initiatives — represent an abrupt reversal of the Trump administration's moves to scale back the safety-net program.

The moves, some of which were funded by the COVID relief bill that passed in March, could further boost Medicaid enrollment — which the pandemic pushed to a record 80.5 million in January, including those served by the related Children's Health Insurance Program. That's up from 70 million before the COVID crisis began. New mothers, inmates and undocumented immigrants are among those who could gain coverage. At the same time, the Biden administration is opening the door to new Medicaid-funded services such as food and housing that the government insurance plan hasn't traditionally offered.

"There is a paradigm change underway," said Jennifer Langer Jacobs, Medicaid director in New Jersey, one of a growing number of states trying to expand home-based Medicaid services to keep enrollees out of nursing homes and other institutions.

"We've had discussions at the federal level in the last 90 days that are completely different from where we've ever been before," Langer Jacobs said.

Taken together, the Medicaid moves represent some of the most substantive shifts in federal health policy undertaken by the new administration.

"They are taking very bold action," said Rutgers University political scientist Frank Thompson, an expert on Medicaid history, noting, in particular, the administration's swift reversal of Trump policies. "There really isn't a precedent."

The Biden administration seems unlikely to achieve what remains the holy grail for Medicaid advocates: getting 12 holdout states, including Texas and Florida, to expand Medicaid coverage to low-income working-age adults through the Affordable Care Act. 

And while some recent expansions — including for new mothers — were funded by close to $20 billion in new Medicaid funding in the COVID relief bill Biden signed in March, much of that new money will stop in a few years unless Congress appropriates additional money.

The White House strategy has risks. Medicaid, which swelled after enactment of the 2010 health law, has expanded further during the economic downturn caused by the pandemic. The programs now cost taxpayers more than $600 billion a year. And although the federal government will cover most of the cost of the Biden-backed expansions, surging Medicaid spending is a growing burden on state budgets.

The costs of expansion are a frequent target of conservative critics, including Trump officials like Seema Verma, the former administrator of the Centers for Medicare & Medicaid Services, who frequently argued for enrollment restrictions and derided Medicaid as low-quality coverage.

But even less partisan experts warn that Medicaid, which was created to provide medical care to low-income Americans, can't make up for all the inadequacies in government housing, food and education programs.

"Focusing on the social drivers of health … is critically important in improving the health and well-being of Medicaid beneficiaries. But that doesn't mean that Medicaid can or should be responsible for paying for all of those services," said Matt Salo, head of the National Association of Medicaid Directors, noting that the program's financing "is simply not capable of sustaining those investments."

However, after four years of Trump administration efforts to scale back coverage, Biden and his appointees appear intent on not only restoring federal support for Medicaid, but also boosting the program's reach.

"I think what we learned during the repeal-and-replace debate is just how much people in this country care about the Medicaid program and how it's a lifeline to millions," Biden's new Medicare and Medicaid administrator, Chiquita Brooks-LaSure, told KHN, calling the program a "backbone to our country."

The Biden administration has already withdrawn permission the Trump administration had granted Arkansas and New Hampshire to place work requirements on some Medicaid enrollees.

In April, Biden blocked a multibillion-dollar Trump administration initiative to prop up Texas hospitals that care for uninsured patients, a policy that many critics said effectively discouraged Texas from expanding Medicaid coverage through the Affordable Care Act, often called Obamacare. Texas has the highest uninsured rate in the nation.

The moves have drawn criticism from Republicans, some of whom accuse the new administration of trampling states' rights to run their Medicaid programs as they choose.

"Biden is reasserting a larger federal role and not deferring to states," said Josh Archambault, a senior fellow at the conservative Foundation for Government Accountability.

But Biden's early initiatives have been widely hailed by patient advocates, public health experts and state officials in many blue states.

"It's a breath of fresh air," said Kim Bimestefer, head of Colorado's Department of Healthcare Policy and Financing.

Chuck Ingoglia, head of the National Council for Mental Wellbeing, said: "To be in an environment where people are talking about expanding healthcare access has made an enormous difference."

Mounting evidence shows that expanded Medicaid coverage improves enrollees' health, as surveys and mortality data in recent years have identified greater health improvements in states that expanded Medicaid through the 2010 health law versus states that did not.

In addition to removing Medicaid restrictions imposed by Trump administration officials, the Biden administration has backed a series of expansions to broaden eligibility and add services enrollees can receive.

Biden supported a provision in the COVID relief bill that gives states the option to extend Medicaid to new mothers for up to a year after they give birth. Many experts say such coverage could help reduce the U.S. maternal mortality rate, which is far higher than rates in other wealthy nations.

Several states, including Illinois and New Jersey, had sought permission from the Trump administration for such expanded coverage, but their requests languished.

The COVID relief bill — which passed without Republican support — also provides additional Medicaid money to states to set up mobile crisis services for people facing mental health or substance use emergencies, further broadening Medicaid's reach.

And states will get billions more to expand so-called home and community-based services such as help with cooking, bathing and other basic activities that can prevent Medicaid enrollees from having to be admitted to expensive nursing homes or other institutions.

Perhaps the most far-reaching Medicaid expansions being considered by the Biden administration would push the government health plan into covering services not traditionally considered healthcare, such as housing.

This reflects an emerging consensus among health policy experts that investments in some non-medical services can ultimately save Medicaid money by keeping patients out of the hospital.

In recent years, Medicaid officials in red and blue states — including Arizona, California, Illinois, Maryland and Washington — have begun exploring ways to provide rental assistance to select Medicaid enrollees to prevent medical complications linked to homelessness.

The Trump administration took steps to support similar efforts, clearing Medicare Advantage health plans to offer some enrollees non-medical benefits such as food, housing aid and assistance with utilities.

But state officials across the country said the new administration has signaled more support for both expanding current home-based services and adding new ones.

That has made a big difference, said Kate McEvoy, who directs Connecticut's Medicaid program. "There was a lot of discussion in the Trump administration," she said, "but not the capital to do it."

Other states are looking to the new administration to back efforts to expand Medicaid to inmates with mental health conditions and drug addiction so they can connect more easily to treatment once released.

Kentucky health secretary Eric Friedlander said he is hopeful federal officials will sign off on his state's initiative.

Still other states, such as California, say they are getting a more receptive audience in Washington for proposals to expand coverage to immigrants who are in the country without authorization, a step public health experts say can help improve community health and slow the spread of communicable diseases.

"Covering all Californians is critical to our mission," said Jacey Cooper, director of California's Medicaid program, known as Medi-Cal. "We really feel like the new administration is helping us ensure that everyone has access."

The Trump administration moved to restrict even authorized immigrants' access to the healthcare safety net, including the "public charge" rule that allowed immigration authorities to deny green cards to applicants if they used public programs such as Medicaid. In March, Biden abandoned that rule.

KHN correspondent Julie Rovner contributed to this report.

Noam N. Levey: nlevey@kff.org, @NoamLevey

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

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