LONG BEACH — On a recent Thursday afternoon, Rhianna Alvarado struggled to don her protective gloves, which were too big for her petite hands.
With her mom coaching her every move, she edged close to her father and gently removed the plastic tube from his throat that allows him to breathe. She then cautiously inserted a new one.
"What's next?" asked her mom, Rocio Alvarado, 43.
"I know, I know," replied Rhianna, her eyes constantly searching for her mom's approval.
Rhianna is only 13. When she finished the delicate task of changing her father's tracheostomy tube, usually performed only by adults, she went back into her room to doodle on her sketch pad and play with her cat.
Rhianna's father, Brian Alvarado, is an Iraq War veteran and neck and throat cancer survivor.
Like most kids, Rhianna has been stuck at home during the COVID-19 pandemic and attends school online. But unlike most other eighth graders, Rhianna is a caregiver, tending to her dad between her virtual classes.
Rhianna is among more than 3 million children and teens who help an ill or disabled family member, according to Caregiving in the U.S. 2020, a national survey published by the National Alliance for Caregiving and AARP. The survey also found that Hispanic and African American children are twice as likely to be youth caregivers as non-Hispanic white children.
Carol Levine, a senior fellow at the United Hospital Fund, a nonprofit that focuses on improving healthcare in New York, said the COVID pandemic, combined with the worsening opioid epidemic, has increased the number of youth caregivers because more children are homebound and must care for ill or addicted parents.
The pandemic has also made caregiving harder for them, since many can no longer escape to school during the day.
"In school they have their peers, they have activities," Levine said. "Because of the contagion, they aren't allowed to do the things they might normally do, so of course there is additional stress."
Levine was an author of a national survey in 2005 that found there were about 400,000 youth caregivers between ages 8 and 11. The survey has not been updated, she said, but that number has likely grown.
Kaylin Jean-Louis was 10 when she started doing little things to care for her grandmother and great-grandmother, who have Alzheimer's disease and live with Kaylin and her mother in Tallahassee, Florida.
Now 15, Kaylin has assumed a larger caregiving role. Every afternoon after her online classes end, the high school sophomore gives the women their medicine, and helps them use the bathroom, dress and take showers.
"Sometimes they can act out and it can be challenging," she said. The hardest thing, she said, is that her grandmother can no longer remember Kaylin's name.
COVID has added another level of stress to an already complex situation, Kaylin said, because she can't decompress outside the house.
"Being around them so much, there has been a little tension," Kaylin acknowledged. She uses art to cope. "I like to paint," she said. "I find it very relaxing and calming."
Kaylin's mother, Priscilla Jean-Louis, got COVID last month and had to rely on Kaylin to care for the elder women while she recovered.
"She isn't forced to do it, but she helps me a great deal," Priscilla said. "If there are moments when I'm a little frustrated, she may pick up on it and be like 'Mommy, let me handle this.'"
Rhianna's dad, Brian, 40, never smoked and was healthy before joining the Marine Corps. He believes he got sick from inhaling smoke from burn pits during the Iraq War.
He was diagnosed with squamous cell carcinoma of the neck and throat in 2007. He also has PTSD, an inflammatory disease that causes muscle weakness and a rash, and hyperthyroidism from chemotherapy and radiation.
Rhianna's mom is Brian's primary caregiver, but Rhianna helps her change her dad's trach tube and feed him through a feeding tube in his abdomen.
"I'm still learning how to do it," Rhianna said. "I get nervous, though."
The two look after him on and off all day. "Our care for him doesn't end," Rocio said.
Rhianna is quiet and reserved. She has autism, struggles with communication and has trouble sleeping. She has been talking to a therapist once a week.
The trach has had the biggest impact on Rhianna, because Brian doesn't join them for meals anymore. "I feel sad that he can't eat anything," she said.
Despite the growing number of youth caregivers, they have little support.
"If you look at all state and national caregiving programs and respite funding, they all begin at the age of 18," said Melinda Kavanaugh, an associate professor of social work at the University of Wisconsin-Milwaukee.
Kavanaugh is researching Alzheimer's and caregiving in Latino and African American communities in Milwaukee.
"We had a number of kids who were much more stressed out because they had no outlet," she said. "Now they're suddenly 24/7 care and there was absolutely no break."
Adult and youth caregivers often suffer from anxiety, depression and isolation, but there is little data on how caregiving affects young people over the long term, Kavanaugh said.
Connie Siskowski, founder of the American Association of Caregiving Youth, helped care for her grandfather as a child. "I was not prepared," she said. "It was traumatic."
Her Florida-based group connects young caregivers and their families with healthcare, education and community resources. The goal is to identify problems such as stress or isolation among the children, and address them so they won't harm them as adults, Siskowski said.
But long-term care experts said caregiving can also enrich a young person's life.
"It can help kids develop a sense of responsibility, empathy and confidence," Levine said. "The problem comes when their schoolwork, their friendships, their lives as a child are so affected by caregiving that they can't develop in those other important ways."
Nearly all women who deliver babies through cesarean section at Columbia University Irving Medical Center in New York City receive injections of the blood thinner heparin for weeks after the procedure, to prevent potentially life-threatening blood clots.
Obstetric leaders there say that's good medical practice because the formation of those clots, called venous thromboembolism or VTE, though uncommon, is a leading cause of maternal death after delivery, particularly C-section delivery. Broad use of heparin has been shown to be effective and safe in the United Kingdom in reducing that risk and should be adopted in the U.S., they argue.
But there's sharp debate among physicians about whether wide use of heparin is effective, worth the cost and safe, since it carries the risk of bleeding. Last year, the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine recommended heparin only for women at elevated risk of VTE, citing a lack of evidence supporting near-universal use.
The controversy illustrates a classic dilemma for physicians: whether and how to adopt promising new treatments before studies have proven their safety and effectiveness. There also are questions about keeping drug company funding from influencing clinical recommendations around the drug.
The Columbia doctors were lead authors of 2016 guidelines from the National Partnership for Maternal Safety — a multidisciplinary group of medical experts — encouraging doctors to give heparin shots to all women after C-sections, except patients with specific risks. Previously, only a small percentage of mothers received them. Nearly 1.2 million U.S. women deliver via C-section each year.
Other U.S. physician groups generally promote heparin use only for women with a personal or family history of deep vein thrombosis or blood clots in the lungs, called pulmonary embolism, or other high-risk factors. They are estimated to make up less than 5% of pregnant or postpartum women.
Despite gaps in evidence, experts said, the use of heparin has increased across the U.S. since the 2016 guidelines came out, though practices vary widely among doctors and hospitals. One reason for the rise is that more women giving birth have risk factors for VTE, such as obesity and older age.
"We have to make sure we're doing everything possible to reduce preventable maternal death," said Dr. Mary D'Alton, chairperson of obstetrics and gynecology at Columbia University and lead author of the 2016 guidelines. She called heparin treatment "very reasonable" after a cesarean delivery.
One of her co-authors has had second thoughts, however.
"I'd have to agree with some of the critics that there isn't solid evidence we should be giving heparin to as many patients as we do here at Columbia," said Dr. Richard Smiley, an anesthesiologist. "I'd probably want to take a step back. But physicians are willing to be a little more aggressive on this because maternal death is so traumatizing."
The deputy editor of BJOG: An International Journal of Obstetrics and Gynaecology scathingly compared widespread use of heparin for post-delivery patients to debunked obstetric practices of the past like enemas and pubic hair shaving. In a 2018 editorial, he suggested that obstetricians deserved a "booby prize" for adopting this practice without adequate scientific evidence.
One big reason for the lack of evidence is that it's a difficult issue to study, because VTE is relatively rare in women during pregnancy and after delivery, with an estimated incidence of 1 in 1,500 patients. A 2014 study found that out of 466,000 women who delivered through C-section and received the standard nondrug therapy of pneumatic compression devices applied to the legs to reduce clotting risk, just one woman died from pulmonary embolism.
"If those data are valid, and heparin were 50% effective in preventing fatal embolism, we'd have to treat almost 1 million women with heparin to prevent a single maternal death from embolism," said Dr. Dwight Rouse, a professor at Brown University and editor-in-chief of Obstetrics & Gynecology, ACOG's journal.
The cost of preventing that one death? A 2016 editorial he co-authored estimated the minimum national cost associated with widespread use of heparin after C-sections would be $52 million to $130 million annually, not counting the cost of treating serious bleeding complications caused by the drug.
Rouse and other critics say there have been no solid studies either of how effective heparin is at preventing clots or of how many women suffer adverse effects from heparin such as hemorrhage or problems in wound healing. Without those numbers, it's impossible to determine how effective and safe heparin is, they argue. There's also a lack of research on how to best calculate patients' clotting risk based on various individual factors.
While D'Alton and her co-authors claim U.K. data show that maternal deaths from VTE have dropped since British obstetricians recommended broad use of heparin in 2004, critics note that deaths actually have ticked up slightly in recent years to the same level as in the 1980s and '90s.
From 2007 to 2017, the death rate in Britain increased from less than 1 per 100,000 births to about 1.5, according to an analysis by Dr. Andrew Kotaska, an adjunct professor of epidemiology at the University of British Columbia who wrote a 2018 BJOG article arguing that broad heparin use may cause more harm than good.
"The basic rule in evidence-based medicine is you don't implement large-scale interventions that have side effects without first demonstrating net benefit over harm," Kotaska said in an interview. "And this is being done to women without discussing it with them and getting their informed consent."
Obstetricians followed other medical specialties in using heparin after surgical procedures. But the American College of Chest Physicians, whose previous guidelines had strongly advocated giving heparin to post-surgical patients, softened its support in 2012 by saying the evidence for net benefit over harm wasn't clear.
The ACCP also acknowledged that the authors of its previous guidelines promoting heparin use had "highly problematic" financial and intellectual conflicts of interest, including financial relationships with major drug companies that produce anti-clotting drugs. To eliminate such conflicts, the ACCP sharply revised its process for choosing the experts who write its guidelines.
A controversy over drug company funding also arose in connection with the 2016 National Partnership for Maternal Safety guidelines on VTE prevention. In 2019, the editors of Obstetrics & Gynecology, which published the guidelines, disclosed that the National Partnership's guidelines effort received funding from industry groups, including three companies that produce anticoagulant drugs — though the journal said none of the authors received any of those funds.
"We didn't disclose the funding originally because we had no knowledge of it," D'Alton said.
Some critics say funding from drugmakers and other health industry players casts doubt on the credibility of this and other guidelines from physician groups.
"It's a toxic problem for medicine and the care of women," said Dr. Adam Urato, chief of maternal and fetal medicine at MetroWest Medical Center in Framingham, Massachusetts, who pressed Obstetrics & Gynecology to disclose the partnership's drug company funding. "Corporate cash will push guidelines toward things that are good for corporate profits, not for patients."
Meanwhile, Canadian researchers are planning to test an alternative drug that may be equally effective, safer and cheaper in preventing VTE in women after delivery — aspirin.
Orthopedic surgeons have reported that aspirin is as effective as injectable blood thinners at preventing clots.
"I'm not against heparin, but we don't know the best way to prevent clots," said Dr. Leslie Skeith, an assistant professor of hematology at the University of Calgary who launched a five-nation study. "We just need better evidence."
Do public health experts generally consider herd immunity to kick in at 60%?
This article was published on Wednesday, March 17, 2021 in Kaiser Health News.
By Carmen Heredia Rodriguez It's been a long, dark winter of COVID concerns, stoked by high post-holiday case counts and the American death tally exceeding 530,000 lives lost. But with three vaccines — Pfizer-BioNTech, Moderna and Johnson & Johnson — now authorized for emergency use in the United States, there seems to be hope that the pandemic's end may be in sight.
A recent analysis by the Wall Street research firm Fundstrat Global Advisors fueled this idea, suggesting as many as nine states were already reaching the coveted "herd immunity" status as of March 7, signaling that a return to normal was close at hand.
"Presumed 'herd immunity' is 'the combined value of infections + vaccinations as % population > 60%,'" noted a tweet by a CNBC anchor based on a more complete analysis by the firm. That got us thinking: Does this calculation hold up?
First, do public health experts generally consider herd immunity to kick in at 60%? In addition, does current scientific thinking equate protection from the antibodies generated by past COVID infections with the same degree of protection as a vaccination?
We decided to find out.
First, a review of herd immunity. Also known as community or population immunity, the term is used to describe the point at which enough people are sufficiently resistant — or have an immune response — to an infectious agent that it has difficulty spreading to others.
In this explainer, we noted that people generally gain immunity either from vaccination or infection. For contagious diseases that have marked modern history — smallpox, polio, diphtheria or rubella — vaccines have been the mechanism through which herd immunity was achieved.
While the United States is getting closer to this point, most health experts caution, it still has ground to cover. Fundstrat's analysis offered a rosier take. Although the site is located behind a paywall, the chart generated buzz on Twitter and in news outlets like the Daily Caller.
Fundstrat relied on a variety of sources — particularly, a data scientist and pandemic modeler named Youyang Gu — to determine what level of immunity a state needs to stamp out COVID, said Ken Xuan, the firm's head of data science research. From there, analysts created a chart intended to track the level of COVID immunity in each state. They calculated the number by adding the percentage of people estimated to have been infected with the virus to the percentage of people who had received the vaccine.
Xuan, who was quick to note that he is not a public health expert, said he and his team followed Gu's predictions and arrived at 60%, a figure he acknowledges is an assumption.
"The idea would be we don't know if 60% is true," he said. However, if states that have reached this threshold see steep declines in COVID cases, "then it's the number to watch."
What About the 60% Marker?
Throughout the pandemic, health experts have tended to set the magic number for herd immunity between 50% and 70% — with most, including Dr. Anthony Fauci, the head of the National Institute of Allergy and Infectious Diseases, leaning toward the higher end of the spectrum.
"I would say 75 to 85% would have to get vaccinated if you want to have that blanket of herd immunity," he told NPR in December.
The experts we consulted were skeptical of the 60% figure, saying the mechanics of the Fundstrat analysis were relatively sound but oversimplified.
Ali Mokdad, chief strategy officer for population health at the University of Washington, said the level of immunity needed to reach this goal can vary due to several factors. "Nobody knows what is herd immunity for COVID-19 because it's a new virus," he said.
That said, Mokdad described using 60% as "totally wrong." Data from other communities around the world show COVID outbreaks happening at or near that level of immunity, he said. Indeed, the city of Manaus in Brazil saw cases drop for several months, then surge despite three-fourths of their residents already having had the virus.
Josh Michaud, associate director for global health policy at KFF, described the 60% assumption as "off-base."
And some said it wasn't even the main point.
Dr. Jeff Engel, senior adviser for COVID at the Council of State and Territorial Epidemiologists, said the question of herd immunity may not even be relevant because, regarding COVID, we may never reach it. The novel virus may become endemic, he said, which means it will continue circulating like influenza or the common cold. For him, lowering deaths and hospitalizations is more important.
"The concept of herd immunity means that once we reach the threshold, it's going to go away," Engel said. "That's not the case. That's a false notion."
Natural and Vaccine Immunity — Should They Be Lumped Together?
When asked why the Fundstrat analysis treated the two types of immunity as equivalent, Xuan said it was an assumption.
Here's what current science supports.
Those who receive any of the three vaccines available in the United States enjoy a high level of protection against getting seriously sick and dying from COVID — even after one dose of a two-shot series.
In addition, people who were infected and recovered from the virus appear to retain some protection for at least 90 days after testing positive. Immunity may be lower and decline faster among people who developed few to no symptoms.
Practically speaking, two experts said, natural and vaccine-induced immunity work the same way in the body. This lends credibility to Fundstrat's approach.
However, some health experts consider vaccine-induced immunity to be better than the protection generated by the infection because it may be more robust, said Michaud. Researchers are still figuring out whether people who were infected with the virus but experienced mild or no symptoms generated an immune response as strong as those who developed more severe disease.
In fact, the Centers for Disease Control and Prevention cites the unknowns surrounding natural immunity and the risk of getting sick again with COVID as reasons for those who had the virus to get a vaccine.
"They haven't been studied well at all yet," said Engel, in reference to asymptomatic people. "And maybe we're going to discover that a large group of them didn't develop really robust immunity."
Both types of viral protection leave room for potential breakthrough infections, Michaud said. Neither offers "perfect immunity," he said. And wild cards remain. How long do both types of immunity last? How do different people's systems respond? How protected will people be from emerging coronavirus variants?
"It's a witches' brew of different factors to consider when you're trying to estimate herd immunity at this point," said Michaud.
This spring, high school senior Nathan Kassis will play baseball in the shadow of covid-19 — wearing a neck gaiter under his catcher’s mask, sitting 6 feet from teammates in the dugout and trading elbow bumps for hugs after wins.
“We’re looking forward to having a season,” said the 18-year-old catcher for Dublin Coffman High School, outside Columbus, Ohio. “This game is something we really love.”
Kassis, whose team has started practices, is one of the millions of young people getting back onto ballfields, tennis courts and golf courses amid a decline in covid cases as spring approaches. But pandemic precautions portend a very different season this year, and some school districts still are delaying play — spurring spats among parents, coaches and public health experts across the nation.
Since fall, many parents have rallied for their kids to be allowed to play sports and objected to some safety policies, such as limits on spectators. Doctors, meanwhile, haven’t reached a consensus on whether contact sports are safe enough, especially indoors. While children are less likely than adults to become seriously ill from covid, they can still spread it, and those under 16 can’t be vaccinated yet.
Less was known about the virus early in the pandemic, so high school sports basically stopped last spring, starting up again in fits and spurts over the fall and winter in some places. Some kids turned to recreational leagues when their school teams weren’t an option.
But now, according to the National Federation of State High School Associations, public high school sports are underway in every state, though not every district. Schedules in many places are being changed and condensed to allow as many sports as possible, including those not usually played in the spring, to make up for earlier cancellations.
Coaches and doctors agree that playing sports during a pandemic requires balancing the risk of covid with benefits such as improved cardiovascular fitness, strength and mental health. School sports can lead to college scholarships for the most elite student athletes, but even for those who end competitive athletics with high school, the rewards of playing can be extensive. Decisions about resuming sports, however, involve weighing the importance of academics against athletics, since adding covid risks from sports could jeopardize in-person learning during the pandemic.
Tim Saunders, executive director of the National High School Baseball Coaches Association and coach at Dublin Coffman, said the pandemic has taken a significant mental and social toll on players. In a May survey of more than 3,000 teen athletes in Wisconsin, University of Wisconsin researchers found that about two-thirds reported symptoms of anxiety and the same portion reported symptoms of depression. Other studies have shown similar problems for students generally.
“You have to look at the kids and their depression,” Saunders said. “They need to be outside. They need to be with their friends.”
Before letting kids play sports, though, the Centers for Disease Control and Prevention said, coaches and school administrators should consider things like students’ underlying health conditions, the physical closeness of players in the specific sport and how widely covid is spreading locally.
Karissa Niehoff, executive director of the high school federation, has argued that spring sports should be available to all students after last year’s cancellations. She said covid spread among student athletes — and the adults who live and work with them — is correlated to transmission rates in the community.
“Sports themselves are not spreaders when proper precautions are in place,” she said.
Still, outbreaks have occurred. A January report by CDC researchers pointed to a high school wrestling tournament in Florida after which 38 of 130 participants were diagnosed with covid. (Fewer than half were tested.) The report’s authors said outbreaks linked to youth sports suggest that close contact during practices, competitions and related social gatherings all raise the risk of the disease and “could jeopardize the safe operation of in-person education.”
Dr. Kevin Kavanagh, an infection control expert in Kentucky who runs the national patient safety group Health Watch USA, said contact sports are “very problematic,” especially those played indoors. He said heavy breathing during exertion could raise the risk of covid even if students wear cloth masks. Ideally, he said, indoor contact sports should not be played until after the pandemic.
“These are not professional athletes,” Kavanagh said. “They’re children.”
A study released in January by University of Wisconsin researchers, who surveyed high school athletic directors representing more than 150,000 athletes nationally, bolsters the idea that indoor contact sports carry greater risks, finding a lower incidence of covid among athletes playing outdoor, non-contact sports such as golf and tennis.
Overall, “there’s not much evidence of transmission between players outdoors,” said Dr. Andrew Watson, lead author of the study, which he is submitting for peer-reviewed publication.
Dr. Jason Newland, a pediatrics professor at Washington University in St. Louis, said all sorts of youth sports, including indoor contact sports such as basketball, can be safe with the right prevention measures. He supported his daughter playing basketball while wearing a mask at her Kirkwood, Missouri, high school.
Doctors also pointed to other safety measures, such as forgoing locker rooms, keeping kids 6 feet apart when they’re not playing and requiring kids to bring their own water to games.
“The reality is, from a safety standpoint, sports can be played,” Newland said. “It’s the team dinner, the sleepover with the team — that’s where the issue shows up. It’s not the actual games.”
In Nevada’s Clark County School District, administrators said they’d restart sports only after students in grades 6-12 trickle back for in-person instruction as part of a hybrid model starting in late March. Cases in the county have dropped precipitously in recent weeks, from a seven-day average of 1,924 cases a day on Jan. 10 to about 64 on March 3.
In early April, practices for spring sports such as track, swimming, golf and volleyball are scheduled to begin, with intramural fall sports held in April and May. No spectators will be allowed.
Parents who wanted sports to start much earlier created Let Them Play Nevada, one of many groups that popped up to protest the suspension of youth athletics. The Nevada group rallied late last month outside the Clark County school district’s offices shortly before the superintendent announced the reopening of schools to in-person learning.
Let Them Play Nevada organizer Dennis Goughnour said his son, Trey, a senior football player who also runs track, was “very, very distraught” this fall and winter about not playing.
With the reopening, he said, Trey will be able to run track, but the intramural football that will soon be allowed is “a joke,” essentially just practice with a scrimmage game.
“Basically, his senior year of football is a done deal. We are fighting for maybe one game, like a bowl game for the varsity squad at least,” he said. “They have done something, but too little, too late.”
Goughnour said Let Them Play is also fighting to have spectators at games. Limits on the numbers of spectators have riled parents across the nation, provoking “a ton of pushback,” said Niehoff, of the high school federation.
Parents have also objected to travel restrictions, quarantine rules and differing mask requirements. In Orange County, Florida, hundreds of parents signed a petition last fall against mandatory covid testing for football players.
Students, for their part, have quickly adjusted to pandemic requirements, including rules about masks, distancing and locker rooms, said Matt Troha, assistant executive director of the Illinois High School Association.
Kassis, the Ohio baseball player, said doing what’s required to stay safe is a small price to pay to get back in the game.
“We didn’t get to play at all last spring. I didn’t touch a baseball this summer,” he said. “It’s my senior year. I want to have a season and I’ll be devastated if we don’t.”
In the nation's battle against the diabetes epidemic, the go-to weapon being aggressively promoted to patients is as small as a quarter and worn on the belly or arm.
A continuous glucose monitor holds a tiny sensor that's inserted just under the skin, alleviating the need for patients to prick their fingers every day to check blood sugar. The monitor tracks glucose levels all the time, sends readings to patients' cellphone and doctor, and alerts patients when readings are headed too high or too low.
Nearly 2 million people with diabetes wear the monitors today, twice the number in 2019, according to the investment firm Baird.
There's little evidence continuous glucose monitoring (CGM) leads to better outcomes for most people with diabetes — the estimated 25 million U.S. patients with Type 2 disease who don't inject insulin to regulate their blood sugar, health experts say. Still, manufacturers, as well as some physicians and insurers, say the devices help patients control their diabetes by providing near-instant feedback to change diet and exercise compared with once-a-day fingerstick tests. And they say that can reduce costly complications of the disease, such as heart attacks and strokes.
Continuous glucose monitors are not cost-effective for Type 2 diabetes patients who do not use insulin, said Dr. Silvio Inzucchi, director of the Yale Diabetes Center.
Sure, it's easier to pop a device onto the arm once every two weeks than do multiple finger sticks, which cost less than a $1 a day, he said. But “the price point for these devices is not justifiable for routine use for the average person with Type 2 diabetes."
Without insurance, the annual cost of using a continuous glucose monitor ranges from nearly $1,000 to $3,000.
Lower Prices Help Propel Use
People with Type I diabetes — who make no insulin — need the frequent data from the monitors in order to inject the proper dose of a synthetic version of the hormone, via a pump or syringe. Because insulin injections can cause life-threatening drops in their blood sugar, the devices also provide a warning to patients when this is happening, particularly helpful while sleeping.
People with Type 2 diabetes, a different disease, do make insulin to control the upswings after eating, but their bodies don't respond as vigorously as people without the disease. About 20% of Type 2 patients still inject insulin because their bodies don't make enough and oral medications can't control their diabetes.
Doctors often recommend that diabetes patients test their glucose at home to track whether they are reaching treatment goals and learn how medications, diet, exercise and stress affect blood sugar levels.
The crucial blood test doctors use, however, to monitor diabetes for people with Type 2 disease is called hemoglobin A1c, which measures average blood glucose levels over long periods of time. Neither finger-prick tests nor glucose monitors look at A1c. They can't since this test involves a larger amount of blood and must be done in a lab.
The continuous glucose monitors also don't assess blood glucose. Instead they measure the interstitial glucose level, which is the sugar level found in the fluid between the cells.
Companies seem determined to sell the monitors to people with Type 2 diabetes — those who inject insulin and those who don't — because it's a market of more than 30 million people. In contrast, about 1.6 million people have Type 1 diabetes.
Helping to fuel the uptake in demand for the monitors has been a drop in prices. The Abbott FreeStyle Libre, one of the leading and lowest-priced brands, costs $70 for the device and about $75 a month for sensors, which must be replaced every two weeks.
Another factor has been the expansion in insurance coverage.
Nearly all insurers cover continuous glucose monitors for people with Type 1 diabetes, for whom it's a proven lifesaver. Today, nearly half of people with Type 1 diabetes use a monitor, according to Baird.
A small but growing number of insurers are beginning to cover the device for some Type 2 patients who don't use insulin, including UnitedHealthcare and Maryland-based CareFirst BlueCross BlueShield. These insurers say they have seen initial success among members using the monitors along with health coaches to help keep their diabetes under control.
The few studies — mostly small and paid for by device-makers — examining the impact of the monitors on patient's health show conflicting results in lowering hemoglobin A1c.
Still, Inzucchi said, the monitors have helped some of his patients who don't require insulin — and don't like to prick their fingers — change their diets and lower their glucose levels. Doctors said they've seen no proof that the readings get patients to make lasting changes in their diet and exercise routines. They said many patients who don't use insulin may be better off taking a diabetes education class, joining a gym or seeing a nutritionist.
“I don't see the extra value with CGM in this population with current evidence we have," said Dr. Katrina Donahue, director of research at the University of North Carolina Department of Family Medicine. “I'm not sure if more technology is the right answer for most patients."
Donahue was co-author of a landmark 2017 study in JAMA Internal Medicine that showed no benefit to lowering hemoglobin A1c after one year regularly checking glucose levels through finger-stick testing for people with Type 2 diabetes.
She presumes the measurements did little to change patients' eating and exercise habits over the long term — which is probably also true of continuous glucose monitors.
“We need to be judicious how we use CGM," said Veronica Brady, a certified diabetes educator at the University of Texas Health Science Center and spokesperson for the Association of Diabetes Care & Education Specialists. The monitors make sense if used for a few weeks when people are changing medications that can affect their blood sugar levels, she said, or for people who don't have the dexterity to do finger-stick tests.
Yet, some patients like Trevis Hall credit the monitors for helping them get their disease under control.
Last year, Hall's health plan, UnitedHealthcare, gave him a monitor at no cost as part of a program to help control his diabetes. He said it doesn't hurt when he attaches the monitor to his belly twice a month.
The data showed Hall, 53, of Fort Washington, Maryland, that his glucose was reaching dangerous levels several times a day. “It was alarming at first," he said of the alerts the device would send to his phone.
Over months, the readings helped him change his diet and exercise routine to avert those spikes and bring the disease under control. These days, that means taking a brisk walk after a meal or having a vegetable with dinner.
“It's made a big difference in my health," said Hall.
This Market 'Is Going to Explode'
Makers of the devices increasingly promote them as a way to motivate healthier eating and exercise.
The manufacturers spend millions of dollars pushing doctors to prescribe continuous glucose monitors, and they're advertising directly to patients on the internet and in TV ads, including a spot starring singer Nick Jonas during this year's Super Bowl.
Kevin Sayer, CEO of Dexcom, one of the leading makers of the monitors, told analysts last year that the noninsulin Type 2 market is the future. “I'm frequently told by our team that, when this market goes, it is going to explode. It's not going to be small, and it's not going to be slow," he said.
“I believe, personally, at the right price with the right solution, patients will use it all the time," he added.
For all of our grousing about COVID fatigue, a few novel trends are clear one year into the pandemic.
In the early weeks of 2021, Californians are staying home way more than we did in our pre-pandemic life. Even so, we're heading out to shop, dine and work far more now than in March 2020, when state officials issued the first sweeping stay-at-home order, or the dark period that followed the winter holidays, when we hunkered down as COVID-19 caseloads exploded.
And to the extent we are venturing out, we are using cars rather than resuming pre-COVID commute patterns on buses and trains, a trend with troubling implications for transit services and the environment should it become long-standing.
The findings come from a Google compilation of vast troves of cellphone location tracking data, part of an ongoing effort the tech giant says it initiated to help leaders around the globe gauge the impact of COVID-related closures and travel restrictions. The mobility logs, drawn from phones with location trackers enabled, show patterns of trip frequency — broken out at country, state and regional levels — in daily snapshots from early 2020 through early March 2021. The baseline for comparison in terms of trip frequency is the first five weeks of 2020, before California and the U.S. initiated broad COVID-related restrictions.
Google groups its trip frequency data into categories based on the nature of the destination: for example, grocery and pharmacy; retail and restaurants; and work-related. In California, the fever lines for those categories in many ways trace the state's yo-yoing response to COVID's spread, a series of shutdowns and reopenings that have grown more targeted and less restrictive as the pandemic has worn on.
On March 19, 2020, after declaring COVID an emergency, Gov. Gavin Newsom announced the state's first hard shutdown order, telling Californians to stay home except for essential needs and shuttering wide swaths of the service and retail sectors. The tracking data indicates residents took the order to heart: After an initial surge in trips to groceries and pharmacies in the days before the order took effect — presumably as people stocked up on provisions — outings plummeted across the board. By early April, trips to stores and restaurants, as well as work, had fallen more than 50% below the baseline. Grocery and pharmacy outings were off by more than 20%.
The mobility trend lines rebounded in May, when the state moved — some say too quickly — toward reopening the economy. By July, retail and restaurant outings had resurged to 27% below the pre-COVID baseline; grocery outings were just 4% below baseline.
With small ebbs and flows, these activity levels continued through summer and fall, before dipping sharply but briefly in late December through early February as COVID flourished, hospitals reeled and the state paid the price for a recklessly social holiday season. As of early March, travel for retail and restaurants was back to 26% below the baseline, while grocery and pharmacy trips were 11% below.
Work-related travel showed the most sustained disruption, at 33% below the baseline.
While this prolonged stasis has been trying, staying home has saved lives, said Serina Chang, a graduate student in computer science at Stanford University who co-authored a paper in the journal Nature on mobility and COVID spread. The research team created a model that looked at 10 U.S. metropolitan areas, including San Francisco and Los Angeles, and simulated a scenario in which residents didn't cut travel in March and April.
"We saw sometimes 10 times the number of actual infections," she said. "And that's just by the beginning of May."
Chang's research also found that trips to tight, crowded spaces where people stay a long time cause more disease transmission than quick trips to large, nearly empty places. California leaders incorporated that thinking into new guidelines released in December and January that let more businesses stay open than in the March 2020 shutdown, but with limits on capacity.
As Californians get out of the house more, auto use is rebounding. In April 2020, California gasoline sales were down nearly 45% compared with April 2019, according to the California Department of Tax and Fee Administration. By November, gasoline sales were down just 16% compared with 2019, indicating residents were once again liberally filling up.
But, for now, the nature of that car travel has shifted. A couple of years ago, traffic peaked during the morning and evening commutes. Lately, car travel is distributed more evenly through the day, said Giovanni Circella, a researcher at the University of California-Davis Institute of Transportation Studies.
At the same time, daily visits to California transit stations were down an average of 51% in the first five weeks of 2021 compared with the same period in 2020. Mass transit systems in the U.S. rely heavily on fares to generate revenue. The decline in use is fueling worries that ridership won't recover fast enough to stave off deep service cuts.
Chang and Circella said there is strong evidence that Californians with low incomes continue to face more challenges in cutting down on trips outside the home. The pandemic has underscored the array of white-collar jobs that can be done readily from home with the aid of the internet. By contrast, many lower-paid service sector jobs must be carried out in person, requiring a commute.
"Lower-income neighborhoods always ended up with a higher level of infection, and so did less white neighborhoods," said Chang, describing findings modeled in her study. "That tells you that mobility is encoding these disparities in some way."
All those trends play out in high relief in the California region that has seen the biggest sustained decline in travel: the San Francisco Bay Area. The tracking data shows visits to stores and restaurants were down 62% in San Francisco during the first five weeks of 2021 compared with the baseline. Visits to workplaces were down 57%.
The Bay Area Council Economic Institute recently released a study showing that up to 45% of jobs in the region are eligible for remote work, a higher proportion than in other parts of the state. Staying in place can mean fewer infections. As of early March, San Francisco had the lowest COVID infection rate among California counties with more than 500,000 residents, followed by Alameda, San Mateo, Contra Costa and Santa Clara, all in the Bay Area.
In the Bay Area, as elsewhere, car traffic is starting to pick up — but not transit ridership. Jeff Bellisario, executive director of the institute, estimated that ridership on Bay Area Rapid Transit trains was down about 85% in mid-February compared with pre-pandemic levels. In contrast, he pointed to data showing vehicle crossings on the San Francisco-Oakland Bay Bridge down by just 13% on a Wednesday in mid-February.
Researchers like Circella and Bellisario are turning their attention to what comes next, when fears of COVID infection fade. Will commuters get used to driving and take fewer transit trips? Will Californians who can work remotely leave high-priced urban areas, transferring traffic headaches to less developed communities? The answers aren't clear.
"The longer the disruption is [and] the bigger the magnitude of the disruption, the higher the likelihood is that we might have bigger longer-term impacts," Circella said.
Phillip Reese is a data reporting specialist and an assistant professor of journalism at California State University-Sacramento.
President Joe Biden's goal of providing healthcare for more Americans advanced this week with his signing of an economic stimulus package that includes subsidies for health insurance premiums and new incentives for states to expand Medicaid, as well as the potential confirmation of Xavier Becerra as secretary of Health and Human Services.
But as the current administration works to reverse the actions of its predecessor, it should recognize that former President Donald Trump introduced policies on medical care and drug price transparency that are worth preserving. Those measures could help struggling patient-consumers while the new administration pushes for the far more ambitious reforms Biden campaigned on, which include a public health insurance option and a system that would allow Medicare to negotiate drug prices.
To be clear, the Trump administration, generally, put the healthcare of many Americans in jeopardy: It spent four years trying to overturn the Affordable Care Act, despite that law's undeniable successes, and when repeal proved impossible, kneecapped the program in countless ways. As a result of those policies, more than 2 million people lost health insurance during Trump's first three years. And that's before millions more people lost their jobs and accompanying insurance during the early days of the COVID-19 pandemic.
But the Trump administration did attempt to rein in some of the most egregious pricing in the healthcare industry. For example, it required most hospitals to post lists of their standard prices for supplies, drugs, tests and procedures. Providers had long resisted calls for such pricing transparency, arguing that this was a burden, and that since insurers negotiated and paid far lower rates anyway, those list prices didn't matter.
Of course, prices do matter to the patients who are uninsured or end up at an out-of-network hospital when illness strikes and are charged full freight, or nearly so. Some patients, facing bills of hundreds of thousands of dollars, have been sued by hospitals or forced into bankruptcy or foreclosure.
In 2019, the Trump administration proposed a rule that hospitals disclose the discounted rates that they agree to accept from insurers for common medical services, as well as prices for patients who pay in cash. To be clear, this type of transparency doesn't directly lower bills, but the information can help patients shop around for medical care.
These master price lists span hundreds of pages and are hard to decipher. Nonetheless, they give consumers a basis to fight back against outrageous charges in a system where a knee replacement can cost $15,000 or $75,000, even at the same hospital. And the requirement might just motivate some providers to lower their prices, if only to compete with neighboring hospitals.
Last summer, hospitals said it was too hard to comply with the new rule while they were dealing with the pandemic. They still managed to continue the appeal of their lawsuit against the measure, which failed in December. The rule took effect, but the penalty for not complying is just $300 a day — a pittance for hospitals — and there is no meaningful mechanism for active enforcement. The hospitals have asked the Biden administration to revise the requirement.
Trump also used his bully pulpit to take on drug prices, remarking at his first news conference as president-elect that pharmaceutical manufacturers were "getting away with murder." His administration ordered drugmakers to list prices in advertisements for medications that cost more than $35 per month. (Some of the most commonly advertised drugs cost thousands of dollars.) Just before the order took effect, a court blocked it.
Then, last summer, Trump issued a bunch of executive orders aimed at forcing drug price reductions. In September his health secretary, Alex Azar, certified that importing prescription medicine from Canada "poses no additional risk to the public's health and safety" and would result in "a significant reduction in the cost." This statement, which previous health secretaries had declined to make, formally opened the door to importing medication. Millions of Americans, meanwhile, now illegally purchase prescription drugs from abroad because they cannot afford to buy them at home.
In Congress, bills allowing prescription drug importation have for years gained bipartisan support, but without the go-ahead from the Department of Health and Human Services, they were nonstarters. Now a number of states are moving ahead with efforts to import drugs from Canada.
Biden said he supported the legalization of importing drugs during his presidential campaign. Becerra, Azar's potential successor, voted for an importation bill in 2003 when he was a member of Congress.
But the drug lobby will no doubt prove a big obstacle: The Pharmaceutical Research and Manufacturers of America, an industry trade group, filed suit in federal court in November to stop the drug-purchasing initiatives. The industry has long argued that importation from even Canada would risk American lives.
Finally, shortly before the election, Trump issued an executive order paving the way for a "most favored nation" system that would ensure that the prices for certain drugs purchased by Medicare did not exceed the lowest price available in other developed countries. The industry responded with furious pushback, and a court quickly ruled against the measure.
Some of these initiatives, such as posting hospital prices, have already taken effect. But executive orders have limited power; some are stuck in court or require further governmental action to move forward. The Biden administration will have to decide which, if any, to pursue.
Biden's proposals to get better, more affordable healthcare to every American are far more substantial — and disruptive to the health industry — than any of Trump's efforts. But Biden may find it difficult to get support for his plans in a Congress that is narrowly controlled by Democrats. The Democratic Party has historically been friendly to the healthcare industry: According to the Center for Responsive Politics, 71% of the money spent by the pharmaceutical industry in the 2020 elections went to Democratic candidates. Biden raised twice as much money from hospitals and nursing homes during the 2020 presidential campaign as Trump did. The healthcare industry is already aggressively advertising and lobbying against any sort of public option.
The Trump administration's attempted market-based interventions shined some light on dark corners of the health market and opened the door to some workarounds. They are not meaningful substitutes for larger and much-needed health reform. But as Americans await the type of more fundamental changes the Democrats have promised, they need every bit of help they can get.
In the year since the World Health Organization declared a global pandemic, millions of families have endured the excruciating rise and fall of the U.S. outbreak — waves of sickness that leave untold wounds long after hospitalizations ebb and infections subside.
Some have borne the tragedy more than others, with multiple family members lost to COVID-19 in a matter of months.
For the Aldaco family of Phoenix, it has shattered a generation of brothers.
All three men — Jose, Heriberto Jr. and Gonzalo Aldaco — were lost to COVID, each at different moments in the pandemic: first in July, then December, and finally last month.
Their deaths are now among more than 530,000 in the United States, where, even as millions are vaccinated, the virus still leaves families grieving the new loss of a loved one each day.
"Those three men, they drove the family. They were like the strong pillars, the bones of the family. And now they're all gone," said Miguel Lerma, 31, whose grandfather Jose Aldaco raised him as his own son.
To Lerma, their deaths feel like an epic American story of resilience, courage and hard work cut short. All three came to the U.S. from Mexico and over the decades made it home for their families.
"They literally showed that you can come from nothing and struggle through all that and still build a life for yourself and your kids," said Lerma. "It just upsets me this is the way their story has to end."
Jose's daughter Brenda Aldaco said that, with so many Americans gone, the magnitude of each death and its reverberations are profound.
"When you really think about each single person, each person individually, what did that person mean to someone? It's just overwhelming. It's overwhelming," she said.
A Family 'Ready to Create Memories'
Jose Aldaco, 69 when he died, arrived in the Southwest in the early '80s when Brenda was still an infant, following his sister, Delia, and older brother, Gonzalo, who had both left Mexico not long before him.
"They came out here for a better opportunity — I don't even want to say a more comfortable life — but a more attainable, elevated life than what they had," said Priscilla Gomez, Jose's niece and Delia's daughter.
Gomez thinks of all three uncles as central figures — symbols of strength — for her and the entire extended family.
"They were so consistent, the most consistent male figures for me," said Gomez.
Big family gatherings were a staple of life in the Aldaco households.
"Those three men, when they were in the same room, it was just a good time," said Lerma, a dance teacher in Phoenix.
Reunions and holidays often evolved into joyous, music-filled events, where Gonzalo, the oldest, would pull out the guitar and the family would dance and sing together till the early hours of the morning.
"If it was someone's birthday, they would sing 'Las Mañanitas.' … They were just always ready to create memories for us," recalled Gomez.
Lerma said what Jose cultivated most of all was a family where love and affection was the main currency. "He's the one who taught us to be so amorous," said Lerma. "He was that warmth. He was that love for us."
Wave After Wave in Arizona
After a calm spring, the pandemic hit Arizona with terrifying force — the first of two waves that would rip through a state where pandemic precautions were slow to come and quick to disappear. Lerma said his family heeded the warnings.
"We were a family that accepted the pandemic was real," he said. "We did take it seriously."
Jose and his wife, Virginia, lived at their daughter Brenda's house, where they helped raise their teenage grandson.
Brenda's father worked a few days a week at his job in a hotel restaurant, but was mostly retired. "He was perfectly able — doing yardwork, cooking every day, jogging three times a week at the park," said Brenda.
Despite the family's effort to stay safe, the virus found a way into their household that summer. Jose was the first to get sick, but soon all four were ill and isolating in their bedrooms.
They waited on test results. Both elders were getting worse. When the bedroom door was open, Brenda's son would hear his grandfather.
"My son would say, 'Mom, Abuelo doesn't sound good. … He sounds like he's dying,'" recalled Brenda.
She felt paralyzed, though. Her mother was adamant that she didn't want him to go to the hospital.
Eventually, Lerma, who lives separately and did not have COVID, put on a mask and came to coax Virginia and Jose to go to the hospital. Lerma found Jose lying in bed, covered in a sheet, with a sky-high fever.
"He was forcing fast breaths to try to get any air that he could into his lungs," said Lerma. "That's when I started freaking out and losing it."
Virginia and Jose were admitted to the hospital. A few days later, Virginia was doing well enough to go home, but Jose's condition only got worse.
The last time Lerma saw him it was over FaceTime, while Jose was being wheeled through the hospital to be put on life support. "Losing my dad, this is what heartbreak is," said Lerma. "This is what the sad songs are about."
Three Brothers — 'Family Men' — Gone
By the time of Jose's death, the virus had already killed about 150,000 Americans. Like so many other families, the Aldacos were not able to have a proper funeral.
"It felt like his death was just brushed under the rug, like he's just another statistic," said Lerma.
Priscilla Gomez said she'll never forget hearing her mother take the phone call when she learned of her brother's death.
"To not be there in-person to comfort them or to hold them up when they feel like they just want to throw themselves on the ground and just sob … you feel completely helpless," she said.
As the pandemic stretched into the winter months, a new wave of infections and deaths gripped Arizona and much of the rest of the U.S. By late December, the total U.S death toll had surpassed 300,000, and Heriberto Aldaco Jr. — the youngest, in his late 50s — was now also hospitalized with COVID.
"You think you've gone to a particular point in your grieving, and then it's not done — here it comes again. … Now my dad's baby brother is sick," said Brenda Aldaco. "Then he passes away."
Less than two months later, yet more shattering news would come to the family.
The last remaining brother, Gonzalo Aldaco, the eldest in his early 70s, was hospitalized with COVID. He died in February.
Brenda Aldaco described her father and uncles as above all else "family men."
"They were totally and completely devoted to the people they loved — always present, always someone you could rely on," she said.
Sometimes, she still expects her father to come home from the hospital: "It was just hard for me to even grasp the concept of 'He's gone'… that the three of them are now gone and under the same circumstances and within a period of six months."
This story is from a reporting partnership between NPR and KHN.
A federal government survey estimated that a shortage of mental health providers exist in 5,800 geographic areas, populations or facilities — such as prisons — across the U.S., with 6,450 practitioners needed to fill the gaps.
This article was published on Monday, March 15, 2021 in Kaiser Health News.
HELENA, Mont. — When the Hazelden Betty Ford Foundation began offering telehealth services in Montana in early February, the nation's largest nonprofit addiction treatment provider promised quality care for far-flung residents without their even having to leave home.
That promise was what Montana and more than 40 other states had in mind when they temporarily relaxed rules restricting telehealth services and allowed out-of-state providers to hold remote patient visits for the duration of the COVID-19 pandemic.
A year into the pandemic, telehealth has become widely accepted. Some states are now looking to make permanent the measures that have fueled its growth. But with it have come some unintended consequences, such as a rise in fraud, potential access problems for vulnerable groups and conflicts between out-of-state and in-state health providers.
In Montana, for example, not everybody cheered the virtual arrival of the Minnesota-based Hazelden Betty Ford Foundation. The head of Montana's largest behavioral health provider, Billings-based Rimrock, worried that an influx of out-of-state providers could lead to Rimrock's losing a significant number of its privately insured patients.
Rimrock patients with private insurance subsidize patients who are on Medicaid, CEO Lenette Kosovich said. The difference in insurance reimbursement rates between the two is so great that the loss of those privately insured patients would hamper Rimrock's operations, she said.
"I'm all for competition, as long as it's fair competition," Kosovich said. She added that she would like to see rules in place ensuring that out-of-state providers that enter Montana via the relaxed regulations of the pandemic meet the same licensing requirements as in-state providers.
"They don't take Medicaid, so they don't have to go through the same rigors," she said. "We've been really very vocal that we want more legislation that speaks to that. Even the playing field."
Hazelden Betty Ford is not out to poach anybody else's patients, said Bob Poznanovich, the foundation's vice president of business development. Instead, it's targeting patients who aren't receiving care and can't go to one of its 15 drug and alcohol rehabilitation centers, he said.
"We think it's important that a national brand like ours is able to provide care nationally," Poznanovich said. "That becomes important to our patients, who come from all over the country. It's also important, I think, for people who can't access quality care, who are in some healthcare deserts where there just isn't good care."
A federal government survey estimated that a shortage of mental health providers exist in 5,800 geographic areas, populations or facilities — such as prisons — across the U.S., with 6,450 practitioners needed to fill the gaps. For primary care, the need is even greater, with nearly 7,300 areas short of health professionals.
For patients nationwide, telehealth can make getting medical care much easier. Ayanna Miller, a 24-year-old student at Northeastern University in Boston, is among those embracing the technology.
"Sometimes you don't really need to go into the office. You really just need, like, a quick conversation with your doctor," she said. "I've also done telehealth for therapy. You don't necessarily need to be in the same room with your therapist."
As the stresses of the pandemic have strained mental health and addiction recovery, the need for help has increased. Hazelden Betty Ford has accelerated its pre-COVID plans for expansion and expects to offer telehealth services in all 50 states within two years. Next on deck: Arizona and New Mexico.
"We've heard grumblings, like 'Why are you coming into our state?'" Poznanovich said. But, he added, "More people have welcomed the entry into the marketplace because they think that we will help create a bigger marketplace."
But now, states are waiving patient copays and coinsurance, reimbursing telehealth services at the same rate as in-person services, waiving licensure requirements and allowing audio-only visits, among other measures.
In the first months of the pandemic, with lockdowns the norm throughout the country, telehealth visits surged to about 7 in 10 medical appointments, according to the Epic Health Research Network. That had tapered off to about 1 in 5 visits as of summer.
Existing and startup services are flourishing. Poznanovich compared the surge to the dot-com boom of the early part of the century, noting that the foundation's internal studies show that hundreds of telehealth companies have received financing.
"There is a land-grab mentality right now," he said. "We're seeing some really crazy market valuations because of the potential number of clients."
Today's rush will lead to permanent changes in healthcare, said Florida radiologist Dr. Ashley Maru, who invested in three telehealth companies. More innovative virtual providers entering the field may come at the expense of physicians who see patients in brick-and-mortar offices. But it also presents a solution to the national shortage of doctors, he said.
"You're going to see a national change in the landscape of medicine," Maru said. "They're going to be able to cross state lines and really uproot and disrupt everything."
The prospect of unfettered interstate virtual healthcare worries some health industry officials. Blue Cross and Blue Shield of Montana spokesperson John Doran said he shares Kosovich's concerns that local providers could suffer or be driven out of business, particularly in smaller states.
"The future of medicine has to include connecting a Montana patient to a Montana provider," Doran said.
Poznanovich said that, besides providing services to people who weren't receiving them before, Hazelden Betty Ford Foundation forms partnerships with local providers in some markets and offers education and resources to providers where it expands.
Some states are forging ahead with plans to make their telehealth changes permanent. A Montana bill passed the state House of Representatives unanimously Feb. 9 and is pending in the Senate.
"We were forced to use technologies in ways that we maybe thought we weren't ready for and it turns out that we were," Jackie Jones, government affairs director for the state's securities and insurance commissioner, recently told state lawmakers in supporting the bill.
Certain patients may be left out of the telehealth revolution. The rapid, wide-scale implementation of telemedicine could leave behind people with limited internet access or tech literacy, including the elderly, poor and non-English speakers, according to a New England Journal of Medicine article.
Meanwhile, telehealth fraud cases have "gone through the roof," said Mike Cohen, an operations officer with the Office of Investigations of the Department of Health and Human Services' inspector general's office. Telehealth in general is a good thing, he said, but with any popular medical advancement, "there's going to be rats on the ship."
Many fraudsters are trying to steal patients' identities and sell them on the black market, he said. Some providers are overcharging for appointments, are billing for services that weren't given, or are not registered or licensed in the U.S. Some scammers offer to put a patient at the front of the line for a COVID vaccine in exchange for payment.
"Our sense is that it's more widespread than we envisioned," Cohen said. "If we're going to make this permanent, we need to make sure there's guardrails to ensure programmatic integrity and also patient safety."
Even when working optimally, telehealth can have its limits. Miller, the Northeastern University student, said she was diagnosed with COVID in January and had mild symptoms. By early February, she felt better and wanted to schedule an in-person physical with her doctor to find out if the virus had affected her in other ways.
The doctor was taking only virtual appointments, and Miller was left feeling unsatisfied just answering the doctor's questions by video call.
"The scariest thing about COVID is you just don't know how it's going to impact you," Miller said. "I can say how I feel, but I don't know if there's anything that I'm not catching because I'm not trained."
After a brutal year in which the pandemic killed half a million Americans, despite unprecedented measures to curb its spread the vaccines are giving hope that an end is in sight.
Joan Phillips, a certified nursing assistant in a Florida nursing home, loved her job but dreaded the danger of going to work in the pandemic. When vaccines became available in December, she jumped at the chance to get one.
Months later, it appears that danger has faded. After the rollout of COVID vaccines, the number of new COVID cases among nursing home staff members fell 83% — from 28,802 for the week ending Dec. 20 to 4,764 for the week ending Feb. 14, data from the Centers for Medicare & Medicaid Services shows.
New COVID-19 infections among nursing home residents fell even more steeply, by 89%, in that period, compared with 58% in the general public, CMS and Johns Hopkins University data shows.
These numbers suggest that "the vaccine appears to be having a dramatic effect on reducing cases, which is extremely encouraging," said Beth Martino, spokesperson for the American Healthcare Association and National Center for Assisted Living, an industry group.
"It’s a big relief for me," said Phillips, who works at the North Beach Rehabilitation Center outside Miami. Now, she said, she's urging hesitant co-workers and anyone else who can to "go out and take the vaccination."
After a brutal year in which the pandemic killed half a million Americans, despite unprecedented measures to curb its spread — including mask-wearing, physical distancing, school closures and economic shutdowns — the vaccines are giving hope that an end is in sight.
Noting that more than 3 million doses of vaccine have been doled out in nursing homes, CMS issued new guidelines Wednesday allowing indoor visits in the facilities, even among unvaccinated residents and visitors, under most circumstances.
National figures on healthcare worker infections in other settings are hard to come by, but some statewide trends look promising. In California and Arkansas, healthcare worker COVID cases have dropped faster than for the general public since December, and in Virginia the number of hospital staffers out of work for COVID-related reasons has fallen dramatically.
Research in other countries suggests that vaccines have led to big drops in infection. A study of publicly funded hospitals in England indicated that a first dose was 72% effective at preventing COVID among workers after 21 days and 86% effective seven days after the second shot. At Sheba Medical Center — Israel's largest hospital, with over 9,600 workers — 170 staff members tested positive from Dec. 19, the first day the vaccine was offered, through Jan. 24. Of those who tested positive, only three had already received both doses of the vaccine, according to The Lancet.
Along with other healthcare workers, nursing home staffers and residents were first in line to get vaccines in December because elderly people in congregate settings are among the most vulnerable to infection: More than 125,000 residents have died of COVID, CMS data shows, while over 550,000 nursing home staff members have tested positive and more than 1,600 have died.
Yet the vaccination rate among staffers is far lower than that of residents. When the first clinics ran from mid-December to mid-January, a median of 78% of nursing home residents took a dose, while the median for staff was only 38%, according to the Centers for Disease Control and Prevention. Now several nursing home associations say the rate of staff vaccination has been climbing, based on informal surveys.
While vaccines are "contributing to the observed declines in COVID-19 cases in nursing homes, other factors, like effective infection prevention and control programs/practices," are also at play, CDC spokesperson Jade Fulce said.
Vaccine uptake by nursing home residents has been "very promising," said Dr. Morgan Katz, a specialist in infectious diseases at Johns Hopkins University who is advising COVID responses in nursing homes. "I do think this is a huge contributing factor” to the drop in staff cases.
"When the immune system is activated more quickly" due to vaccination, "the virus is not able to multiply in your body and your respiratory tract," Katz said. So, having even one or two vaccinated people in a building can slow transmission.
Another factor, Katz said, is that "many nursing homes have already experienced large outbreaks — so there are probably a significant proportion of residents and staff who are already immune." Also, COVID rates have fallen nationally after a spike from holiday travel and gatherings in November and December, so staff members have less exposure in their communities.
But "even though we’re seeing a really wonderful turn in the number of cases," she said, "we need to remember that as long as the staff is 50 or 30% vaccinated, they remain vulnerable, and they’re also putting incredibly vulnerable long-term care residents at risk."
Vaccination efforts are racing against time as new COVID variants circulate and some states dramatically relax COVID restrictions, making it easier for the virus to spread.
During the second week in February, 2,850 nursing homes still reported at least one new COVID-positive test result for a staff member, CMS data shows.
When this happens, residents suffer, said Lori Smetanka, executive director of the National Consumer Voice for Quality Long-Term Care. She said she's hearing of cases in which one positive COVID test result sends a facility into lockdown, preventing families from visiting their loved ones.
‘They're Afraid’
The New Jersey Veterans Memorial Home at Menlo Park endured a major outbreak last year in which over 100 workers contracted COVID and over 60 residents and a certified nurse assistant, Monemise Romelus, died. Shirley Lewis, a union president representing CNAs and other workers, said it was traumatizing. Still, only about half of workers there have taken the vaccine, Lewis said, and one is out sick with COVID.
"A lot of my members are not too excited about taking this vaccine because they’re afraid," Lewis said.
Some workers want to wait a little longer to see how safe the vaccine is, she said. Others tell her they don't trust the vaccines because they were developed so quickly, she said.
Other staffers "feel like it’s an experimental drug," Lewis said, "because as you know, Blacks, Latinos, other groups have been used for experiments" like the Tuskegee syphilis study, she said. She said her members are mostly Black or Hispanic.
Certified nursing assistants, who make up the bulk of long-term care workers, have historically been less likely to get flu vaccines than other healthcare workers, noted Jasmine Travers, an assistant professor of nursing at New York University who studies vaccine hesitancy. Nursing homes typically don't have nurse educators, who address worker concerns about vaccines in hospitals, she said, and CNAs also face structural barriers such as limited internet access. Nursing homes tend to be hierarchies commonly led by white staffers, while about 50% of CNAs, at the bottom of the power structure, are Black or Hispanic, and carry mistrust and different attitudes toward vaccination, she added.
With the COVID vaccine, some are afraid they'll have to take sick time to miss work and don't want to burden their co-workers, who are already short-staffed, Travers said.
Low vaccine uptake among long-term care workers has been a concern nationally — so much so that LeadingAge, a national group representing not-for-profit long-term care facilities, held a virtual town hall about vaccine safety this month with the Black Coalition Against COVID-19.
The event, which drew over 45,000 viewers, was geared toward Black long-term care workers.
Dr. Reed Tuckson, co-founder of the Black Coalition Against COVID-19, said viewers raised concerns about fertility, pregnancy and contraindications. He said the event also had "a lot of provocateurs" who insisted, "It’s all a myth. It’s all a lie."
His group plans to hold more public informational sessions aimed at Black audiences.
"There is no question that the three vaccines that we now have available to us are extraordinarily safe and tremendously effective," said Tuckson, a former public health commissioner in Washington, D.C.
The nursing home industry has set a goal of having 75% of staff members vaccinated nationwide by the end of June.
A Vaccine Mandate?
Most nursing homes have not mandated vaccinations, industry officials say, for fear of losing staff members. Because the vaccines were authorized on an emergency basis, liability is also a concern.
Juniper Communities, which runs 22 long-term care facilities in four states and employs almost 1,300 people, had 30 workers leave the job after it mandated vaccines, according to Dr. Lynne Katzmann, president and CEO.
"At the end of the day, if you can make a choice to promote well-being and prevent illness, that's the choice we want to make," she said.
Greenbrier Nursing and Rehabilitation Center in Arkansas made the vaccine mandatory, but because of medical exemptions it hasn't led to 100% vaccination.
However, Greenbrier has seen a significant drop in COVID infections since vaccinations began. In late November and early December, over 60% of staff members tested positive, according to Regina Jones, Greenbrier’s director of nursing. After the staff started receiving the vaccine in late December, four workers who had already received a dose tested positive but were asymptomatic.
Hesitancy Doesn't Mean Refusal
Tuckson said he's seeing a "dramatic decrease" in vaccine hesitancy based on surveys of Black audiences. He has heard "a hunger for scientifically valid information delivered to them by trusted sources," he said. "It's not as if their opinions are locked in stone."
Staff participation rates are rising with each round of vaccines, said Martino, the nursing home industry spokesperson.
At the Los Angeles Jewish Home, Chief Medical Officer Dr. Noah Marco said his staff has done "everything we could to counterbalance the nonsense out there on social media that has contributed to vaccine hesitancy," including producing videos and a weekly newsletter.
"The vaccine may have some unknown side effects," he recalled telling workers, "but we know the virus kills."
About 80% of his staff of 1,600 — which includes workers in nursing homes and other settings — are vaccinated, he said, along with 99% of residents. No nursing home residents have contracted COVID since Jan. 13, he said.
In southwestern Ohio, Kenn Daily runs two Ayden Healthcare nursing homes. About half his staff and 85% of residents got vaccinated by mid-February, he said, and they haven't had a case of COVID since. Still, he said, vaccine resistance persists among younger staffers who read misinformation online.
"Facebook is the bane of my existence," Daily said. Workers tell him they worry that "they’re going to microchip me," or that the vaccine will change their DNA.
Now that time has passed since the initial rollout, Daily said, "I’m hoping to put a little pressure on my staff to step up and get vaccinated." His message: "It’s working, guys. It’s working very well."
KHN data editor Elizabeth Lucas contributed to this report.