Many long haulers have found it impossible to fulfill their professional obligations and are making the tough decision to stop working and seek disability benefits.
This article was published on Wednesday, March 10, 2021 in Kaiser Health News.
Rickie Andersen took a brief break from work in March after she fell ill. Her cough, fever and chills were typical COVID-19 symptoms, but coronavirus tests were so scarce she could not obtain one to confirm the diagnosis.
After Andersen returned to her job as an information systems project manager in the San Francisco Bay Area, she struggled with profound fatigue, cognitive difficulties and other disabling complaints. For six months, she tried to keep awake during meetings and finish basic tasks that took much longer than before.
Finally, she decided to retain legal help so she could take advantage of the disability insurance coverage offered as an employee benefit. "I realized this is not going to be a short-term thing," Andersen said.
Hundreds of thousands of people around the world are experiencing what is being called "long COVID" — a pattern of prolonged symptoms following an acute bout of the disease. Many have managed to continue working through accommodations like telecommuting, cutting down on hours and delegating responsibilities.
Others have found it impossible to fulfill their professional obligations and are making the tough decision to stop working and seek disability benefits. But as they pursue the application process, they are discovering a particular set of challenges.
Given the lack of testing in the first months, many "long haulers," like Andersen, have no laboratory proof of infection. While antibody tests can provide such evidence, their accuracy varies. Moreover, many of the reported symptoms, including fatigue and cognitive impairment, are subjective and not clearly linked to specific organ damage.
Beyond that, compiling a thorough record for a disability application and navigating the bureaucratic hurdles require sustained brain power, something many long-haul patients can no longer muster. Barbara Comerford, a New Jersey disability lawyer, said she received dozens of inquiries starting last fall from long haulers seeking advice on filing for disability and often citing what is being called "brain fog" as their main complaint.
"Most are people calling to say, 'I thought I could do it. I can't. My mind doesn't function for more than really brief periods of time,'" Comerford said. She gave a presentation to the New Jersey State Bar Association in mid-February on how to develop evidence for such cases.
In the U.S., close to 30 million people have tested positive for the coronavirus, although many cases of infection are asymptomatic. What proportion might be affected by long-term illness isn't known. Scientific understanding of the phenomenon is in its infancy.
In January, The Lancet reported that around three-quarters of more than 1,700 COVID patients who had been hospitalized in Wuhan, China, reported at least one ongoing symptom six months later. More recently, investigators from the University of Washington reported in JAMA Network Open that around 30% of 177 patients who had tested positive for the coronavirus still reported symptoms when they were surveyed one to 10 months later.
The Social Security Administration provides long-term disability to American workers who qualify under its strict criteria, but applicants often get turned down on the first try. A few states, including California and New York, provide short-term disability benefits, in some cases for up to a year.
Tens of millions of Americans also have private disability coverage, most often as part of their employment benefit packages.
The maximum currently available to an individual through the Social Security Disability Insurance program is just over $3,000 a month. A typical private long-term disability plan might cover 60% of a beneficiary's base salary, with a much higher maximum amount.
Sandy Lewis, a pharmaceutical industry researcher, fell ill last March with what she assumed was COVID. She recovered but relapsed in April and again in May.
Through her employer-based insurance coverage, she received short-term disability for November and December, but the insurer, Prudential Financial, rejected her request for an extension. Soon after, she was diagnosed with myalgic encephalomyelitis/chronic fatigue syndrome, or ME/CFS, a debilitating illness that can be triggered by viral infections.
Lewis, who lives outside Philadelphia, is planning to appeal Prudential's rejection of the short-term extension and apply for long-term disability. But the matter is unlikely to be resolved before fall. The situation has left her feeling "devastated," she said, and in serious financial distress.
"This has been such an arduous journey," she said. "I have no income and I'm sick, and I'm continuing to need medical care. I am now in a position, at 49 years old, that I may have to sell my home during a pandemic and move in with family to stay afloat."
In Lewis' case, a Prudential reviewer noted that her symptoms were "subjective" and that there were "no physical exam findings to correlate with any ongoing functional limitations," according to Cassie Springer Ayeni, an Oakland disability lawyer who is representing her as well as Andersen.
Prudential would not comment on a specific case. Evan Scarponi, chief claims officer, said in a statement that "our collective understanding of COVID-19 and any associated long-term effects are still evolving" but that Prudential is "well-versed in evaluating both subjective and objective aspects of disability claims."
Lawyers and advocates in the field expect the numbers of COVID-related long-term disability applicants to rise this year. But it's still too soon to detect any such increase, said a spokesperson for the American Council of Life Insurers, a trade association. Workers typically must be unable to work for half a year before becoming eligible for long-term disability benefits, and applying can itself be a lengthy process.
Brian Vastag, a former Washington Post science and health reporter with ME/CFS, stopped working in 2014 and then sued Prudential after it rejected his long-term disability claim. Insurance companies, he said, can easily find reasons to dismiss applications from claimants with chronic illnesses characterized by symptoms like fatigue and cognitive impairment.
"The insurance companies will often say, 'There's no objective evidence, so we have nothing to support your claim,'" said Vastag, who won his case against Prudential in 2018. "I'm worried about the long-COVID patients who can't work anymore."
Claimants can appeal a rejection. If the insurer rejects the appeal, claimants have the right to sue, as Vastag did. However, most such cases fall under the Employee Retirement Income Security Act of 1974. Because this federal law requires a losing insurer to pay the unpaid claims but does not provide for punitive or compensatory damages, critics argue it incentivizes the denial of coverage.
In the event of litigation, the court's role is to assess the already existing evidentiary record. That means it is essential to present a robust case in the initial application or during the administrative appeal before any litigation begins, said Ayeni, the disability lawyer for Andersen and Lewis.
"It's the only shot to build a record for the courts, to develop a full body of evidence," she said.
However, a successful disability case ultimately depends on documenting inability to work, not on obtaining a specific diagnosis. To augment the medical evidence, Ayeni often sends clients for neuropsychological testing, investigations of lung function and other specialist assessments. She also gathers affidavits from family members, professional colleagues and friends to confirm patients' accounts.
In Rickie Andersen's case, the strategy worked. Recognizing how complicated the application process was likely to be, she sought legal help early on. The insurer contracted by her employer approved her for short-term benefits late last year and granted her application for long-term benefits in February.
"I knew all of it was completely exhausting, so it wasn't something I thought I could do on my own," Andersen said.
Pfizer's management knew last year there was "a mold issue" at the Kansas facility now slated to produce the drugmaker's urgently needed COVID-19 vaccine, according to a Food and Drug Administration inspection report.
The McPherson, Kansas, facility, which FDA inspectors wrote is the nation's largest manufacturer of sterile injectable controlled substances, has a long, troubled history. Nearly a decade's worth of FDA inspection reports, recalls and reprimands reviewed by KHN show the facility as a repeat offender. FDA investigators have repeatedly noted in reports that the plant has failed to control quality and contamination or fully investigate after production failures.
The 1970s-era manufacturing site has had persistent mold concerns over the years and been the focus of at least four intense FDA inspections since Pfizer took over its operations in late 2015, when it acquired Hospira. At the end of the January 2020 inspection, FDA investigators appeared to be growing frustrated.
Pfizer's plant managers told investigators they knew they had either bacteria or mold throughout the facility at various times of the year. In a Jan. 17, 2020, establishment inspection report obtained by KHN, one of three FDA experts who visited wrote that Pfizer said it addressed problems and added "more cleaning activities in response to mold" after a 2018 inspection and "yet, there are still unexplained discrepancies."
After the January 2020 inspection report, Pfizer immediately developed and put in place a corrective action plan, company spokesperson Eamonn Nolan told KHN. Neither Pfizer nor the FDA responded to requests to provide a copy of the plan.
Nolan, in an email last week, said "significant investments have been made" in resources, equipment and the facility. He stated all improvements related to COVID manufacturing would be completed before vaccine production begins. He declined to provide details on when production of the vaccine would begin, but said the site is currently operating in a state of good manufacturing, which means it has met a regulatory standard enforced by the FDA.
"We are confident in the McPherson site's ability to manufacture high-quality COVID-19 vaccine," he wrote.
Large clinical trials have found Pfizer's vaccine to be safe and 95% effective against COVID.
News that the plant will be a fill-and-finish site for the Pfizer-BioNTech COVID vaccine means more watchful eyes focused on the facility. "That alone should be helpful," said Barbara Unger, a former pharmaceutical industry executive who now does manufacturing audits for companies.
It is unclear whether FDA investigators have returned to check on production practices in McPherson or plan to visit before vaccine production begins. The FDA did not respond to specific questions. FDA spokesperson Abigail Capobianco wrote in an email that the public "can be assured that the agency used all available tools and information to assess compliance."
Pfizer's emergency use authorization letter for its mRNA vaccine includes safeguards, such as quarterly reports to the FDA and a quality analysis from the company for each manufactured drug lot at least 48 hours before it is distributed.
The plant's manufacturing issues can be traced in FDA reports dated from 2011 to last year. Several former FDA staffers and industry experts said the ongoing challenges in McPherson highlight how agency officials must balance aggressively going after a company's manufacturing practices with the need to keep the supply of medications flowing to patients.
"I do not envy the FDA choices," Unger said, describing a balancing act. "Which has the more significant public health risk?"
The site produces a wide array of sterile, generic medications used in hospitals, and its troubles have played a role in some big health system shortages, specifically for injectable opioid analgesics, according to a 2018 FDA statement.
The FDA rejected Pfizer's biosimilar version of Amgen's anemia drug Epogen because of concerns about the fill/finish plant in 2017. The same year, John Young, who was a group president at Pfizer, told investors the company had submitted a "corrective and preventative action plan" for the facility.
That is the same language used after the January 2020 inspection, which said there were contamination concerns for the site but not in the medicines. And it was Young, now Pfizer's chief business officer, who last month told Congress that Pfizer had added production lines at the McPherson site to help meet COVID-19 vaccine demands.
The facility's record of recalls and field alerts include vials of medication that contained glass and cardboard particles and, as one customer complained, a "small insect or speck of dust."
A 2017 FDA warning letter — which is a strong rebuke for the agency — said the contaminants such as cardboard and glass found in vials posed a "severe risk of harm to patients" and indicated that the facility's process for manufacturing sterile injectable products was "out of control."
FDA records show that multiple batches of vancomycin hydrochloride, a drug injected into hospital patients who have an infection that penicillin won't treat, were recalled in 2016 and 2017.
John Avellanet, an FDA compliance expert and principal at Cerulean Associates, reviewed the 2020 inspection reports. He said he fears the fixes have been little but "window dressing."
"They may have solved it in one instance, like the cardboard particles. But for some reason, they were never able to solve the contamination," Avellanet said. "Whatever they are doing for quality control testing doesn't appear to be working, because if it was working they wouldn't continue to have these contamination problems."
Pfizer shut down McPherson's manufacturing in December 2017 even though the FDA had visited two months earlier and improved the facility's inspection rating. McPherson's management suspended production and rejected batches of finished products after finding mold on equipment in a filling area, according to an FDA inspection report. The facility returned to production weeks later.
When the FDA came back to inspect in late summer 2018, it found that procedures to prevent microbiological contamination of drugs were lacking. It also noted a lack of employee training, employees not following procedures, obstructed surfaces and in-house testing that did not guarantee drugs met standards.
In 2019, when CEO Albert Bourla took the helm at Pfizer, he told analysts it would be another hard year for U.S. hospitals to get their hands on sterile injectables because of ongoing work at the McPherson plant.
Since then, the coronavirus pandemic has taken a toll on the FDA's ability to inspect plants, according to a recent report from the U.S. Government Accountability Office. The agency halted non-urgent foreign and domestic inspections in March 2020 out of concerns for staff safety and has since resumed select visits to domestic plants.
John Fuson, a partner at the law firm Crowell & Moring and former associate chief counsel at the FDA, said the agency has sent surveys to manufacturers to help it prioritize inspections. While not speaking directly about the Pfizer plant, Fuson said the FDA lacks the resources to do all the inspections "we might like it to do."
It is unclear what oversight Pfizer's McPherson facility has had in the past year. In 2020, the pharmaceutical company Gilead Sciences signed a multiyear agreement with Pfizer to produce its COVID treatment remdesivir in the Kansas plant. Gilead spokesperson Arran Attridge wrote in an email that Gilead "evaluates our manufacturing partners' facilities" to make sure they follow regulations.
FDA inspectors visited the McPherson plant annually before the pandemic, according to public FDA records. The plant was given ratings of VAI, or voluntary action indicated, or OAI, official action indicated, depending on the inspection. John Godshalk, a former FDA investigator who worked on vaccines, said a VAI is one of the most common inspection ratings given. That means the FDA is "trusting the company to fix" the observations made during the inspections, he said.
The FDA assigned Pfizer's McPherson facility a VAI rating in January 2020 — and company executives were so pleased they reported in their third-quarter financial filing that the agency had "upgraded" the plant.
Before January 2020, the McPherson plant appears to have been operating with the more severe OAI rating since its 2018 inspection, according to FDA reports. Former FDA investigator Godshalk said an OAI puts the company on notice. It's "what you don't want as a company," he said.
Pfizer employs about 1,500 people at the McPherson plant, plus contractors. Kasi Morales, executive director of McPherson Industrial Development Co., said the facility is the largest employer in the industrial town about an hour north of Wichita, Kansas, and not far from Interstate 70, a major east-west thoroughfare across the country.
The 2020 inspection report that led to McPherson's "upgraded" rating listed repeat observations that involved quality control procedures not being fully followed and "contamination" with mold and bacteria on surfaces because of humidity and cleaning practices.
No contamination was found in the medications themselves during the inspection, but investigators described seeing operators "leaning over and talking over sterilized items being unwrapped."
Notably, the 2020 inspection report states early on that Pfizer had made "significant management changes" since the previous inspection in 2018. That latest inspection spanned three weeks from December 2019 to January 2020 and inspectors wrote "management was cooperative and no refusals were encountered."
Christopher Smith, vice president of quality operations for Pfizer's U.S. and European Union sterile injectables, was at the McPherson facility periodically during the visit. In the end, he "expressed discontent" with several of the 2020 observations made by investigators and "repeatedly sought clarifications."
Nearly 11 million undocumented immigrants living in the U.S. without legal permission are particularly vulnerable to the economic fallout wrought by the pandemic.
This article was published on Tuesday, March 9, 2021 in Kaiser Health News.
Ana's 9-year-old son was the first in the family to come down with symptoms that looked like COVID-19 last March. Soon after, the 37-year-old unauthorized immigrant and three of her other children, including a daughter with asthma, struggled to breathe.
For the next three weeks, the family fought the illness in isolation — Ana clutching the top of door frames to catch her breath — while friends and neighbors left food on the porch of their home in Colorado Springs, Colorado. Ana and her children never took tests to confirm they caught the coronavirus, but the pressure in her lungs, the fever, the headache and the loss of smell and taste convinced her it couldn't be anything else.
"It was horrible," said Ana, a Colorado resident for more than two decades who requested her last name not be used because of her immigration status. "We had to lay on the floor to breathe."
Nearly a year later, the effects of the virus go far beyond nagging shortness of breath for Ana. She lost her job cleaning houses when she got sick last March, so she couldn't pay rent. A local nonprofit's cash assistance funded by some federal COVID relief helped her catch up in the fall, but she still had no work and fell behind on rent again. Her landlord finally threw the family out of their home at the beginning of January with 30 hours' notice, she said.
Ana is one the nearly 11 million undocumented immigrants living in the U.S. without legal permission, who are particularly vulnerable to the economic fallout wrought by the pandemic and have no direct access to the billions of dollars in federal pandemic relief over the past year. An estimated 4 in 5 of them work essential jobs that put them at high risk to catch the COVID virus. They are also more likely to suffer the economic consequences, even with protections in place — such as the Centers for Disease Control and Prevention's eviction moratorium, extended through March — because they fear that reaching out for help or reporting landlords could lead to deportation or detention.
President Joe Biden's inauguration brought some encouraging news, as he's said he wants to create a path for citizenship for many of the nation's undocumented immigrants. He also said they should be able to be vaccinated against COVID without worrying that they will be arrested and deported.
Even though the COVID vaccines are available to everyone no matter their citizenship, a distrust of government and law enforcement in the immigrant community and a lack of culturally competent vaccination information and even misinformation have made some undocumented immigrants reluctant to come forward early in the vaccination rollout.
Even if Biden makes good on his pledge of equitable access to a vaccine, unauthorized U.S. residents continue to have no direct access to billions of dollars in federal pandemic relief. The issue was brought up again on March 6 when Republican Sen. Ted Cruz claimed Biden's new $1.9 trillion aid package would send stimulus checks to every illegal alien in America. Democratic Sen. Dick Durbin clarified that undocumented immigrants don't qualify for checks in the measure that passed the Senate. The House was set to take up the Senate's changes on Tuesday.
Advocacy groups have argued for "inclusive" aid packages that provide direct aid to as many immigrants as possible no matter citizenship status, and while a few states set up aid for the undocumented, it's not nearly enough, according to Marielena Hincapié, executive director of the National Immigration Law Center.
"Immigration status shouldn't be the gatekeeper to any of these programs. It really ultimately is about need and ensuring that families have the economic stability, to not only survive, but to get through this pandemic that all of us are impacted by," Hincapié says. "Eighty percent of undocumented immigrants are working as essential workers. We are relying on them, and yet are denying their families this basic support that everyone else is getting."
Couples with mixed immigration status — in which only one partner is a U.S. citizen — were also blocked from aid until December. They can now apply for stimulus payments retroactively but will still receive less than couples who are U.S. citizens. Though the change made millions more families eligible for some aid, couples in which both partners are undocumented immigrants also have not received stimulus payments for their children even if their children were born in the U.S. and are citizens. A group of families sued the Trump administration in May 2020 after it excluded children in the first COVID-19 aid package known as the CARES Act. The Department of Justice under the Biden administration has continued to defend the policy and has asked a federal judge to dismiss the lawsuit. A decision is pending.
Meanwhile, in February, eight Senate Democrats, including John Hickenlooper of Colorado, voted in favor of a budget amendment that continues to block both documented and undocumented immigrants who pay taxes using ITINs (individual taxpayer identification numbers) from receiving direct relief. (A Social Security number is a requirement for federal pandemic aid, which means immigrants who pay taxes with ITINs can't qualify.) After getting blowback for his vote from Colorado's immigration rights community and a letter from the Colorado ACLU accused the senator of breaking campaign promises to stand with immigrants, Hickenlooper met with community members and released a statement to a local news station: "I recognize how this vote has distorted that important fact and fed dangerous and damaging narratives about the undocumented community. … I remain committed to working together to finally achieve a comprehensive fix for our broken immigration system, including a pathway to citizenship."
Hincapié calls the vote "morally unconscionable." "The pandemic has shown how interdependent we are and that this is a time in our nation to make sure we're taking care of everyone. It's the only way we're going to get out of this," she said. "There is no recovery without including immigrants."
Nearly half of the nearly 11 million immigrants living illegally in the United States (including some 190,000 in Colorado) pay taxes, according to the American Immigration Council, a Washington, D.C.-based advocacy organization. In Colorado, they paid an estimated $272.8 million in federal taxes and $156.5 million in state and local taxes in 2018. According to the IRS, ITIN filers nationwide pay over $9 billion in annual payroll taxes.
The Migration Policy Institute, a nonprofit think tank in Washington, D.C., reported in January that 9.3 million unauthorized immigrants whose income meets the threshold for COVID aid are blocked from accessing it, and also can't apply for federal programs that provide cash and food assistance. It reported that undocumented people represent more than half of the workers in the hardest-hit industries, such as meatpacking, the restaurant business, healthcare and child care.
The Colorado nonprofit that provided Ana with rental assistance, Servicios de la Raza, received applications from 300 families for rental help. The group could assist only 51 of them, said Julissa Soto, the group's director of statewide programs. Soto, who used to be undocumented herself, said she knows of at least 30 undocumented families that are homeless because of the pandemic in El Paso County, which includes Colorado Springs. She said she is frustrated by a lack of action by Colorado's political leaders to address the problem.
"My community is starving and getting evicted, and this is because we are undocumented and we don't exist," she said. "No one wants to talk about the undocumented community."
It's unclear how many people living illegally across the nation have been evicted during the pandemic. One reason for the uncertainty is because they often leave the moment a landlord threatens to kick them out to avoid going to eviction court and risking deportation, immigration advocates say. As a result, landlords can often evict undocumented people without ever officially filing in civil court and without following the state and federal rules, so there is no paper trail to track.
"Rather than go to court and assert their rights, they just move out," said Zach Neumann, founder of the Colorado COVID-19 Eviction Defense Project. "They often do so in a way that's really disruptive to their families and their lives."
Ana's landlord evicted her at the end of her lease exploiting a loophole in the federal eviction moratorium that allows evictions when leases expire. She said her landlord threatened to call the police, so she left as quickly as possible. The short time frame her landlord set does not follow Colorado law, which allows tenants 10 days to appeal an eviction in court or leave the property after official notice is given.
A phone number listed for the landlord, AB Property Management, was disconnected, and multiple attempts to contact the owners of Ana's past rental property were unsuccessful.
Though President Joe Biden's proposed emergency pandemic aid package mentions ensuring vaccine access to Americans "regardless of their immigration status," there is no similar statement included for the $30 billion proposed in rental and critical energy and water assistance, or extended unemployment benefits or individual stimulus checks..
California and New York City developed payment programs for undocumented residents. But despite having an undocumented population of almost 200,000 — accounting for about 3% of the state's population in 2016 — Colorado has no financial aid program to address that community.
Ana and her children are now sleeping on the floor in a friend's unfurnished spare room. She recently found a cleaning job that pays $300 a week. It's not much, but she's thankful to have it after nine months of looking for work. She's still terrified of losing her kids if social-service workers find out the family is homeless.
"This is not living. This is just surviving. Let's be clear. This is just surviving, and I want to live. I want a house for my kids," she said.
Many people don't like needles, and that could further slow vaccination efforts as winter turns to spring when supplies are expected to multiply and efforts to get the hesitant to sign up for a dose will intensify.
Each night it's the same. Story after story on the TV news is about the COVID vaccination effort, and they are all illustrated with footage of needles sinking into exposed upper arms.
Could those visuals, ostensibly making this all seem routine, backfire?
More than causing squeamish people to look away or change the channel, researchers say such illustrations could hamper efforts to get a broad swath of U.S. residents vaccinated.
Bottom line: Many people don't like needles, and that could further slow vaccination efforts as winter turns to spring when supplies are expected to multiply and efforts to get the hesitant to sign up for a dose will intensify.
"Fear of needles was one of the barriers that was a significant predictor of people saying, 'I don't think I will get this vaccine,'" said Jeanine Guidry, an assistant professor at Virginia Commonwealth University who researches visual communication and conducted a survey of 500 people in July.
And it's not just TV news using what could be sensitive video footage.
Disinformation spread on social media often incorporates images of giant syringes, Guidry recently told the National Vaccine Advisory Committee, which makes recommendations to federal health officials. Social media has been a source of much incorrect information about vaccines in general, and COVID specifically, designed to dissuade people from getting shots.
Such "fear visuals," Guidry said, "get more attention," and may be remembered longer than other types of illustrations.
Legitimate efforts to encourage vaccination may have also inadvertently sparked fear by showing exaggeratedly large syringes, said Guidry, who urged public health experts to be careful with their messages, too.
"If you use a picture of a huge syringe that looks twice the size of my head, that makes you go, 'OK, that's big,'" said Guidry. "I can't fathom what that would do to someone who has a needle phobia."
Even attempts to reassure people by showing leaders such as Dr. Anthony Fauci or the president and vice president getting their COVID vaccinations on TV can be triggering, said Hillel Hoffmann, an independent communications consultant and freelance writer in Philadelphia.
"I always turn away," said Hoffmann, who recently wrote of his near lifelong fear of needles in a piece for Medicalbag, an online publication aimed at physicians.
"I know those pictures are supposed to psych me up for the fact that the vaccine is safe and available, and I'm not worried at all about the vaccines' safety," said Hoffmann. "But what I can't take because of my fear of needles is looking at a picture of someone with a small-bore needle buried in their deltoid muscle."
Public health experts say it's important to get at least 70% to 80% of the public vaccinated to reach what is called herd immunity, when enough people will either have had the COVID virus or a vaccination, to severely limit its further spread.
But fear of needles contributes to some people's vaccine hesitancy.
An analysis of a broad range of studies from the U.S. and other countries on this topic by researchers at the University of Michigan showed that 20% to 30% of adults studied cited concern about needles, ranging from mild anxiety to a phobia strong enough to keep some from seeking medical care. Even many healthcare workers cited a fear of needles, according to the research, published in the Journal of Advanced Nursing in August 2018.
"There's a perception that people who work in hospitals would be less afraid of needles, because they're surrounded by them all the time, but one study found 27% of hospital employees who did not take the flu vaccine said it was because of needle fear or they did not like needles," said Jennifer McLenon, an infection preventionist at Henry Ford Hospital in Detroit who completed the study while getting her master's degree in epidemiology.
Another study found that 18% of healthcare workers in long-term care facilities felt the same way, she said.
An extreme fear of needles or medical procedures involving injections is technically called trypanophobia, said Jeffrey Geller, president of the American Psychiatric Association.
"Some people avoid needles because of fear of pain, some from fear of fainting," said Geller. "And some people do faint."
It may have an evolutionary basis, said Thea Gallagher, an assistant professor and the director of the clinic at the Center for the Treatment and Study of Anxiety at the University of Pennsylvania. "We know from evolutionary biologists that seeing a sharp object going into our bodies is not something we are supposed to be cool with," said Gallagher.
But Geller and Gallagher said barriers created by this fear or phobia could be lowered with careful public health messaging, along with self-help techniques individuals can practice or, in severe cases, professional assistance from a therapist.
Public health messaging should avoid drawings that exaggerate the size of needles or syringes, "which are not helpful," said Geller, noting that the COVID vaccinations involve "a small syringe and needle."
But, as to the effect of those TV images night after night? Well, it could go either way.
"For those with a fear, it could exacerbate it," said Geller. "For those who don't have the fear, it could be reassuring to show that it's a routine practice."
McLenon, the researcher from Michigan, said she has heard, anecdotally, that those shots on TV "make people more afraid." "Can't we get some pictures of the vials or something else?" she suggested.
For instance, Hoffmann, the writer, said if he were designing the perfect visuals for a COVID vaccination campaign, it would not refer to injections directly at all.
"If I were to drive by a drugstore and it had a poster in the window saying 'Come get it today for your family. Do it for the nation. Do it for the public good' We would all know what the 'it' is. They don't have to show it."
Still, McLenon and others say no one has yet studied the effect specific images about the COVID vaccine have on people because it's so new. And the desire to get back to a more normal society may help those with a fear of needles push themselves to get a COVID vaccine, whereas they might not feel the same way about, say, an annual flu vaccination.
Hoffmann, who said his fear began after extensive dental work as a child, said he intends to get a shot. But when his turn comes, he said, he'll likely be very nervous; his heart will race and he will sweat. Unlike some people with a fear of needles, he does not faint, although he understands that reaction.
"A lot of people assume that what I'm afraid of is the pain," said Hoffmann. The worst part for him, he said, is how he can't control his fear in that public setting. And it's embarrassing. "I'm not alone when it happens. The person giving me the injection sees it. I can't hide it."
The emergency use authorization granted Feb. 27 by the Food and Drug Administration for the single-dose Johnson & Johnson vaccine is good news for people like Hoffmann. Both the Pfizer and Moderna vaccines currently available require two doses, spaced a few weeks apart. Which means facing fears twice.
Whether it's one or two shots, experts suggest a variety of steps to help people who struggle get through the process — bring a support person, take deep breaths, stay positive, just to name a few.
"It's nothing to be ashamed of. We come by it honestly," said Gallagher from the University of Pennsylvania. "Anxiety is likely making it into a bigger monster" than it should be. "It's not worth beating yourself up about."
Facing the Fear
For the millions of Americans who have some fear of needles, there are ways to help yourself cope, say experts.
— Put it in perspective. Be positive about the reasons you are getting the vaccine and remember that the pain will be short-lived, like a stubbed toe, said Thea Gallagher, director of the clinic at the Center for the Treatment and Study of Anxiety at the University of Pennsylvania. For those getting the two-dose regimens, "be objective about how the first one went," she said, "and that you got through it."
— Bring a support person. Some vaccination sites will allow this. Ask.
— Practice deep breathing or other techniques to help stay calm at the site. Eat something and drink water beforehand; it reduces the chance of fainting. And you can request being inoculated in a reclined position.
— Tell your vaccinator of your concerns. "When you get there, you can say, 'Look, I don't like needles.' The healthcare providers are used to that," said Dr. Georges Benjamin, executive director of the American Public Health Association.
— Don't be afraid to seek professional help if your fear is intense but you feel strongly about getting vaccinated. A therapist can use cognitive-behavioral techniques or exposure therapy to help, said Dr. Jeffrey Geller, president of the American Psychiatric Association.
The dozens of open appointment slots in the three Southern states stood in sharp contrast to the availability in states such as Delaware, Connecticut and Pennsylvania.
Last week, as COVID vaccine appointment slots were snapped up within an hour at CVS stores in 20 states, slots remained open all day at CVS pharmacies in Alabama, South Carolina and Louisiana.
The dozens of open appointment slots in the three Southern states stood in sharp contrast to the availability in states such as Delaware, Connecticut and Pennsylvania, where appointments generally were gone by midmorning or earlier. CVS and other retailers typically post appointment slots around 7 a.m. for the next day.
In many counties across the three states — particularly in rural areas — retailers and outpatient clinics are among the few places offering COVID-19 shots. CVS and other large pharmacies, including Walgreens and Walmart, are among the biggest providers of the vaccinations.
South Carolina health officials said they noticed demand was waning at some vaccine sites — and, as a result, lowered the age eligibility for the shots from 65 to 55 starting Monday.
"Reports here and there from around the state, not everywhere, indicate vaccine appointments have not been filling, so this was the time to do this," said Nick Davidson, senior deputy for public health at the South Carolina Department of Health and Environmental Control.
Marvella Ford, a professor in the department of public health sciences at the Medical University of South Carolina in Charleston, wasn't surprised by the vacant appointments.
"We know we have work to do to engage with the community to get the word out about the safety and effectiveness of the vaccine," she said. Many in the state's large Black community are skeptical about the vaccine, she said, and many poor residents in rural areas face hurdles, including lack of transportation to vaccine sites and lack of internet access to book appointments.
"There are a lot of barriers," Ford added, "and we want to shine a light on them so we can figure out a way to overcome them."
Ford is a leader of a Black faculty group that, along with a Hispanic faculty group at the medical school, has been meeting with community organizations across the state to urge Black and Hispanic residents to get vaccinated.
Dr. Scott Harris, Alabama's state health officer, attributed the openings at CVS to the pharmacy chain having recently added several stores offering the vaccine. "I do not believe there is an issue with uptake, but we will continue to monitor this," he said.
As of 4 p.m. Friday, all 33 Louisiana CVS stores that are offering vaccines had dozens of open Saturday appointments for COVID vaccines.
Two-thirds of the 80 participating CVS stores in South Carolina had openings. About half of the 56 CVS stores in Alabama administering vaccines still had availability.
CVS spokesperson Mike DeAngelis could not explain why the three states had more supply than demand. "We are aware that demand for vaccine appointments at our pharmacies is stronger in some states than it is in others," he said. "We are working across multiple fronts to increase awareness of vaccine availability, safety and effectiveness."
CVS is one of several large, national pharmacies offering COVID shots. But it's the only retailer that makes it easy for people to go online and search by state for open appointments over several days. At Walgreens and Walmart, users can search for the shots only by ZIP code.
As a result, consumers in states where vaccines remain extremely limited can easily see where CVS appointments remain aplenty. While some states have enacted residency requirements to block out-of-state visitors from getting vaccines, other states such as South Carolina have not.
Lior Rennert, a biostatistician at the Clemson University School of Public Health who has worked on South Carolina's vaccine rollout, said he was surprised to hear of the open slots since the state ranks in the top 10 nationally in the number of vaccines given out, measured as a percent of population. Yet, he said, politically conservative states like those in the Deep South face more challenges overcoming vaccine hesitancy than more liberal states.
He expects open slots to get filled up as the state expands eligibility.
"If there continue to be a lot of openings in the next week or two, that may indicate either a lack of communication about availability at CVS locations or that there is simply not as great of a demand due to vaccine hesitancy," Rennert said.
As President Joe Biden's pandemic relief package steams through Congress, Democrats have hitched a ride for a top healthcare priority: strengthening the Affordable Care Act with some of the most significant changes to insurance affordability in more than a decade.
The bill would spend $34 billion to help Americans who buy insurance on the marketplaces created by the ACA through 2022, when the benefits would expire. The Senate sent its relief package, one of the largest in congressional history, back to the House where it could come up as early as Tuesday. It is expected to pass and then go to Biden for his signature.
Those who have studied the legislation said it would throw a lifeline to lower- and middle-income Americans who have fallen through the cracks of the government's eligibility requirements for ACA assistance. Stephanie Salazar-Rodriguez of Denver, for instance, is hopeful it will make a difference. Without changes, she expects to spend more than $10,000 on premiums this year after losing her primary job, and her insurance, last month.
If her annual income were $3,000 less, she could pay as little as $3,000 a year after subsidies.
"To me, that's not affluence," Salazar-Rodriguez said. "You're talking about people who are struggling to survive."
The legislation could also provide relief to others who purchase insurance on the exchanges and opt for policies with lower premiums but high deductibles — and often avoid seeking care because they don't have the cash to cover those costs. Most of the nearly 14 million people enrolled in plans sold on the marketplaces would pay less under the new provisions, with the option to use those savings to buy a new plan with a lower deductible.
The Congressional Budget Office also estimated an additional 1.7 million people would enroll in the exchanges under the proposal, about 1.3 million of whom are currently uninsured.
Republicans, who have repeatedly tried to repeal the ACA, hammered Democrats over the years with allegations that many of the marketplace plans are not affordable and prevent people from buying coverage. They argue the new legislation offers unnecessary help to wealthier Americans while doing nothing to lower the cost of insurance.
Now that Democrats have control of the White House and Congress for the first time since the passage of the ACA, they are moving quickly to make changes to the landmark healthcare program.
The COVID relief package also includes other proposals to increase healthcare affordability, particularly for the unemployed. Those receiving unemployment benefits, typically ineligible for subsidies on the exchange, would be temporarily eligible.
In addition, the Senate version of the bill would pick up 100% of the cost of premiums for those on COBRA, the program allowing recently unemployed workers to privately purchase coverage offered by their former job, often at a high cost. The House had included a similar provision but provided only an 85% subsidy. According to CBO, the House COBRA changes would have cost nearly $8 billion with about 2.2 million people expected to enroll — a huge expansion of the subsidy program.
The legislation, which includes a bevy of anti-poverty provisions, also offers an extra financial incentive to about a dozen states that have not expanded Medicaid, the program that covers low-income Americans.
Pandemic Spurs Effort
Advocates and public health experts say it is critical to help people afford health insurance since millions lost their jobs and their job-based health insurance in the pandemic and about 59,000 Americans are contracting COVID-19 every day.
"It just becomes the thing people can't afford when they've lost their job," said Katie Keith, an expert on the Affordable Care Act with Georgetown University's Center on Health Insurance Reforms.
About 15 million uninsured people could buy insurance through the exchanges, most of whom would be eligible for new or larger subsidies under the proposal, according to KFF. (KHN is an editorially independent program of KFF.)
Frederick Isasi, executive director of Families USA, which advocates for healthcare affordability and supported the passage of the ACA, said more than half of those eligible for coverage cannot afford it. "Health insurance is about financial security and health security," he said.
Under the ACA, subsidies are calculated based on the recipient's income, age and their area's average premium costs.
The proposal would ensure no one who buys insurance on the exchanges pays more than 8.5% of income. Currently, subsidies are available only to those making between 100% and 400% of the federal poverty level (for those seeking subsidies in 2021, between $12,760 and $51,040, for an individual).
Some marketplace customers near the federal poverty level who now must pay some of the premiums out-of-pocket could get a subsidy that pays the entire cost of a silver, or midlevel, plan.
The change would also benefit Americans who make more than the subsidy cutoff. About 3.4 million uninsured people fall into this category, according to the KFF analysis.
For example, currently, a 60-year-old who makes $50,000 annually pays no more than $410 per month out-of-pocket for a silver plan on the exchanges, with the government chipping in $548 per month.
A 60-year-old who makes $52,000 annually would receive no subsidy and would be expected to pay the full premium herself, at a cost of about $957 per month for the same plan, KFF found.
For Salazar-Rodriguez, that cutoff carries a heavy cost. She was recently laid off from her job at a community health organization that has struggled during the pandemic, and now she pays $913 per month out of her own pocket for insurance.
In a little less than a year, at age 65, she will qualify for Medicare. For now, her age is a liability. Older, pre-retirement Americans pay some of the highest premiums in the nation.
Having once worked assisting people enrolling in the exchanges, Salazar-Rodriguez went straight to the marketplace for coverage when she lost her job. But she was startled to discover how high her premiums would be — and that, because of her income from her other work as a consultant, she is ineligible for a subsidy or Medicaid.
She opted instead for COBRA coverage, which she said was comparable in cost and had more of the benefits she needs than the unsubsidized plans she found on the exchanges in that price range.
She worries she will have to run up her credit card and find extra work to afford her premiums. The pandemic has made forgoing insurance unthinkable, she said. Many of her loved ones have had COVID-19. Some friends are still suffering symptoms months after falling ill. She lost a brother-in-law in Texas.
"That's why I am paying that nearly $1,000 a month, because I know one hospitalization could bankrupt me if I didn't have it, and I can't take that chance," Salazar-Rodriguez said.
Changes Are Temporary
Though the subsidy fixes are temporary, lasting two years to address the economic impacts of the pandemic, experts and lawmakers expect the new subsidy criteria would eventually become permanent.
The KFF analysis found that subsidies would gradually phase out for those with higher incomes — for instance, a single 60-year-old making about $160,000 would not receive a subsidy because no silver plan would cost more than 8.5% of his income.
Brian Blase, a senior fellow at the Galen Institute, a nonprofit group that researches free-market approaches to health reform, criticized the proposal in a recent analysis, saying it shifts the burden of paying premiums from private payers to taxpayers without addressing the causes of high premiums.
He argued a family of four headed by a 60-year-old earning almost $240,000 could qualify for a nearly $9,000 subsidy.
The Wall Street Journal seized on Blase's example in a recent op-ed. "These are not the folks hit hard by the pandemic," the editorial staff wrote.
Many of the changes in the relief package date back to the passage of the ACA, President Barack Obama's signature domestic policy that overhauled the nation's healthcare system. At the time, those who wrote the law expected Congress would observe how it worked and make adjustments over time. But the law became a lightning rod for GOP opposition.
The proposal is part of the ACA's "unfinished business," said Keith of Georgetown University.
She noted there are other coverage gaps not addressed by this package, such as the so-called family glitch, in which a family's eligibility for marketplace subsidies is based on whether the cost of job-based coverage for one individual rather than the family is affordable.
The current bill "is narrow compared to the wish list Democrats have, but it would do so much with premium affordability in this way right now," Keith said.
California rolled out a statewide covid vaccination website this week aiming to streamline the appointment process after months of criticism, but the site is riddled with its own snags, preventing many from signing up for shots.
The vaccine sign-up website, My Turn, is the state’s answer to a previous hodgepodge of vaccination appointment systems that residents had to log on to through websites belonging to various hospitals, pharmacies, clinics and many of California’s 58 counties.
The site, created by tech giant Salesforce, is being integrated into insurer Blue Shield of California’s $15 million contract with the state to take over its covid vaccination distribution system. My Turn is considered a clearinghouse, allowing most California residents to register for covid vaccinations and then receive an alert when they’re eligible to sign up for a vaccine appointment. The app then directs users on how to sign up for available appointments at certain venues.
The My Turn database, however, does not include information about vaccinations available at most pharmacies, or at Kaiser Permanente and Sutter Health hospitals. People who want to get vaccinated at those locations must contact the companies by phone or through their websites.
Like most aspects of state, local and federal government response to covid, My Turn’s rollout has been glitchy. Technology experts say the kinks are not surprising, given the multiplicity of health care information-sharing systems in the state, and a tendency of government officials to overlook the need for consumer usability when building IT systems.
California Department of Public Health spokesperson Darrel Ng said My Turn “is being continually updated to add features to make it easier and more convenient for Californians to make vaccine appointments. If there are technological snafus, they are corrected quickly.” Salesforce did not respond to a request for comment.
So far, more than 650,000 vaccines have been administered via the My Turn system and 600,000 more are scheduled, Ng said. But widespread failures on the site have unleashed a chain of desperate and sarcastic social media responses.
“Here in the Bay Area, with Silicon Valley and all its wealth & technological brilliance, here is how we vaccinate our populace a year into a pandemic,” William Boos tweeted, showing a screenshot of an error message saying an “authentication token” was missing.
Several Twitter users said they were unable to register for the first shot because no slot for a second shot was being shown as available through the system.
“Seeing spots open on 3/1 on @Walgreens for my category, but no second dose appointments are available. And the MyTurn website shows spots, but has an error message after you choose a time,” tweeted Jennifer Lazo.
Others say the system directed them to vaccination sites with no available slots.
“There are no appointments in San Diego County. Try it yourself. Put in that you are 65+. It’ll say you are eligible and bring you to a site in El Cajon where there are 0 appointments available,” tweeted another user.
One irregularity allowed anyone who had registered in the state to book a vaccine appointment in tiny, rural Kings County. Clinics had to turn away residents who had driven in from neighboring counties, and county officials stopped booking appointments through My Turn entirely until the issue was resolved.
Technological issues with vaccination websites have been an issue nationwide.
In New York, hundreds of seniors lined up one chilly mid-February morning after being told to come for second vaccine appointments between 7 and 8 a.m., only to learn the appointment offer was a computer error. Health officials in Georgia resorted to hand-counting vaccine doses to determine how many available appointments there were.
We asked four health tech experts to explain why My Turn and other systems are not running smoothly. Their responses have been edited for length and clarity:
Arien Malec, senior vice president of research and development at Change Healthcare:
The My Turn website and vaccination dissemination system are products of a reactive, rather than proactive, response that has plagued the medical and tech industries since covid first came on the scene. Everybody is making this up on the fly. My Turn, in particular, is a usability nightmare. The site clearly favors already tech-savvy users and doesn’t appear to have been properly vetted. Tech companies typically spend time and money on testing out software before being released to the general public. My Turn doesn’t seem to pass such muster. There are informal ways of doing usability testing that are relatively cheap. Given all the money that we’re spending on covid vaccination, and given the economic benefit of vaccinating more people, it is cheap at any price.
Hana Schank, director of strategy for the Public Interest Technology program at the New America think tank:
The issues with My Turn and other state-adopted vaccination sites are rooted in government officials’ lack of technological expertise. The people who are making the policy decisions are not equipped to make the tech decisions. Their ultimate goal is less focused on a good consumer experience and more on achieving a tangible result — which, in this case, is getting people vaccinated. Are people signing up? Yes. Are vaccines being distributed? Yes. Done. They think that checks their boxes. A tech issue is never just a tech issue. It’s always a bureaucracy issue, or it’s a silo issue or it’s a lack of expertise. The way the government thinks about success is from another era. Government is really bad at providing a good user experience.
Atul Butte, director of the Bakar Computational Health Sciences Institute at the University of California-San Francisco:
Considering where California was just two months ago, when the vaccines first began getting distributed in the state, My Turn should be viewed as a success. While the user interface may contain glitches, a lot of work goes on behind the scenes, trying to get the various counties and their health data aligned in order to get proper vaccination counts for residents. The website draws on four databases: one for ordering the vaccines and tracking shipments; one for inventorying at all sites; the California Immunization Registry, or CAIR; and finally the vaccine appointment scheduler. Each of those databases has many components. CAIR is spread across regions and its system is old; its user-facing website hasn’t been updated since 2013.
Dr. Chris Longhurst, chief information officer at UC San Diego Health:
Even if you had the perfect technology, and everybody was using My Turn, people are still gonna be upset because they can’t get vaccinated. We’re in the valley of despair right now, because we had the weather issues in Texas that impacted not only transportation with the vaccine, but also the manufacturing of some of the vaccine. And then you’ve got the state’s transition to Blue Shield as the new third-party authority, which is bumpy at best. Then you’ve got technology transitions — My Turn, and My Turn integration with electronic health records, that are also bumpy at best. And then you also have the governor opening up a bunch of new tiers for educators and essential workers. There’s no supply to meet that new demand. So that creates tremendous misalignment and frustration.
During a March 2 news conference on the COVID-19 pandemic, President Joe Biden claimed that former President Donald Trump's administration did not ensure there would be enough vaccines for the American public.
During a March 2 news conference on the COVID-19 pandemic, President Joe Biden claimed that former President Donald Trump's administration did not ensure there would be enough vaccines for the American public.
"When I came into office, the prior administration had contracted for not nearly enough vaccine to cover adults in America," said Biden. "We rectified that."
Biden then announced he was using the Defense Production Act to facilitate a partnership between two competing drug companies: Merck had agreed to help manufacture the recently authorized Johnson & Johnson vaccine.
The move, he said, would accelerate the timeline for the availability of vaccines: "We're now on track to have enough vaccine supply for every adult in America by the end of May," he said, two months earlier than he had previously projected.
It's been a common political message since the Biden administration took office that the initial vaccine rollout under Trump was "chaotic." PolitiFact previously rated a claim by Biden's chief of staff, Ron Klain, that the Trump administration left no vaccine plan behind as Mostly False.
So, we thought it was important to check whether Biden was going too far in alleging that the Trump administration hadn't contracted for enough vaccines to cover the American public. Let's see what the contracts, which are public documents, say.
The Operation Warp Speed Contracts and FDA's Process
As part of Operation Warp Speed, the Trump administration entered into contracts with multiple drugmakers. The contracts were generally signed while potential vaccines were still in clinical trials.
Experts told us this was smart because the Trump administration didn't know which vaccines from which drugmakers would work, how effective they would be or how quickly they could be produced.
"That was the whole approach of Operation Warp Speed," said Dr. Amesh Adalja, a senior scholar at the Johns Hopkins Center for Health Security. "Not knowing which one would cross the finish line, the Trump administration took a portfolio approach and invested in multiple vaccines."
Here's what the Trump team's contracts called for drugmakers to supply to the U.S. government:
In all, the amounts agreed to under these contracts total about 800 million vaccine doses, or enough for more than 400 million people.
The U.S., based on U.S. Census estimates, has around 328 million people, of whom about 255 million are 18 or older. (Vaccines are not yet authorized for children.)
So, it appears that the Trump administration's contracts with drugmakers did cover enough doses to vaccinate the entire U.S. adult population — and then some. By that measure, Biden's statement is inaccurate.
An important point to remember, though, is that these contract numbers don't necessarily represent deliverable vaccines. The contracts represent early promises. There were still important hurdles to be cleared before these possible vaccine candidates could be a reality.
Kevin Gilligan, a senior consultant with Biologics Consulting, a firm focused on pharmaceuticals, said that once drugmakers develop a vaccine they must test it through clinical trials with humans and amass enough data to show the vaccines are safe and effective and cause minimal side effects.
The data is then presented to the Food and Drug Administration, which decides whether the vaccine should be authorized for emergency use. Granting an emergency use authorization means the vaccine can then be distributed to the public.
Until recently, the Pfizer and Moderna vaccines were the only two that had reached that point, gaining authorization on Dec. 11 and 18 respectively.
The Trump administration announced Dec. 23 that it would buy an additional 200 million doses in total of both companies' vaccines.
A Caveat Worth Noting: The Real Numbers Were Lower
A Biden administration press official told KHN that the president was referring only to orders for the authorized vaccines: "When the Trump administration was in office, there were only two approved vaccines (Pfizer and Moderna) and the Trump administration had not contracted for enough of them to vaccinate all Americans. They only had 400 million doses of these authorized vaccines, which is only enough for 200 million Americans. Upon coming into office, one of our first steps was to ensure that we had enough supply secured for every American. We were prepared from Day One."
On this point, the Biden White House is correct. The U.S. government had in place agreements to buy 400 million doses of the authorized vaccines, which were both two-dose vaccines — not enough for the entire U.S. adult population.
It's also true that five days after Biden became president, he announced his administration had reached agreements with Moderna and Pfizer to buy a combined additional 200 million doses. That purchase was finalized on Feb. 11 and brought the total U.S. supply to 600 million, or enough to vaccinate 300 million people.
In addition, on Feb. 27, Johnson & Johnson's vaccine was authorized for emergency use. Under the Operation Warp Speed contract, J&J is supposed to provide 100 million doses to the U.S. by the end of May, but the company is reportedly behind on production. The Biden administration's move to get J&J to team up with Merck to achieve its production goal will increase vaccine supply.
But, is it fair for Biden to blame the Trump administration for not buying more of the Pfizer and Moderna vaccines once they became authorized for emergency use?
The answer to that isn't clear-cut, said the experts.
"It's not totally fair to say the prior administration didn't purchase enough, since they did move to purchase more doses after the vaccine was authorized," said Jennifer Kates, senior vice president and director of global health and HIV policy at KFF. "I think the question is should they have purchased it earlier?"
The New York Times reported on Dec. 7 that before Pfizer's COVID vaccine was shown to be highly effective in clinical trials, the company had offered the U.S. government the option to buy additional doses, but the Trump administration declined. Former Health and Human Services secretary Alex Azar disputed the news report, saying during a TV interview that Pfizer hadn't agreed to a production amount or delivery time for the additional vaccine, so he couldn't agree to the deal: "I'm certainly not going to sign a deal with Pfizer giving them $10 billion to buy vaccine that they could deliver to us five, 10 years hence. That doesn't make any sense."
James Love, director of Knowledge Ecology International, a nongovernmental organization that obtained copies of COVID government contracts, agreed that once it was clear the Pfizer and Moderna vaccines were likely to receive FDA authorization, the Trump administration could have taken action to make competing drug companies increase their vaccine manufacturing capacity in the way Biden did with Merck and J&J.
"The U.S. could have forced technology transfer between companies, which meant they would have been assured of additional vaccine manufacturing capacity," said Love. "The agreements we have now about scaling manufacturing are coming pretty late actually. It takes several months to get stuff up and running."
But Gilligan noted that the Biden administration had the advantage of hindsight. "Biden inherited the success of vaccine development done under Trump and then expanded on it," said Gilligan. "And the Biden administration has the benefit of looking back at what was done well and what wasn't and making the appropriate corrective changes. Hindsight is 20/20."
Overall, there are questions around whether the Trump administration could have acted more quickly to buy doses or increase vaccine manufacturing capacity. And the Biden administration has certainly taken significant measures to expand supplies.
But it's stretching the truth to say the Trump administration hadn't contracted for enough COVID vaccines to inoculate the U.S. adult population.
Our Ruling
Biden said the Trump administration "had contracted for not nearly enough vaccine to cover adults in America."
While Trump was still in office, his administration had agreements in place to buy 400 million doses of authorized vaccine, or enough to inoculate about 200 million people. That wouldn't cover the U.S. adult population.
However, KHN-PolitiFact reviewed the Trump administration's Operation Warp Speed contracts and found those included enough vaccine doses that, once cleared for use by the FDA, would inoculate about 550 million people — more than double the U.S. adult population.
Biden's statement contains an element of truth but ignores facts that would give a different impression.
Griffin Dalrymple is an energetic 7-year-old who loves going to school in Eureka, Montana. But two years ago, the boy described by his mother, Jayci, as a "ball of fire" was suddenly knocked back by severe bacterial pneumonia that hospitalized him for two weeks.
As her son lay in the intensive care unit with a tube in his tiny lungs, Jayci began imagining worst-case scenarios. She worried that if Griffin ended up needing a lung transplant, he might be refused because he has Down syndrome.
"It was terrifying knowing that they could deny him certain lifesaving services," she said.
Denying organ transplants to people with intellectual and neurodevelopmental disabilities like Down syndrome or autism is common in the United States, even though it is illegal under the Americans with Disabilities Act.
According to one widely cited 2008 study, 44% of organ transplant centers said they would not add a child with some level of neurodevelopmental disability to the organ transplant list. Eighty-five percent might consider the disability as a factor in deciding whether to list the person.
After Griffin recovered, Jayci brought Montana lawmakers' attention to the issue. Largely as a result of her campaigning, the state is considering a bill that would ban physicians from denying an organ transplant based solely on a patient's disability. Last month, the bill — nicknamed "Griffin's Law" — passed the Montana Senate 50-0.
Although Montana has no transplant centers of its own, advocates hope this bill and others like it will draw attention to the issue and pressure physicians to examine why they are making certain decisions. Andrés Gallegos, chairman of the National Council on Disability, said he hopes such legislation will inspire "a change of heart so people understand that they are discriminating."
If the bill passes the state House and is signed by the governor, Montana would become the 17th state to ban such discrimination. Seven other states and the federal government have similar bills pending, although some experts doubt such laws will be enforceable enough to eliminate discrimination.
According to a 2019 report from the NCD, many physicians and organ transplant centers worry that patients with intellectual or neurodevelopmental disabilities are more likely to have co-occurring conditions that would make a transplant dangerous, or that these patients' quality of life is unlikely to improve with a transplant. Others believe that these patients may not be able to comply with post-transplant requirements, such as taking immunosuppressive drugs.
But the report, which scoured research papers and medical reports, found that none of these concerns is universally true. Rather, disabled patients can benefit as much as any other patient, according to the NCD, an independent federal agency.
"If a determination is made to not include a person on the list only because that individual has a disability, that's blatant discrimination," said Gallegos.
Many intellectually disabled patients and their families see this firsthand. When Joe Eitl was born in 1983 with a congenital heart defect, his mother, Peg, was told that Joe would never be a candidate for a new heart because of his Down syndrome. So, when his heart failed in 2019, eight hospitals refused to even consider a transplant for Joe, who lives with his mother in Philadelphia.
Peg Eitl conceded that Joe's case was difficult, given he'd had prior reconstructive heart surgery that would complicate a transplant. She pleaded with transplant centers for more than a year and even considered suing them. Last October, Vanderbilt University agreed to perform the procedure. Joe came home Feb. 10 and is recovering.
"I think my greatest frustration was the value placed on someone with special needs," Peg Eitl said. "It pains me that they're discounted as being less than and not as worthy."
Bioethicist David Magnus of Stanford University, who authored the 2008 study on the extent of transplant discrimination, said people like Peg Eitl shouldn't have to prove that Joe would benefit from a transplant. Because people with disabilities are a protected class in the United States, he said, "the burden is on people who want to discriminate."
But that doesn't appear to be the case in practice. In September, Magnus published a follow-up survey of more than 300 transplant programs. Of these, 71% said they would automatically disqualify an adult with an IQ under 35, which is considered severe intellectual disability, while 12% would disqualify a child at that level. Only about 20% of the institutions had formal guidelines regarding child patients.
Magnus suspects these numbers are low given that some physicians may be unwilling to admit to discrimination. He has not yet studied whether new state laws have affected physicians' likelihood to discriminate against disabled patients.
But Magnus doubts that laws like Montana's bill will be enforceable. Part of determining any patient's eligibility for a transplant, he said, is whether they or a caretaker can comply with post-transplant requirements such as remembering to take immunosuppressant drugs. If a person with a disability can't meet these criteria, that person might not be a good candidate.
"All of these are terribly difficult judgments," Magnus said.
Transplant surgeons need to maximize the limited supply of organs and ensure they survive in the patients who receive them. If they don't, "it's taking an organ from someone who could have benefited from it," said Dr. Marwan Abouljoud, president of the American Society of Transplant Surgeons.
Abouljoud said institutions have differing standards for weighing the importance of an intellectual disability in a transplant decision. Ideally, he said, the committee that determines whether to list someone for a transplant will include social workers and behavioral psychologists, as well as program leadership, who can find ways to help the person comply.
On Feb. 12, the transplant surgeons' society adopted a new statement supporting nondiscrimination and encouraging transplant centers to find ways to support these patients. "We will be urging states to adopt local policies on this," Abouljoud said.
Sam Crane, legal director at the Autistic Self Advocacy Network, which has written model legislation adopted by several states, said that some bills — including Montana's — address the concern about post-transplant care. They ban transplant centers from basing their decision solely on a person's ability to carry out post-transplant requirements and require an investigation into sources of support to help the patient comply.
But Crane said physicians could still come up with a pretext to avoid adding a disabled person to the transplant list if they believe a person without a disability would benefit more from receiving an organ.
"It's very difficult to prove discrimination in that sort of situation," she said.
Although a similar nondiscrimination bill has been introduced in the U.S. House of Representatives, Crane said advocates prefer to focus on state laws. Organizations like the autism group have taken the position that the ADA and other federal laws already prohibit this kind of discrimination, making federal legislation unnecessary. Gallegos added that states can also enact stricter requirements than the federal government and fit them to their specific medical systems.
Under state laws, patients can appeal to local courts for an emergency injunction or restraining order. These hearings can be conducted quickly, allowing a judge to decide whether to compel an institution to add a person to the transplant list.
That speed is what Jayci Dalrymple hopes Griffin's Law will achieve. "When you're needing to stop discrimination, you're racing the clock," she said.
Studies have shown that the Moderna, Pfizer-BioNTech and Johnson & Johnson vaccines, the three vaccines currently available in the U.S. under emergency use authorizations, significantly reduce covid symptoms and are effective in preventing hospitalizations and death from the disease.
As cold weather descended upon Washington, D.C., last fall, I deleted my dating apps.
I had tried a few video-chat dates when the pandemic was new last spring. They were fun and novel at the time, and felt like a “quarantine experience.” By summer, I went on several physically distant dates in the park.
But once the temperature started dropping, meeting outside lost its appeal. First dates are awkward enough without shivering as your breath freezes to your mask, all while trying to uncover the title of someone’s favorite book. So I bailed.
Something happened recently, though, that made me return to the dating app world. A local website published an article about people announcing their vaccination status in dating app profiles. Other news outlets followed. I had to see it with my own eyes.
So, I redownloaded my favorite apps: Hinge, Bumble and Tinder. I disclosed in my bio that I was a journalist working on a story about people announcing their vaccination status in dating profiles. Then, I spent the next three hours madly swiping.
Lo and behold, I found several 20- and 30-somethings proudly displaying their vaccine status. One wrote at the top of his profile, “I got both doses of the Pfizer, Covid vaccine!” Another said, “im covid19 free got vaccinated too.”
I messaged them all. Noel, a nurse who lives in the D.C. area, got back to me. He said he put “COVID vaccinated” in his bio as a statement for what he stands for. (KHN is not identifying Noel by his last name because he’s concerned about being identified by his employer.)
“I take very seriously the responsibility to care for myself in order to keep others safe,” he wrote. Noel, who has received both vaccine doses already, said his status announcement has gotten him only positive responses so far. Some people even seemed reassured by it.
It made me wonder: Should this declaration give people the peace of mind to start increasing the frequency of in-person dates? When considering whether to meet up with someone who is vaccinated versus unvaccinated, vaccinated does sound safer. It even initially gave me a spark of hope. But should it?
I polled a few friends who use dating apps. They told me they had indeed spotted the same trend. One who lives in Los Angeles is even going on a FaceTime date with a guy who had “PS I’m vaccinated” in his Hinge bio. She still opted for a video chat, though. “Can’t they still be carriers even if they’re vaccinated?” she texted me.
The next day, I called Dr. Leana Wen, an emergency room physician, public health expert and visiting professor at George Washington University.
I asked her what those of us who might be swiping on the apps should think if we come across someone who advertises that they have been vaccinated.
First, Wen gave me the reality check I expected, and kind of deserved.
“It’s not a free pass,” she said. “We don’t know whether ‘if’ somebody is vaccinated means they will no longer be a carrier of coronavirus. They may still be able to infect you even if they are safe from coronavirus themselves.”
Studies have shown that the Moderna, Pfizer-BioNTech and Johnson & Johnson vaccines, the three vaccines currently available in the U.S. under emergency use authorizations, significantly reduce covid symptoms and are effective in preventing hospitalizations and death from the disease. But it’s still possible for those who are vaccinated to get sick with covid. And research is pending on how great the risk is that those who are vaccinated can carry the virus and pass it on to others.
Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, said in a recent White House covid-19 press briefing that early studies from Spain and Israel indicate vaccination seems to lead to lower viral loads in the body, which can mean a fully inoculated person is less likely to pass covid on to someone else. But questions remain about transmissibility.
The Centers for Disease Control and Prevention recommends that those who are vaccinated continue to wear masks and maintain physical distance as the vaccine rollout proceeds. Public health experts also point to the emerging covid variants that are finding a foothold in the U.S. The available vaccines appear to be less effective against the variants, another reason for people to be vigilant.
Wen said if two unvaccinated parties who match on a dating app want to meet up, they should take the precautions we’ve heard about since the beginning of the pandemic: meet outdoors, keep 6 feet apart and ask about your favorite book from behind a face-fitting mask.
If both unvaccinated people eventually want to meet indoors, she added, and they both live alone, they could. But it is not exactly a romantic process. They could quarantine for several days. Then both could get a covid test and, as long as they both have negative results, meet up.
However, if you’re like me and live with roommates, and especially if your new paramour also lives with others, too, then that adds more layers of complications.
“Then you take on the risk of all those individuals that live in the other house,” said Wen. “Let’s say all those other people have relationships with someone else, who then have extended networks too. Now your pandemic pod is not with four roommates, it’s potentially with dozens of individuals.”
“You’re only as safe as the highest-risk person,” she added.
There is one silver lining, though, said Wen. She believes if two people are vaccinated they can safely get together.
“We don’t know this for certain, but here’s what I would say for people who are vaccinated and live alone,” said Wen. “I actually think you could pretty safely see somebody else who is vaccinated.”
Wen issued this advice, she said, with the assumption that both people are trying to mitigate their covid transmission risk by wearing masks in public, washing hands, minimizing social circles and not frequenting indoor spaces. Matches should discuss what safety precautions they’re taking before meeting up.
This recommendation also applies to us unvaccinated daters — we should all be having open conversations with our matches about what covid precautions we’re taking and in what circumstances we would feel comfortable meeting in person.
Think about this open communication the way you would talk to a potential sexual partner about the precautions you’re taking to prevent sexually transmitted infections or pregnancy. If it’s not something the person is willing to discuss, then perhaps they aren’t someone with whom you want to meet up.
But, never fear. As eligibility for the covid vaccine opens up to groups that may include younger people, it’s likely vaccine status will gain more prominence in dating profiles. While vaccines were initially limited to health care workers, long-term care facility residents and those 65 and older, eligibility categories in some states are widening to include other essential workers and people with underlying medical conditions.
It also seems possible that dating app companies may eventually roll out a feature to select or highlight your vaccination status in your profile, rather than having to write it in the bio, said Jennifer Reich, a sociology professor at the University of Colorado-Denver, who studies vaccine attitudes.
“I think we could imagine a range of things around covid. We could imagine fields about working from home, vaccine status, antibody status,” said Reich. “Adding these to your profile could help users figure out how they want to manage risk in their lives and what levels of risk they want to take.”
As for me, now that the dating apps are downloaded on my phone again, maybe I’ll give video dates another shot. At least until it’s summer again or I get my own vaccine — whichever comes first.