Listen: A Rookie Doctor Starts Her Career, Forged by the Pandemic

KFF Health News, April 21, 2021

Because of COVID precautions, many of the socializing and orientation traditions for new doctors were set aside.

This interview was published on Wednesday, April 21, 2021 in Kaiser Health News.

On this week's episode of "America Dissected," host Dr. Abdul El-Sayed spoke with Dr. Paloma Marin-Nevarez, an emergency medicine resident at UCSF Fresno, and KHN senior correspondent Jenny Gold about the challenges Marin-Nevarez faced as a new doctor learning the ropes during a devastating pandemic.

Each July, thousands of new physicians begin their on-the-job training at hospitals across the U.S. Marin-Nevarez began caring for severely ill COVID patients just a few months after the beginning of the pandemic.

"We were pretty much just abducted from med school, ripped out of our med school community and just thrown into our residencies," she told El-Sayed.

Because of COVID precautions, many of the socializing and orientation traditions for new doctors were set aside. Soon, Marin-Nevarez was working more than 80 hours a week in a new, unfamiliar city. "So it was an isolating time," she said.

The trio's conversation begins at 9:59 of the podcast.

Gold's audio story, produced in collaboration with the Reveal podcast, follows Marin-Nevarez during her first emotional months as a doctor, surrounded by death as she counseled families who had lost loved ones. Her time caring for patients in the ICU also highlighted the inequality of the pandemic, with Latino, Black and Native American people dying of COVID-19 at much higher rates than white people.

Another Soda Tax Bill Dies. Another Win for Big Soda.

KFF Health News, April 21, 2021

Despite its tarnished reputation, the deep-pocketed soft drink industry continues to exert its political influence in California.

This article was published on Wednesday, April 21, 2021 in Kaiser Health News.

By Samantha Young

SACRAMENTO — A rogue industry. A gun to our head. Extortion.

That's how infuriated lawmakers described soft drink companies — and what they pulled off in 2018 when they scored a legislative deal that bars California's cities and counties from imposing taxes on sugary drinks.

Yet, despite its tarnished reputation, the deep-pocketed industry continues to exert its political influence in the nation's most populous state, spending millions of dollars on politically connected lobbyists and doling out campaign contributions to nearly every state lawmaker.

The result? Bills long opposed by Coca-Cola Co., PepsiCo and other beverage companies continue to flounder. Just two weeks ago, a measure that would have undone the 2018 deal that lawmakers so vehemently protested was shelved without a hearing.

"Big Soda is a very powerful lobby," said Eric Batch, vice president of advocacy at the American Heart Association, which has petitioned lawmakers nationwide to crack down on sugar-laden drinks that health advocates say contribute to diabetes, obesity and other costly medical conditions.

"They've spent a lot of money in California to stop groups like ours from passing good policy," Batch added. "And they've been doing it for a long time."

In the past four years, soft drink companies spent about $5.9 million lobbying California lawmakers and giving to their campaigns or favorite charities. A California Healthline analysis of campaign finance records from Jan. 1, 2017, to Dec. 31, 2020, found that the American Beverage Association, Coca-Cola and Pepsi have given to nearly every state officeholder — from Gov. Gavin Newsom to roughly five-sixths of the 120-member legislature.

The American Beverage Association declined an interview request to discuss its political giving and this year's bill that would have upended the soda tax moratorium it helped orchestrate. Coca-Cola and Pepsi did not return requests seeking comment.

In 2018, the industry spent $8.9 million to boost a statewide ballot measure sponsored by the California Business Roundtable that would have made it more difficult for cities and counties to levy taxes — not just taxes on sugary drinks — by requiring them to be approved by two-thirds of voters instead of a simple majority. Fearful that local governments could face a higher voting threshold for taxes and fees that would fund libraries, public safety and other services, lawmakers at the time said they had no choice but to negotiate with the industry.

In a deal that several lawmakers described as "extortion" and a "Sophie's Choice," the legislature agreed to pass a bill banning new local taxes on sugary drinks until Jan. 1, 2031, if the industry and other supporters dropped the ballot measure. Then-Gov. Jerry Brown, who had dined with industry executives several weeks before, signed the bill.

The California deal was a coup for Big Soda, which doesn't appear to have paid a political price: Legislation that would have imposed a state tax on sugary drinks died a year later, as did a bill that would have required health warning labels on sugary drinks and another that would have banned sodas in grocery store checkout aisles.

This year's bill, which would have reinstated cities and counties' ability to put soda taxes before voters, is all but dead.

"They're gaming the political system," said Assembly member Adrin Nazarian (D-North Hollywood), the author of AB 1163. Nazarian said he hopes to revive the measure before April 30, the deadline for policy committees to hear legislation for the year.

"It's one thing for us to make a bad policy decision once," he said. "It's another thing to give a signal to all the industries that will then utilize this loophole against us. How many more times are we going to be doing this?"

Public health advocates point to such taxes as a way to cut consumption of soda, sports drinks, fruit juices and other sweet beverages, citing studies that show the more they cost, the less people buy them. On average, a can of soda contains 10 teaspoons of sugar, nearly the entire recommended daily amount for someone who eats 2,000 calories a day. Some energy drinks contain twice that.

Four California cities — Albany, Berkeley, Oakland and San Francisco — had soda taxes in place before the 2018 legislative deal that were allowed to remain. Boulder, Colorado; Philadelphia; Seattle; and the Navajo Nation also have soda taxes, with proposals under consideration in Rhode Island and Washington, D.C.

The revenue stream from the taxes could help fund financially strapped public health departments depleted by the COVID pandemic, health advocates say.

For example, last year San Francisco directed $1.6 million of its soda tax revenue to local programs that feed residents affected by school closures and job losses. Seattle tapped its soda tax revenue to give grocery vouchers to its hardest-hit residents.

Nazarian said he expected his attempt to undo the soda tax moratorium to be an uphill battle, but he is frustrated the bill was denied even one hearing.

Nazarian, like lawmakers before him, is butting up against a strong anti-tax environment in U.S. politics, said Tatiana Andreyeva, director of economic initiatives at the University of Connecticut's Rudd Center for Food Policy & Obesity. So, while more than 40 countries have imposed national taxes on sugary drinks — including the United Kingdom, Mexico, Portugal and South Africa — national and state efforts have stalled here.

There's also the political might of the soda industry.

"Look at how much money they spend fighting all these bills that have been proposed," said Andreyeva, who has studied the soda industry since 2007. "We have seen dozens and dozens of bills at the state and local level. There's always a lot of opposition by the industry. They are well-funded, they will organize and it's very hard."

In California, soft drink companies spent $4.4 million in the past four years lobbying lawmakers and state officials, treating them to dinners and sporting events. They hired veteran political firms staffed by former government employees who know how the Capitol works and often already have relationships with lawmakers and their aides.

For instance, until earlier this year the American Beverage Association had Fredericka McGee on its payroll as its top California lobbyist. She had worked for five Assembly speakers. Now, McGee is chief of staff to Los Angeles County Supervisor Holly Mitchell, a former state legislator who in 2018 was the chair of the powerful Senate Budget Committee, which oversaw the deal banning new local soda taxes.

In addition to lobbying, the industry spent just over $1.5 million on contributions to lawmakers, including big checks written to charities on their behalf.

The largest contributions flowed to the lawmakers with the most influence.

Pepsi and Coca-Cola gave a total of $25,000 to charities in the name of Assembly Speaker Anthony Rendon, according to the state Fair Political Practices Commission, which tracks the donations, known as "behested payments." That's on top of the $35,900 Rendon collected in his campaign account from the industry over the past four years.

Senate President Pro Tem Toni Atkins cashed $26,000 in campaign checks from Coca-Cola and Pepsi, and accepted a $5,000 donation to one of her charities from Coke's bottling plant in her San Diego district.

In an emailed statement, Rendon described the issue of sugary drinks as complex and said he co-authored legislation in 2015 that would have imposed a tax on distributors of sugary drinks. It died in committee.

"I want us to do something to reduce the consumption of sweetened beverages," Rendon said. "These bills have been hard to pass, but I think it's simplistic to pin it on contributions."

Atkins did not comment on Big Soda's political power but said in an emailed statement she would review Nazarian's bill "on its merits" if it comes before the Senate.

Nazarian's bill is on hold in the Assembly Revenue and Taxation Committee, led by Autumn Burke (D-Inglewood). A spokesperson for Burke did not return calls and emails requesting comment.

Burke also received money from soda companies, collecting about $22,000 from Coca-Cola, Pepsi and the American Beverage Association from 2017 through 2020.

Public health groups aren't willing to admit defeat and are mobilizing a grassroots effort to get a hearing for Nazarian's bill. They say California must address the disproportionate health effects of sugary drinks on Black and Latino communities, which COVID-19 only exacerbated.

"If the members of the legislature were looking at data and using data as the decision-making criteria for whether we should allow a ban on local taxes to be lifted, they would have to support that," said Michael Dimock, president of Roots of Change, a program of the Public Health Institute. "But they are not looking at the data. Something else is influencing them."

Elizabeth Lucas of KHN contributed to this report.

Censorship or Misinformation? DeSantis and YouTube Spar Over COVID Roundtable Takedown.

KFF Health News, April 21, 2021

The Florida governor claims that Google and YouTube have not acted as "repositories of truth and scientific inquiry" throughout the COVID pandemic but instead as "enforcers of a narrative."

This article was published on Wednesday, April 21, 2021 in Kaiser Health News.

By Victoria Knight

In early April, YouTube took down a video featuring Florida Gov. Ron DeSantis and a group of controversial scientists at a March 18 coronavirus roundtable. The online video platform, owned by Google, cited as its rationale that the video contained false statements about the efficacy of children's mask-wearing.

The decision has drawn public blowback on social media and from DeSantis himself.

DeSantis held another public roundtable on April 12 (which is currently available on YouTube), along with three of the same scientists who participated in the March 18 session, during which he blasted YouTube for taking down the earlier video, calling the action "censorship."

He said Google and YouTube have not acted as "repositories of truth and scientific inquiry" throughout the COVID pandemic but instead as "enforcers of a narrative."

"What we're witnessing is Orwellian," DeSantis said. 'It's a Big Tech corporate media collusion."

And when polled by DeSantis during the second roundtable, the scientists defended the video, saying it should have been left up so that it could contribute to scientific debate. We checked with DeSantis' office for more information and were referred to an April 12 press release, which summarized the events of the day's roundtable.

In an emailed statement, a YouTube spokesperson pointed to the platform's policies on medical misinformation about COVID: "We removed this video because it included content that contradicts the consensus of local and global health authorities regarding the efficacy of masks to prevent the spread of COVID-19. We allow videos that otherwise violate our policies to remain on the platform if they contain sufficient educational, documentary, scientific, or artistic context. Our policies apply to everyone, and focus on content regardless of the speaker or channel."

The video, though no longer on that platform, can still be viewed on The Florida Channel, a website that posts recordings of Florida governmental proceedings.

So who exactly are these scientific panelists and what was said during the roundtable? And have social media companies ramped up efforts to crack down on medical misinformation recently?

Let's break it down.

DeSantis' Panel Reflected Controversial Herd Immunity Movement

The scientists who spoke at DeSantis' roundtable and gave their opinions about masks and lockdowns were Dr. Scott Atlas of Stanford University, Sunetra Gupta of Oxford University, Dr. Jay Bhattacharya of Stanford University and Martin Kulldorff of Harvard University.

Three of the scientists, Gupta, Bhattacharya and Kulldorff, were the primary authors of the Great Barrington Declaration, a contentious document that circulated in October. In it, the scientists argued that lockdowns should end, most people should resume their daily lives and only the most vulnerable should take precautions against COVID. The document asserted that members of the public who resumed normal lives would then build up their immunity to COVID through exposure to natural infection.

The Great Barrington Declaration received immediate criticism from scientists, including the top U.S. health official, Dr. Anthony Fauci; World Health Organization Director-General Tedros Adhanom Ghebreyesus; and the United Kingdom's health secretary, Matt Hancock.

Atlas was part of President Donald Trump's White House COVID team and was reported to have promoted herd immunity views to the former president. After the reports about Atlas, Trump and his press team later walked back the idea that the White House was considering any type of herd immunity strategy to combat the pandemic.

Atlas' tenure at the White House was also dogged by other controversies, including Twitter removing one of his tweets because it contained false information about face masks, and his urging of Michigan residents to go against Gov. Gretchen Whitmer's public health recommendations. Atlas stepped down from the White House team in December.

The Panel's Factual Mistake and Why YouTube Took It Down

During DeSantis' almost two-hour March 18 COVID roundtable, the governor and the scientists discussed a range of topics, including the efficacy of lockdowns and face masks for children.

According to YouTube, the video was removed because it violated the company's policy on medical misinformation. YouTube says it doesn't allow content that poses a serious risk of egregious harm, such as videos that contradict the consensus of local and global health authorities regarding the efficacy of masks.

The clips YouTube cited as violating its medical misinformation policy involved specific instances in which DeSantis and the scientists said face masks were not necessary for children — statements the platform said were contrary to recommendations from U.S. public health authorities. Here are the specific clips in the format provided by YouTube:

  • "Dr. Gupta mentioned about, you know, not putting masks on kids that's not effective, not necessary. Uh, Martin, do you agree in school there's no need for them to be wearing face masks?" — Gov. DeSantis
     
  • "Uh, children should not wear face masks, no. They don't need it for their own protection and they don't need it for protecting other people either." — Kulldorff
     
  • "… and I think it is developmentally inappropriate and it just doesn't help on the disease spread. I think it's absolutely not the right thing to do. … I think [the data] is a little bit, uh, clearer because we've had a year of experience. If we went back a year, a lot of the experts would say that wearing masks for the general public is not evidence-based." — Dr. Bhattacharya
     
  • "There's no scientific rationale or logic to have children wear masks in schools." — Dr. Atlas

The Centers for Disease Control and Prevention recommends that children 2 years old and older wear masks. The agency also recommends that children wear masks in schools, child care settings and any environment when they are around people who don't live in their home.

"We know children of all ages are at risk for being infected with SARS-CoV-2 and are capable of transmitting the virus. This is particularly true of older children, especially middle-school and high-school aged kids," Josh Michaud, associate director of global health policy at KFF, wrote in an email. "We also know that masking, when employed widely and effectively, helps reduce the risk of transmission of the virus."

Studies back this up.

The CDC published a study in February showing that different types of masks block cough particles and double-masking is the most effective at doing so. Another experiment from that study showed that a person in a mask emits fewer aerosol particles that can be passed on to an unmasked person. A multitude of reports also show, generally, that mask-wearing is effective at reducing the risk of spreading or catching other respiratory diseases.

Other studies have shown that children carry almost as much coronavirus in their upper-respiratory tract as adults, despite often having no or mild symptoms. And it is possible for children to pass the virus on to adults.

Also, multiple studies of schools that reopened in fall 2020 and had high compliance with mask-wearing have been shown to have low numbers of COVID transmission. And the American Academy of Pediatrics said mask-wearing will not make it more difficult for children to breathe, nor will it interfere with a child's lung development.

Are Tech Companies Actually Increasing Their Crackdowns?

DeSantis' protests regarding the removal of his roundtable from YouTube echo those of Trump, who railed against tech companies and their policies during his presidency.

Trump was eventually de-platformed from other online entities such as Twitter and Facebook, among others, following the Jan. 6 insurrection at the U.S. Capitol. Conservatives have since complained they're being censored on social media platforms.

After the YouTube video removal, DeSantis used the opportunity to promote censorship bills that are moving through his state's legislature and would prevent social media companies from blocking politicians from their platforms in Florida. (State attempts to regulate social media companies will face constitutional hurdles, including First Amendment protections, the Tampa Bay Times reported.)

Social media platforms including YouTube, Facebook, Instagram and Twitter have introduced COVID misinformation policies since the pandemic started, and even updated those policies in the past couple of months to take a harder line in removing posts and notifying users. However, the companies state that they aren't targeting certain users when removing content, but rather anyone who spreads misinformation.

According to data shared by YouTube in March, the company has removed more than 800,000 videos containing coronavirus misinformation since February of last year. Facebook reported in February that the company and its sister platform, Instagram, had removed more than 1 million pieces of COVID misinformation in the last three months of 2020. And last month, Twitter said it had removed more than 8,400 tweets and challenged 11.5 million accounts since the implementation of the COVID guidance.

Victoria Knight: vknight@kff.org, @victoriaregisk

Strides Against HIV/AIDS Falter, Especially in the South, as Nation Battles COVID

KFF Health News, April 21, 2021

The COVID-19 pandemic has caused profound disruptions in almost every aspect of the HIV / AIDS battle.

This article was published on Wednesday, April 21, 2021 in Kaiser Health News.

By Sarah Varney

Facing a yearlong siege from the coronavirus, the defenses in another, older war are faltering.

For the last two decades, HIV/AIDS has been held at bay by potent antiviral drugs, aggressive testing and inventive public education campaigns. But the COVID-19 pandemic has caused profound disruptions in almost every aspect of that battle, grounding outreach teams, sharply curtailing testing and diverting critical staff away from laboratories and medical centers.

The exact impact of one pandemic on the other is still coming into focus, but preliminary evidence is disturbing experts who have celebrated the enormous strides in HIV treatment. While the shift in priorities is nationwide, delays in testing and treatment carry particularly grievous risks in Southern states, now the epicenter of the nation's HIV crisis.

"This is a major derailing," said Dr. Carlos del Rio, a professor of medicine at Emory University in Atlanta and head of the Emory AIDS International Training and Research Program. "There will be damage. The question is, how much?"

Clinics have limited in-person visits and halted routine HIV screening in doctors' offices and emergency rooms, with physicians relying instead on video calls with patients, a futile alternative for those who are homeless or fear family members will discover their status. Rapid-testing vans that once parked outside nightclubs and bars and handed out condoms are mothballed. And, in state capitals and county seats, government expertise has been singly focused on the all-hands-on-deck COVID response.

Concrete signs of the impact on HIV surveillance abound: One large commercial lab reported nearly 700,000 fewer HIV screening tests across the country — a 45% drop — and 5,000 fewer diagnoses between March and September 2020, compared with the same period the year before. Prescriptions of PrEP, a preexposure prophylaxis that can prevent HIV infection, have also fallen sharply, according to new research presented at a conference last month. State public health departments have recorded similarly steep declines in testing.

That dearth in new data has led to a precarious, unknowable moment: For the first time in decades, the nation's lauded HIV surveillance system is blind to the virus's movement.

Nowhere will the lack of data be felt more profoundly than in the South: The region accounts for 51% of all new infections, eight of the 10 states with the highest rates of new diagnoses, and half of all HIV-related deaths, according to the most recent data available from the Centers for Disease Control and Prevention.

Even before the COVID pandemic, Georgia had the highest rate of new HIV diagnoses of any state, though lower than that of Washington, D.C. The Georgia Department of Public Health recorded a 70% drop in testing last spring compared with spring 2019.

The slowdown in HIV patient services "could be felt for years," said Dr. Melanie Thompson, principal investigator of the AIDS Research Consortium of Atlanta.

She added, "Every new HIV infection perpetuates the epidemic and will likely be passed to one or more people in the months to come if people are not diagnosed and offered HIV treatment."

Coronavirus testing has commandeered the machines previously used for HIV/AIDS testing, further straining surveillance efforts. The polymerase chain reaction — or PCR — machines used to detect and measure the genetic material in the human immunodeficiency virus are the same machines that run COVID tests around-the-clock.

Over the decades, as HIV migrated inland from coastal cities like San Francisco, Los Angeles and New York, it took root in the South, where poverty is endemic, lack of health coverage is commonplace, and HIV stigma is pervasive.

"There is the stigma that's real. There is legacy racism," said Dr. Thomas Giordano, medical director of Thomas Street Health Center in Houston, one of the largest HIV clinics in the U.S. The state's political leaders, he said, view HIV as "a disease of the poor, of Blacks, Latinos and gay. It's just not mainstream at the state level."

Black people represent 13% of the U.S. population but about 40% of HIV cases — and deaths. In many Southern states, the disparities are stark: In Alabama, Black residents account for 27% of the population and 70% of new diagnoses; in Georgia, Black people make up 33% of residents and 69% of people with HIV.

HIV clinics that serve low-income patients also face limitations using video and phone appointments. Clinic directors say poor patients often lack data plans and many homeless patients simply don't have phones. They also must contend with fear. "If a friend gave you a room to sleep and your friend finds out you have HIV, you might lose that place to sleep," said del Rio of Emory University.

Texting can be tricky, too. "We have to be cautious about text messages," said Dr. John Carlo, chief executive officer of PRISM Healthcare North Texas in Dallas. "If someone sees their phone, it can be devastating."

In Mississippi, HIV contact tracing — which was used as a model for some local efforts to track the coronavirus — has been limited by COVID-related travel restrictions meant "to protect both staff and client," said Melverta Bender, director of the STD/HIV office at the Mississippi State Department of Health.

Of all regions in the U.S., the South has the weakest health safety nets. And Southern states have far fewer resources than states like California and New York. "Our public health infrastructures have been chronically underfunded and undermined over the decades," said Thompson, the Atlanta researcher. "So we stand to do worse by many metrics."

Georgia's high HIV infection rate and the state's slow pace of COVID vaccinations "are not unrelated," Thompson said.

The porous safety net extends to health insurance, a vital need for those living with HIV. Nearly half of Americans without health coverage live in the South, where many states have not expanded Medicaid under the Affordable Care Act. That leaves many people with HIV to rely on the federal Ryan White HIV/AIDS Program and state-run AIDS drug assistance programs, known as ADAPs, which offer limited coverage.

"As a matter of equity, insurance is critical for people to live and thrive with HIV," said Tim Horn, director of healthcare access at NASTAD, the National Alliance of State and Territorial AIDS Directors. Ryan White and ADAPs "are not equipped to provide that full sweep of comprehensive care," he said.

Roshan McDaniel, South Carolina's ADAP program manager, says 60% of South Carolinians enrolled in ADAP would qualify if her state expanded Medicaid. "The first few years, we thought about it," said McDaniel. "We don't even think about it nowadays."

Enrollment in the Ryan White program jumped during the early months of the pandemic when state economies froze and Americans hunkered down amid a grinding pandemic. Data from state health departments reflect the increased need. In Texas, enrollment in the state's AIDS drug program increased 34% from March to December 2020. In Georgia, enrollment jumped by 10%.

State health officials attribute the increased enrollment to pandemic-related job losses, especially in states that didn't expand Medicaid. Antiretroviral treatment, the established regimen that suppresses the amount of virus in the body and prevents AIDS, costs up to $36,000 a year, and medication interruptions can lead to viral mutations and drug resistance. But qualifying for state assistance is difficult: Approval can take up to two months, and missing paperwork can lead to canceled coverage.

Federal health experts say Southern states have generally lagged behind getting patients into medical care and suppressing their viral loads, and people with HIV infections tend to go undiagnosed longer there than in other regions. In Georgia, for example, nearly 1 out of 4 people who learned they were infected developed AIDS within a year, indicating their infections had long gone undiagnosed.

As vaccinations become widely available and restrictions ease, HIV clinic directors are scouring their patient lists to determine who they need to see first. "We are looking at how many people haven't seen us in over a year. We think it's over several hundred. Did they move? Did they move providers?" said Carlo, the doctor and healthcare CEO in Dallas. "We don't know what the long-term consequences are going to be."

Sarah Varney: svarney@kff.org, @SarahVarney4

Public Health Experts Worry About Boom-Bust Cycle of Support

KFF Health News, April 20, 2021

If budgets are slashed again, public health officials warn, that could leave the nation where it was before COVID: unprepared for a health crisis.

This article was published on Monday, April 19, 2021 in Kaiser Health News.

By Michelle R. Smith, The Associated Press and Lauren Weber and Hannah Recht

Congress has poured tens of billions of dollars into state and local public health departments in response to the COVID-19 pandemic, paying for masks, contact tracers and education campaigns to persuade people to get vaccinated.

Public health officials who have juggled bare-bones budgets for years are happy to have the additional money. Yet they worry it will soon dry up as the pandemic recedes, continuing a boom-bust funding cycle that has plagued the U.S. public health system for decades. If budgets are slashed again, they warn, that could leave the nation where it was before COVID: unprepared for a health crisis.

"We need funds that we can depend on year after year," said Dr. Mysheika Roberts, the health commissioner of Columbus, Ohio.

When Roberts started in Columbus in 2006, an emergency preparedness grant paid for more than 20 staffers. By the time the coronavirus pandemic hit, it paid for about 10. Relief money that came through last year helped the department staff up its COVID response teams. While the funding has helped the city cope with the immediate crisis, Roberts wonders if history will repeat itself.

After the pandemic is over, public health officials across the U.S. fear, they'll be back to scraping together money from a patchwork of sources to provide basic services to their communities — much like after 9/11, SARS and Ebola.

When the mosquito-borne Zika virus tore through South America in 2016, causing serious birth defects in newborn babies, members of Congress couldn't agree how, and how much, to spend in the U.S. for prevention efforts, such as education and mosquito abatement. The Centers for Disease Control and Prevention took money from its Ebola efforts, and from state and local health department funding, to pay for the initial Zika response. Congress eventually allocated $1.1 billion for Zika, but by then mosquito season had passed in much of the U.S.

"Something happens, we throw a ton of money at it, and then in a year or two we go back to our shrunken budgets and we can't do the minimum things we have to do day in and day out, let alone be prepared for the next emergency," said Chrissie Juliano, executive director of the Big Cities Health Coalition, which represents leaders of more than two dozen public health departments.

Funding for Public Health Emergency Preparedness, which pays for emergency capabilities for state and local health departments, dropped by about half between the 2003 and 2021 fiscal years, accounting for inflation, according to Trust for America's Health, a public health research and advocacy organization.

Even the federal Prevention and Public Health Fund, established with the Affordable Care Act to provide $2 billion a year for public health, was raided for cash over the past decade. If the money hadn't been touched, eventually local and state health departments would have gotten an additional $12.4 billion.

Several lawmakers, led by Democratic U.S. Sen. Patty Murray of Washington, are looking to end the boom-bust cycle with legislation that would eventually provide $4.5 billion annually in core public health funding. Health departments carry out essential government functions — such as managing water safety, issuing death certificates, tracking sexually transmitted diseases and preparing for infectious outbreaks.

Spending for state public health departments dropped by 16% per capita from 2010 to 2019, and spending for local health departments fell by 18%, KHN and The Associated Press found in a July investigation. At least 38,000 public health jobs were lost at the state and local level between the 2008 recession and 2019. Today, many public health workers are hired on a temporary or part-time basis. Some are paid so poorly they qualify for public aid. Those factors reduce departments' ability to retain people with expertise.

Compounding those losses, the pandemic has prompted an exodus of public health officials because of harassment, political pressure and exhaustion. A yearlong analysis by the AP and KHN found at least 248 leaders of state and local health departments resigned, retired or were fired between April 1, 2020, and March 31, 2021. Nearly 1 in 6 Americans lost a local public health leader during the pandemic. Experts say it is the largest exodus of public health leaders in American history.

Brian Castrucci, CEO of the de Beaumont Foundation, which advocates for public health, calls Congress' giant influx of cash in response to the crisis "wallpaper and drapes" because it doesn't restore public health's crumbling foundation.

"I worry at the end of this we're going to hire up a bunch of contact tracers — and then lay them off soon thereafter," Castrucci said. "We are continuing to kind of go from disaster to disaster without ever talking about the actual infrastructure."

Castrucci and others say dependable money is needed for high-skill professionals, such as epidemiologists — data-driven disease detectives — and for technology upgrades that would help track outbreaks and get information to the public.

In Ohio, the computer system used to report cases to the state predates the invention of the iPhone. State officials had said for years they wanted to upgrade it, but they lacked the money and political will. Many departments across the country have relied on fax machines to report COVID cases.

During the pandemic, Ohio's state auditor found that nearly 96% of local health departments it surveyed had problems with the state's disease reporting system. Roberts said workers interviewing patients had to navigate several pages of questions, a major burden when handling 500 cases daily.

The system was so outdated that some information could be entered only in a non-searchable comment box, and officials struggled to pull data from the system to report to the public — such as how many people who tested positive had attended a Black Lives Matter rally, which last summer was a key question for people trying to understand whether protests contributed to the virus's spread.

Ohio is working on a new system, but Roberts worries that, without a dependable budget, the state won't be able to keep that one up to date either. 

"You're going to need to upgrade that," Roberts said. "And you're going to need dollars to support that."

In Washington, the public health director for Seattle and King County, Patty Hayes, said she is asked all the time why there isn't a single, central place to register for a vaccine appointment. The answer comes down to money: Years of underfunding left departments across the state with antiquated computer systems that were not up to the task when COVID hit.

Hayes recalls a time when her department would conduct mass vaccination drills, but that system was dismantled when the money dried up after the specter of 9/11 faded.

Roughly six years ago, an analysis found that her department was about $25 million short of what it needed annually for core public health work. Hayes said the past year has shown that's an underestimate. For example, climate change is prompting more public health concerns, such as the effect on residents when wildfire smoke engulfed much of the Pacific Northwest in September.

Public health officials in some areas may struggle to make the case for more stable funding because a large swath of the public has questioned — and often been openly hostile toward — the mask mandates and business restrictions that public health officials have imposed through the pandemic.

In Missouri, some county commissioners who were frustrated at public health restrictions withheld money from the departments.

In Knox County, Tennessee, Mayor Glenn Jacobs narrated a video posted in the fall that showed a photo of health officials after referencing "sinister forces." Later, someone spray-painted "DEATH" on the department office building. The Board of Health was stripped of its powers in March and given an advisory role. A spokesperson for the mayor's office declined to comment on the video.

"This is going to change the position of public health and what we can and cannot do across the country," said Dr. Martha Buchanan, the head of the health department. "I know it's going to change it here."

A KHN and AP investigation in December found at least 24 states were crafting legislation that would limit or remove public health powers.

Back in Seattle, locally based companies have pitched in money and staff members for vaccine sites. Microsoft is hosting one location, while Starbucks offered customer service expertise to help design the sites. Hayes is grateful, but she wonders why a critical government function didn't have the resources it needed during a pandemic.

If public health had been getting dependable funding, her staff could have been working more effectively with the data and preparing for emerging threats in the state where the first U.S. COVID case was confirmed.

"They'll look back at this response to the pandemic in this country as a great example of a failure of a country to prioritize the health of its citizens, because it didn't commit to public health," she said. "That will be part of the story."

KHN senior correspondent Anna Maria Barry-Jester and Montana correspondent Katheryn Houghton contributed to this report.

Michelle R. Smith, The Associated Press: mrsmith@ap.org, @MRSmithAP

Lauren Weber: LaurenW@kff.org, @LaurenWeberHP

Hannah Recht: hrecht@kff.org, @hannah_recht  

After a Deadly Year on the Roads, States Push for Safety Over Speed

KFF Health News, April 20, 2021

States are grappling with how to reduce traffic deaths, a problem that has worsened over the past 10 years but gained urgency since the onset of the COVID-19 pandemic.

This article was published on Tuesday, April 20, 2021 in Kaiser Health News.

By Rachel Bluth

As more Americans start commuting to work and hitting the roads after a year indoors, they'll be returning to streets that have gotten deadlier.

Last year, an estimated 42,000 people died in motor vehicle crashes and 4.8 million were injured. That represents an 8% increase over 2019, the largest year-over-year increase in nearly a century — even though the number of miles driven fell by 13%, according to the National Safety Council.

The emptier roads led to more speeding, which led to more fatalities, said Leah Shahum, executive director of the Vision Zero Network, a nonprofit organization that works on reducing traffic deaths. Ironically, congested traffic, the bane of car commuters everywhere, had been keeping people safer before the pandemic, Shahum said.

"This is a nationwide public health crisis," said Laura Friedman, a California Assembly member who introduced a bill this year to reduce speed limits. "If we had 42,000 people dying every year in plane crashes, we would do a lot more about it, and yet we seem to have accepted this as collateral damage."

California and other states are grappling with how to reduce traffic deaths, a problem that has worsened over the past 10 years but gained urgency since the onset of the COVID-19 pandemic. Lawmakers from coast to coast have introduced dozens of bills to lower speed limits, set up speed camera programs and promote pedestrian safety.

The proposals reflect shifting perspectives on how to manage traffic. Increasingly, transportation safety advocates and traffic engineers are calling for roads that get drivers where they're going safely rather than as fast as possible.

Lawmakers are listening, though it's too soon to tell which of the bills across the country will eventually become law, said Douglas Shinkle, who directs the transportation program at the National Conference of State Legislatures. But some trends are starting to emerge.

Some states want to boost the authority of localities to regulate traffic in their communities, such as giving cities and counties more control over speed limits, as legislators have proposed in Michigan, Nebraska and other states. Some want to let communities use speed cameras, which is under consideration in Massachusetts, Rhode Island, Florida and elsewhere.

Connecticut is considering a pedestrian safety bill that incorporates multiple concepts, including giving localities greater authority to lower speeds, and letting some municipalities test speed cameras around schools, hospitals and work zones.

"For decades really we've been building roads and highways that are suitable and somewhat safe for motorists," said Connecticut Sen. Will Haskell (D-Westport), who chairs the committee overseeing the bill. "We also have to recognize that some people in the state don't own a car, and they have a right to move safely throughout their community."

A huge jump in road fatalities started showing up in the data "almost immediately" after the start of the pandemic, despite lockdown orders that kept people home and reduced the number of drivers on the road, said Tara Leystra, the National Safety Council's state government affairs manager.

"A lot of states are trying to give more flexibility to local communities so they can lower their speed limits," Leystra said. "It's a trend that started before the pandemic, but I think it really accelerated this year."

In California, citations issued by the state highway patrol for speeding over 100 miles per hour roughly doubled to 31,600 during the pandemic's first year.

Friedman, a Democrat from Burbank, wants to reform how California sets speed limits on local roads.

California uses something called the "85th percentile" method, a decades-old federal standard many states are trying to move away from. Every 10 years, state engineers survey a stretch of road to see how fast people are driving. Then they base the speed limit on the 85th percentile of that speed, or how fast 85% of drivers are going.

That encourages "speed creep," said Friedman, who chairs the state Assembly's transportation committee. "Every time a survey is done, a lot of cities are forced to raise speed limits because people are driving faster and faster and faster," she said.

Even before the pandemic, a California task force had recommended letting cities have more flexibility to set their speed limits, and a federal report found the 85th percentile rule similarly inadequate to set speeds. But opposition to the rule is not universal. In New Jersey, for instance, lawmakers introduced a bill this legislative session to start using it.

Friedman's bill, AB 43, would allow local authorities to set some speed limits without using the 85th percentile method. It would require traffic surveyors to consider areas like work zones, schools and senior centers, where vulnerable people may be using the road, when setting speed limits.

In addition to lowering speed limits, lawmakers also want to better enforce them. In California, two bills would reverse the state's ban on automated speed enforcement by allowing cities to start speed camera pilot programs in places like work zones, on particularly dangerous streets and around schools.

But after a year of intense scrutiny on equity — both in public health and in law enforcement — lawmakers acknowledge they need to strike a delicate balance between protecting at-risk communities and overpolicing them.

Though speed cameras don't discriminate by skin color, bias can still enter the equation: Wealthier areas frequently have wide streets and walkable sidewalks, while lower-income ones are often crisscrossed by freeways. Putting cameras only on the most dangerous streets could mean they end up mostly in low-income areas, Shahum said.

"It tracks right back to street design," she said. "Over and over again, these have been neighborhoods that have been underinvested in."

Assembly member David Chiu (D-San Francisco), author of one of the bills, said the measure includes safeguards to make the speed camera program fair. It would cap fees at $125, with a sliding scale for low-income drivers, and make violations civil offenses, not criminal.

"We know something has to be done, because traditional policing on speed has not succeeded," Chiu said. "At the same time, it's well documented that drivers of color are much more likely to be pulled over."

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

Rachel Bluth: rbluth@kff.org, @RachelHBluth

From Rotten Teeth to Advanced Cancer, Patients Feel the Effects of Treatment Delays

KFF Health News, April 20, 2021

Along with exacerbating existing health problems, the COVID pandemic has also caused a host of new medical issues in patients.

This article was published on Tuesday, April 20, 2021 in Kaiser Health News.

By Bruce Alpert

With medical visits picking up again among patients vaccinated against COVID-19, health providers are starting to see the consequences of a year of pandemic-delayed preventive and emergency care as they find more advanced cancer and rotting and damaged teeth, among other ailments.

Dr. Brian Rah, chair of the cardiology department at Montana's Billings Clinic, was confused in the early days of the COVID pandemic. Why the sudden drop in heart attack patients at the Billings Clinic? And why did some who did come arrive hours after first feeling chest pains?

Two patients, both of whom suffered greater heart damage by delaying care, provided what came to be typical answers. One said he was afraid of contracting COVID by going to the hospital. The other patient went to the emergency room in the morning, left after finding it too crowded, and then returned that night when he figured there would be fewer patients — and a lower risk of catching COVID.

"For a heart attack patient, the first hour is known as the golden hour," Rah said. After that, the likelihood of death or a lifelong reduction in activities and health increases, he said.

Dr. JP Valin, executive vice president and chief clinical officer at SCL Health of Colorado and Montana, said he is "kept awake at night" by delays in important medical tests. "People put off routine breast examinations, and there are going to be some cancers hiding that are not going to be identified, potentially delaying intervention," he said.

Valin is also concerned that patients aren't seeking timely treatment when suffering appendicitis symptoms like abdominal pain, fever and nausea. A burst appendix generally involves more risk and a week's hospitalization, instead of one day of treatment for those who get care quickly, he said.

Dr. Fola May, a gastroenterologist who is also quality director and a health equity researcher at UCLA Health, worries about the consequences of an 80% to 90% drop in colonoscopies performed by the health system's doctors during the first months of COVID.

"All of a sudden we were downplaying health measures that are usually high-priority, such as trying to prevent diseases like cancer, to manage the pandemic," May said.

Along with exacerbating existing health problems, the COVID pandemic has also caused a host of new medical issues in patients. The American population will be coming out of the pandemic with teeth worn down from grinding, back problems from slouching at makeshift home-work stations and mental health problems from a combination of isolation and being too close to family.

Dr. Despina Markogiannakis, a dentist in Chevy Chase, Maryland, said patients don't argue when she tells them they have been grinding or clenching their teeth and might require a root canal procedure, dental implant or night guard.

"These are people stuck at home all day and feeling lonely and feeling a little depression. It is induced by the world we live in and all the changes in our lives," said Markogiannakis.

A recent American Dental Association survey found that more than 70% of member dentists reported an increase in patients grinding or clenching their teeth since COVID. More than 60% reported an increase in other stress-related conditions, such as chipped and cracked teeth.

Dr. Gerard Mosby, a Detroit pediatrician, finds his young patients are suffering more stress, depression and weight gain than before the pandemic. They are confined in their homes, and many are living in multigenerational homes or foster homes or have experienced COVID illnesses or death among family members.

"Since their ability to get out is limited, they can't vent to friends or other family members. Also, most will not have access to mental health for grief counseling," Mosby said.

Nancy Karim, a Bridgeport, Connecticut, licensed professional counselor and art therapist, said that, in addition to struggling with isolation, her patients are conversely stressed by living too closely with people without the benefit of breaks on work and school days.

Meanwhile, optometrist Matthew Jones, who practices in Blytheville and Osceola, Arkansas, reports worsening eye conditions for patients, some of whom stopped taking drops during COVID for conditions like glaucoma. He's also seeing much more eyestrain "because people are spending so much time in front of a computer screen" and recommends eyeglasses that filter out blue light to his patients.

Physical therapy needs are also on the rise.

"Patients that have transitioned to remote work are typically working with poor ergonomic set-ups and spending a lot more time sitting," said Kaylee Smith, founder and president of Smith Physical Therapy and Performance Studio in San Diego.

"I am seeing more pain and injuries related to poor posture (i.e., neck pain, low back pain, etc.) and a significant increase in patients coming in with tight hips related to increased sitting time," Smith said in an email.

Some providers report they are finally nearing pre-COVID patient levels, but others still face COVID resistance.

"Although we have seen an improvement over the past six weeks, it's still not much," said Neville Gupta of Gupta Gastro in Brooklyn and Far Rockaway, New York. "Our patients are still avoiding getting the care they need, no matter the safety precautions in place."

UVA Health Will Wipe Out Tens of Thousands of Lawsuits Against Patients

KFF Health News, April 20, 2021

The decision to wipe out liens that can drain home equity years after a hospital visit is extremely rare.

This article was published on Tuesday, April 20, 2021 in Kaiser Health News.

By Jay Hancock

University of Virginia Health System, which for years has sued thousands of patients annually for unpaid bills, said Monday it will cancel a massive backlog of court judgments and liens resulting from those lawsuits dating to the 1990s.

Combined with reforms UVA announced in 2019, the move is likely to benefit tens of thousands of families and make UVA Health's collections policies much more generous than those of many hospital systems, said scholars who study health care finance. The decision to wipe out liens that can drain home equity years after a hospital visit is extremely rare, they said.

UVA had been suing patients for decades, many with unpaid bills in the tens or hundreds of thousands of dollars, KHN reported in 2019. Once the health system won cases in court, it could seize wages and the value of patient homes when they were sold. UVA limited its collections lawsuits after KHN's investigation.

"This is very significant and a much-needed and overdue step," said Erin Fuse Brown, a law professor at Georgia State University who studies hospital billing. "I don't know if I've heard of that [lien abolition] happening anywhere else."

But most families who have already surrendered money to UVA as a result of lawsuits or liens will not get their money back.

UVA will release all liens and judgments filed against all households making less than 400% of federal poverty guidelines, or $106,000 for a family of four, which should account for most of them, said Douglas Lischke, the system's chief financial officer.

"This is a proud moment for us," he said in an interview. "We want our financial care to be as good as our clinical care."

"I am proud to see UVA Health System taking real steps to scale back aggressive medical collections and address the pain they've caused," said Virginia Gov. Ralph Northam, a pediatric neurologist. 

Doris Hutchinson was surprised two years ago to find a UVA lien related to a relative's bill on her mother's Charlottesville, Virginia, home. The medical system demanded $39,000 from the family before the house could be sold. The money was placed in escrow.

Three weeks ago, she learned the judgment would be canceled and the money released.

"I'll be excited about that," said Hutchinson, who said she needs the funds to help pay for her grandchildren's college education and replace income from her husband, who died two years ago. "I'm also happy for everybody else" who gets UVA bill relief, she said.

UVA will also stop blocking enrollment for university students with outstanding balances at the health system, university spokesperson Brian Coy said Monday. Keeping students from completing their education because they owed hospital bills was another practice revealed by KHN.

KHN reported in 2019 that UVA Health had sued patients 36,000 times over six years for more than $100 million, often for amounts far higher than what an insurer would have paid for their care. In response to the articles, the system suspended lawsuits against patients and wage garnishments, increased discounts for the uninsured and broadened financial assistance, including for cases dating to 2017.

Over six years, the state institution filed 36,000 lawsuits against patients seeking a total of more than $106 million in unpaid bills, a KHN analysis finds.

The system named an advisory council of UVA officials and community leaders to consider permanent changes. The council delivered recommendations in October.

Like most hospitals, UVA wasn't using property liens to foreclose on patients' homes. But it was seizing money owed — plus 6% interest — from home equity when home sales went to settlement.

In response to KHN's investigation, UVA said in 2019 it would improve financial assistance but continue to use the courts to recover money owed from families making more than 400% of the poverty threshold.

While unusual, UVA's decision to substantially reduce lawsuits and erase liens stops short of moves recently made by VCU Health, its sister system based at another state university. VCU pledged to stop suing all patients and, in a process taking more than a year in courthouses across Virginia, is abolishing all old judgments and liens regardless of a family's income.

"This seems like many steps in the right direction" for UVA, said Jenifer Bosco, an attorney at the National Consumer Law Center who specializes in health care. "There is always more that could be done. But providing assistance to families with income of up to 400% of the poverty level is a great step."

The number of outstanding UVA Health judgments is unknown. For its part, VCU eventually found about 80,000 statewide. In Virginia, liens expire after 20 years, but UVA was taking the trouble to renew claims dating to the 1990s, KHN found.

Canceling them should take more than a year, Lischke said. UVA's changes to billing and collections, including improvements to financial assistance announced in late 2019, will cost the system about $12 million a year, he said.

UVA's move is far more beneficial to its patients and its region than other so-called community benefits that many nonprofit hospitals offer to justify their tax-exempt status, said Ge Bai, associate professor at Johns Hopkins Bloomberg School of Public Health.

Instead of testing services or medical education that are often hospital marketing campaigns in disguise, "this action is a concrete effort to relieve the financial burden of the community," she said. "It also improves mental health. It relieves the stress."

Jay Hancock: jhancock@kff.org, @JayHancock1

Humana Health Plan Overcharged Medicare by Nearly $200M, Federal Audit Finds

KFF Health News, April 20, 2021

The OIG's recommendation to repay, if finalized, would be "by far the largest" audit penalty ever imposed on a Medicare Advantage company.

This article was published on Tuesday, April 20, 2021 in Kaiser Health News.

By Fred Schulte

A Humana Inc. health plan for seniors in Florida improperly collected nearly $200 million in 2015 by overstating how sick some patients were, according to a new federal audit, which seeks to claw back the money.

The Health and Human Services Office of Inspector General's recommendation to repay, if finalized, would be "by far the largest" audit penalty ever imposed on a Medicare Advantage company, said Christopher Bresette, an HHS assistant regional inspector general.

"This [money] needs to come back to the federal government," he said in an interview.

Humana sharply disputed the findings of the audit, which was set for public release Tuesday. A spokesperson for the company said Humana will work with Medicare officials "to resolve this review," and noted the recommendations "do not represent final determinations, and Humana will have the right to appeal."  

Medicare Advantage, a fast-growing private alternative to original Medicare, has enrolled more than 26 million people, according to America's Health Insurance Plans, an industry trade group. Humana, based in Louisville, Kentucky, is one of the largest of these insurers, with about 4 million members.

While popular with seniors, Medicare Advantage has been the target of multiple government investigations, Department of Justice and whistleblower lawsuits and Medicare audits that concluded some plans boosted their government payments by exaggerating the severity of illnesses they treated. One 2020 report estimated improper payments to the plans topped $16 billion the previous year.

But efforts to recover even a tiny fraction of the overpayments in past years have stalled amid intense industry opposition to the government's audit methods.

Now the OIG is rolling out a series of audits that could for the first time put health plans on the hook for refunding tens of millions of dollars or more to Medicare. The OIG is planning to release five to seven similar audits within the next year or two, officials said.

The Humana audit, conducted from February 2017 to August 2020, tied overpayments to medical conditions that pay health plans extra because they are costly to treat, such as some cancers or diabetes with serious medical complications.

Auditors examined a random sample of 200 patients' medical charts to make sure that the patients had the diseases the health plans were paid to treat, or that the conditions were as severe as the health plan claimed.

For instance, Medicare paid $244 a month, or $2,928 for the year, for one patient said to be suffering from serious complications of diabetes. But medical records Humana supplied failed to confirm that diagnosis, meaning the health plan should have received $163 less per month for the patient's care, or $1,956 for the year, according to the audit.

Similarly, Medicare paid $4,380 too much in 2015 for treatment of a patient whose throat cancer had been resolved, according to the audit. In other cases, however, auditors said Medicare underpaid Humana by thousands of dollars because the plan submitted incorrect billing codes.

In the end, auditors said Medicare overpaid Humana by $249,279 for the 200 patients whose medical charts were closely examined in the sample. Auditors used a technique called extrapolation to estimate the prevalence of such billing errors across the health plan.

"As a result, we estimated that Humana received at least $197.7 million in net overpayments for 2015," the audit states, adding that Humana's policies to prevent these errors "were not always effective" and need improvement.

The OIG notified Humana of its findings in September 2020, according to the audit. A final decision on collecting the money rests with the Centers for Medicare & Medicaid Services, or CMS, which runs Medicare Advantage. Under federal law, the OIG is responsible for identifying waste and mismanagement in federal healthcare programs but can only recommend repayment. CMS had no comment.

Though controversial, extrapolation is commonly used in medical fraud investigations — except for investigations into Medicare Advantage. Since 2007, the industry has criticized the extrapolation method and, as a result, largely avoided accountability for pervasive billing errors.

Industry protests aside, OIG officials say they are confident their enhanced audit tools will withstand scrutiny. "I believe what we have here is solid," OIG official Bresette said.

Michael Geruso, an associate professor of economics at the University of Texas-Austin, who has researched Medicare Advantage, said extrapolation "makes perfect sense," so long as it is based on a random sample.

"It seems like this is a healthy step forward by the OIG to protect the U.S. taxpayer," he said.

The OIG used the extrapolation technique for the first time in a February audit of Blue Cross and Blue Shield of Michigan that uncovered $14.5 million in overpayments for 2015 and 2016. In response, Blue Cross said it would take steps to ferret out payment mistakes from other years and refund $14.5 million. Blue Cross spokesperson Helen Stojic said that process "is still pending."

But Humana, with a lot more money on the line, is fighting back. Humana "takes great pride in what the company believes to be its industry-leading approach" to ensuring proper billing, Sean O'Reilly, a company vice president, wrote in a December 2019 letter to the OIG that blasted the audit.

O'Reilly wrote that Humana "has never received feedback from CMS that its program is deficient in any respect."

The nine-page letter argues that the audit "reflects misunderstandings related to certain statistical and actuarial principles, and legal and regulatory requirements." Requiring Humana to repay the money "would represent a serious departure from the statutory requirements underlying the [Medicare Advantage] payment model," the company said.

Humana did persuade the OIG to shave off about $65 million from its initial estimate of the overpayment. In 2015, Medicare paid the plan about $5.6 billion to treat about 485,000 members, mostly in South Florida.

Humana is not alone in disapproving of the audits.

AHIP, the industry trade group, has long opposed extrapolation of payment errors, and in 2019 called a CMS proposal to start doing it "fatally flawed." The group did not respond to requests for comment.

Healthcare industry consultant Richard Lieberman said insurers remain "vehemently opposed" and will likely head to court to try to sidestep any multimillion-dollar penalties.

Lieberman noted that CMS has "waffled" in deciding how to protect tax dollars as Medicare Advantage plans have grown rapidly and cost taxpayers more than $200 billion a year. CMS says it has yet to complete its own audits dating to 2011, which are years overdue.

The dispute has been largely invisible to patients, who are not directly affected by overpayments to the plans. Many seniors sign up because Medicare Advantage offers benefits not included in original Medicare and may cost them less out-of-pocket, though it restricts their choice of doctors.

But some critics argue that inaccurate medical files pose a risk of improper treatment. Dr. Mario Baez, a Florida physician and whistleblower, said seniors can be "placed in harm's way due to false information in their medical records."

Fred Schulte: fschulte@kff.org, @fredschulte

Snag a Vaccine Appointment, Then Face the Next Hurdle: How to Get There?

KFF Health News, April 19, 2021

Some people have found it hard to get to a vaccine appointment a few miles away.

This article was published on Monday, April 19, 2021 in Kaiser Health News.

By Rae Ellen Bichell

The airport says a lot about Cortez, Colorado: The single-engine planes that fly into its one-room airport seat nine passengers at most. The city of about 9,000 is known largely as a gateway to beautiful places like Mesa Verde National Park and the Four Corners Monument. But COVID vaccines have made Cortez a destination in its own right.

"We had a couple fly in to get their vaccine from Denver that couldn't get it in the Denver metro area," said Marc Meyer, director of pharmacy services and infection control for Southwest Health System, which includes clinics and a community hospital in Cortez. Others have come from neighboring states and as far away as California, Florida and the Carolinas. "They all come back for their second dose," he said. "Because it's so hard to get in the cities."

With vaccines now becoming available to the general public in much of the country, the privilege of easy access is coming into sharper focus. On the most extreme end, vaccine tourists with means can nab inoculations, as Forbes has reported, in places such as Israel, the United Arab Emirates and even Cuba, where ads offered "mojitos and vaccine." On the flip side, some people have found it hard to get to a vaccine appointment a few miles away.

In fact, around the same time people were flying into Cortez to get their shots, Meyer said, some locals couldn't get to vaccine locations. That was particularly true for people who are homebound or homeless.

So Meyer and his colleagues came up with a vaccine SWAT team of sorts, composed of paramedics and a handful of ambulances stocked with vaccine vials. The team visited about 40 homebound people. For 30 or so people who are homeless in the area, Meyer snagged leftover doses of the single-dose Johnson & Johnson vaccine from a nearby county.

But he said he doesn't know if his team got to everyone who wanted vaccines. "The problem with health disparities in rural areas is there's no data," he said. "It would be really helpful to know how many people have transportation issues."

A KHN analysis of Colorado health department data shows that by the end of March about 43% of Coloradans who had received their first doses, and had addresses on file, got those shots outside of their home county. At least 60,000 Coloradans — about as many people as live in Grand Junction, the biggest city in western Colorado — got their first vaccine dose 50 or more miles away, as the crow flies, from their home ZIP codes.

And the state vaccinated more than 20,000 people from out of state — tourists, traveling nurses, cross-border dwellers and others whose primary residence is elsewhere — about 1% of the total number of people who had received first doses by April 1 in Colorado.

Other states have noticed similar migrations. Missouri, for example, saw an exodus of urbanites to rural areas in search of vaccines, leading critics to say doses had been misallocated in a way that neglected cities such as St. Louis.

But traveling for a vaccine requires money, flexibility with one's time and a vehicle. Transportation was a health issue even before the pandemic, said Lori Tremmel Freeman, CEO of the National Association of County and City Health Officials. Researchers writing in the American Journal of Public Health found that, in 2017 alone, 5.8 million people in the U.S. delayed medical care because they lacked transportation. This group was disproportionately poor and had chronic health conditions.

Access issues, Freeman said, are likely being mischaracterized as vaccine hesitancy. Even some who live in cities with robust public transportation and ride-hailing services have found themselves jumping through hoops to get to a vaccine appointment.

Bob McIntyre, 81, lives in Denver in an apartment close enough to a major highway that the traffic "sounds like ocean waves in the distance." But he doesn't have a car. "It's just too expensive," he said. Before the pandemic hit, McIntyre could walk or take public transit. With the coronavirus circulating, though, he'd rather not be closed in a box with a bunch of strangers. "So, I've been hermitized."

Ride-hailing companies Uber and Lyft have offered free rides to vaccine appointments, but McIntyre doesn't feel safe using those services. He eventually learned of A Little Help, a nonprofit that offers everything from free yardwork to rides for COVID vaccine appointments. Volunteer drivers took him to both of his vaccine slots, which were about 15 minutes from his home but otherwise would have remained out of reach.

Maggie Lea, director of programs at Mile High Connects, worries others may not be as lucky. Her organization believes more affordable and accessible transportation is key to achieving a racially and economically equitable Denver — especially right now.

"There are people who may or may not be motivated already to get the vaccine," she said. "If they don't have access to transport, or it's particularly expensive for them to get over there, or burdensome for them to get to a vaccine site, we're noticing that they just won't go."

Transit systems can use federal COVID relief funding to help people get their vaccines, said Amy Conrick, director of the National Center for Mobility Management.

In West Texas, the SPARTAN public transit agency offers free rides to COVID vaccine appointments, including many at its headquarters.

In Oxford, Ohio, older adults can get vaccinated by nurses aboard buses that accommodate oxygen tanks and wheelchairs. The city set up a hotline for residents to schedule their vaccine and transportation in one call.

"We live in a rural community where some people just don't have internet," said Assistant City Manager Jessica Greene.

Transit systems need to talk to public health officials, Conrick said. "Now is the time," she said. "Well, actually, yesterday was the time."

But many places lack decent public transit. For them, Freeman of NACCHO imagines COVID shots waiting anywhere people congregate, even at NASCAR races, once the supply increases. "You should be able to just turn in any direction and be able to get a vaccine," she said.

For now, demand is so high that vaccines go into arms as soon as they are available, Freeman said, but soon public health officials will have plenty of vaccine but a shrinking group of people who want to bother getting it. "We will hit a hard stop where we're looking full face onto the universe of people that do not want to get the vaccine."

Then, she said, it will be even more important for vaccination to not only be possible, but for it to be easy.

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

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