Montana's rate of COVID vaccines given is in the top tier in the nation.

This article was published on Monday, April 5, 2021 in Kaiser Health News.

By Katheryn Houghton Photos by Tailyr Irvine

MISSOULA, Mont. — Montana's COVID-19 vaccine distribution is among the most efficient in the nation, but closer examination reveals a patchwork of systems among counties and tribal governments that will be put to the test as the state opens vaccine eligibility to all people 16 and older starting this month.

KHN, Montana Free Press and the University of Montana School of Journalism surveyed all 56 counties and eight tribal governments to find out how vaccine distribution has worked over the past four months and what residents might expect when the floodgates open.

Montana's rate of COVID vaccines given is in the top tier in the nation, according to the Centers for Disease Control and Prevention. More than 186,500 people — roughly 17% of the state's population — had been fully vaccinated by the end of March. But that progress papers over a disjointed rollout that's been left to individual public health departments that are already overstretched. An increasing number of employees have resigned after working long hours while being harassed and blamed for enforcing COVID restrictions such as mask mandates. At least 10 counties have lost their top health official in the past year, though many more public health workers have left jobs.

The pressure remains as larger shipments of vaccines arrive and highly contagious variants of the coronavirus spread in Montana. More pharmacies are coming online to administer doses, which is expected to help in the race to vaccinate Montanans. But the task of ensuring everyone who wants a shot gets that chance will likely continue to fall on local health officials.

For those seeking vaccines, the process can be bewildering. In Missoula County, Dennis Klemp qualified early on for the shot as an 81-year-old with kidney disease. Klemp, who doesn't have a computer, put the county's health department on his phone's speed dial and called daily, but he was unable to secure a spot in vaccination clinics that filled within minutes.

"I was pretty despondent," Klemp said. "There was mass confusion, and I've got a lot of friends who were just as confused as I was."

After spending more than a month trying to book an appointment, Klemp called his local television station for help in February. NBC Montana reporter Maritsa Georgiou said she managed to book an appointment for him over the phone, and she estimated she similarly helped at least 30 others register for vaccines.

There are multiple ways to get a vaccine in Montana. Tribal governments are getting doses to Native Americans and some are also vaccinating non-Natives either through the state or the federal Indian Health Service program. The U.S. Department of Veterans Affairs is a source for veterans, their spouses and caregivers. Federally contracted pharmacies are giving vaccines to the general public after distributing shots in assisted living centers.

For counties and tribes that participate in the state program, a mishmash of strategies has resulted in the absence of a detailed state plan to sign up people for doses. Montana's patchwork approach is no accident. State leaders deliberately left it up to local governments with few rollout guidelines because they said local leaders know best how to reach their residents.

Some states have set up one-stop vaccine registration systems to bring order to the scramble of the largest vaccine effort in history. But Jim Murphy, head of Montana's Communicable Disease Control and Prevention Bureau, said that a pandemic wasn't the time to force a new system on local governments, and that Montana's approach is working.

"Most of our major providers already have those systems built, so we weren't going to say, 'Well, here's another big road you can take,'" Murphy said. "Just didn't seem like it would be worth that effort."

Nicholas Stewart, a senior research scientist at the international health data nonprofit Surgo Ventures, said Montana's high national ranking, despite its lack of a unified system, has been a surprise.

Montana's success may be partly due to officials' familiarity with the inherent challenges that come with delivering healthcare in the fourth-largest state by land, yet eighth-smallest state by population. Public health workers have long worked to reach isolated people and spot hurdles to accessing care, such as a lack of internet access.

Ideally, states would test different scenarios before expanding vaccine eligibility, but needs have rapidly shifted. "What we have constantly been seeing is decisions are being made on the fly," Stewart said.

In Carter County, in the southeastern corner of the state, early vaccine efforts faltered because nobody was on hand to administer the shots. The area's health officer resigned in mid-December and the county had been without a public health nurse since summer. In January, residents eligible for a shot had to drive to neighboring Fallon County, where Carter County had sent its allotment of vaccines to prevent wasting doses.

Trish Loughlin, Carter County's interim public health nurse, has led the vaccine effort part time since late January. Despite the initial lag, Loughlin said, the county is catching up and everyone who wants a dose should be able to get one by early April.

"The collaboration of a neighboring county is what helped; it's the only way we did that," Loughlin said.

Fallon County's health director also resigned in December. Mindi Murnion, Fallon County's public health specialist, said residents angry about pandemic-related rules drove out the health director before the county got its first supply of COVID vaccines.

"There was a little bit of panic," Murnion said. "But after we got through that first clinic, now we whip it out like clockwork."

She said she's relieved the state let Fallon create its own vaccine plan, which includes calling people already in its system to book appointments and working with other counties to move doses based on need.

"It might not be the way everybody else does stuff, but it's the way we do stuff," Murnion said.

In larger counties, a major hurdle is making sure all residents can navigate systems in which they're competing with thousands for appointments.

Despite Klemp's difficulty making an appointment by phone, Missoula County set aside 20% of available vaccine appointments for seniors without internet access, according to Adriane Beck, Missoula County's emergency management director. The county also held an outreach campaign using nonprofit agencies, utility bill inserts and ads run by newspapers and radio and television stations to prod people to make appointments by phone.

But, to the dismay of some, the county doesn't offer a vaccine waitlist for people struggling to book an appointment.

"From a logistical and just a management perspective, we were not going to be successful and we were not going to meet people's expectations," Beck said.

She said making vaccines available to all people over 16 may complicate access for more vulnerable groups until supplies increase. An effort is underway, she said, to reach "stragglers" and homebound residents.

The Flathead Nation's Confederated Salish and Kootenai Tribes have outpaced many Montana counties when it comes to vaccine distribution, despite what Health Director Chelsea Kleinmeyer described as a low initial allocation by the state to the tribes. Weeks before the state's April 1 expansion of eligibility to the general population, tribal health officials were offering shots to all adult tribal members along with descendants and other Native Americans.

Kleinmeyer said tribal health officials relied heavily on community health representatives to identify and contact vulnerable elders. Health officials eventually worked their way to anyone living in an American Indian household along with tribal and nontribal teachers and employees. The Salish and Kootenai Tribes had planned to vaccinate approximately 12,000 people.

"We feel like maybe we hit this saturation point with tribal people on the reservation," Kleinmeyer said, adding the tribe is now preparing to help nearby counties.

Silver Bow County is using its civic center ticketing system, usually used for concerts and sporting events, as one way to schedule vaccine appointments.

"We thought, if you could get a ticket to go to a basketball game, why couldn't we do that here? And it worked," said Karen Sullivan, health officer for Butte-Silver Bow County.

Sullivan said the overall joy that people exhibit at vaccine clinics has been a bright spot during a difficult period. The past year has been one of threats and verbal attacks against her and her staffers for implementing COVID restrictions. Sullivan, 62, said she's considering early retirement after seeing the vaccine rollout through.

"I'm not gonna leave in the middle of this," Sullivan said. "When we get to the point where we have a great percentage of our people vaccinated, I'll give retirement some serious thought. I need the rest."

Eric Dietrich and Chris Aadland of Montana Free Press and Andrea Halland, Antonio Ibarra Olivares, Aidan Morton and Addie Slanger of the University of Montana School of Journalism contributed to this report.

Katheryn Houghton: khoughton@kff.org, @K_Hought

Some of the nation's richest hospitals and health systems recorded hundreds of millions of dollars in surpluses after accepting the lion's share of the federal healthcare bailout grants.

This article was published on Monday, April 5, 2021 in Kaiser Health News.

By Jordan Rau and Christine Spolar

Last May, Baylor Scott & White Health, the largest nonprofit hospital system in Texas, laid off 1,200 employees and furloughed others as it braced for the then-novel coronavirus to spread. The cancellation of lucrative elective procedures as the hospital pivoted to treat a new and less profitable infectious disease presaged financial distress, if not ruin. The federal government rushed $454 million in relief funds to help shore up its operations.

But Baylor not only weathered the crisis, it thrived. By the end of 2020, Baylor had accumulated an $815 million surplus, $20 million more than it had in 2019, creating a 7.5% operating margin that would be the envy of most other hospitals in the flushest of eras, a KHN examination of financial statements shows.

Like Baylor, some of the nation's richest hospitals and health systems recorded hundreds of millions of dollars in surpluses after accepting the lion's share of the federal healthcare bailout grants, their records show. Those included the Mayo Clinic, Pittsburgh's UPMC and NYU Langone Health. But poorer hospitals — many serving rural and minority populations — got a tinier slice of the pie and limped through the year with deficits, downgrades of their bond ratings and bleak fiscal futures.

"A lot of the funding helped the wealthy hospitals at a time, especially in New York, when safety-net hospitals were hemorrhaging," said Colleen Grogan, a health policy professor at the University of Chicago. "We could have tailored it to hospitals we knew were really suffering and taking on a disproportionate amount of the burden."

In Baylor's case, the system, which runs Baylor University Medical Center in Dallas and 51 other hospitals, said it spent $257 million last year on pandemic-related costs, including protective clothing for employees and patients and creating isolation rooms. Baylor has $197 million in unspent federal relief funds to use this year to cover costs of battling the virus and refrigerating vaccines, it said.

"Our COVID-19-related expenses and lost revenue continue to exceed the funding we have received to date," Baylor said in a statement to KHN.

Other well-heeled hospitals or large systems faced bigger problems. Both NewYork-Presbyterian Hospital and CommonSpirit Health, a 140-hospital Catholic system that operates in 21 states, lost money despite federal grants in the vicinity of a billion dollars each. A few systems, including the for-profit chain HCA Healthcare, returned federal funds when they saw they had skirted their worst-case scenarios. But most spent the aid and held onto any leftover money and new grants to cover anticipated pandemic costs this year because hospital executives fear more case spikes.

Much of the lopsided distribution was caused by the way the Department of Health and Human Services based the allotment of the initial bailout funds on hospitals' past revenue. That favored institutions with well-off patients who have private health plans over those that rely on lower-paying government insurance, which is what many poor people use.

HHS distribution formulas did not take into account which hospitals had enough assets to survive.

Baylor, for instance, began 2020 with $5.4 billion in cash and investments, enough to keep it running for 238 days, the financial disclosures show.

Hospitals that ended the year with profits were entitled to federal aid because of the extraordinary latitude Congress and HHS set in how hospitals could classify their pandemic costs.

Last fall, when HHS attempted to limit how much aid hospitals could keep based on their profits — so the money could be redirected to struggling hospitals — the effort was swiftly beaten back by the industry and Congress. HHS officials declined requests for an interview but noted in a statement that Congress had ordered it to revert to its "broader definition of permissible use of PRF funds."

"The Biden Administration continues to review programs and policies including considerations for the unallocated funding under the PRF program and the $8.5 billion recently appropriated under the recently signed American Rescue Plan Act," the statement said.

Avoiding a Drawdown of Reserves

The bailouts were initiated last spring to help healthcare providers ride out a once-in-a-century public health calamity. The money designated to hospitals and other healthcare providers from the Coronavirus Aid, Relief, and Economic Security (CARES) Act and subsequent legislation totaled $178 billion.

It was intended to offset all costs of treating infected patients, including purchasing ventilators, masks, gowns and other personal protective equipment. Congress further authorized hospitals to use the money to compensate for a drop in revenue when they shut down elective surgeries and non-emergency treatments to prepare for the anticipated deluge of COVID-19 patients.

The money, referred to as the Provider Relief Fund, helped many poorer hospitals avert cash crunches, layoffs and bond rating downgrades. A survey by the consulting firm Kaufman Hall found that the median hospital gain during 2020 would have been 0.3% without the federal support. With it, half of hospitals posted gains of 2.7% or more, below the 2019 median margin of 3.1%, according to the firm, which also produces analytic work for the American Hospital Association.

In February, the association urged Congress to replenish the nearly empty relief fund, saying, "hospitals have never experienced such a widespread, national health crisis."

Some hospitals' finances deteriorated significantly during the pandemic. From the end of March through December, the rating agency Moody's downgraded 28 hospitals, primarily because of weaknesses such as higher debt or more competition, said Lisa Goldstein, associate managing director at Moody's.

Others suffered worse fates, like Williamson Memorial Hospital, which shut down last April. The hospital, in West Virginia's coal country, had been trying to climb out of bankruptcy protection, but "unfortunately, the decline in volumes experienced from the current pandemic were to[o] sudden and severe for us to sustain operations," its CEO wrote on Facebook.

Conversely, many prosperous health systems emerged unscathed from the moratoriums of last spring, often due to the federal aid. "It gave them an ability to not have to draw down on their reserves to make up for the loss in revenue," said Suzie Desai, a senior director at S&P Global Ratings.

Systems saw patient visits return to near normal as the year wore on. In some cases, business in the latter half of 2020 was even higher than in the same period in 2019 because of pent-up demand for treatments postponed from the spring, financial records show.

"We saw volumes spring back" in every area except emergency room visits, said Kevin Holloran, a senior director at Fitch Ratings. Major hospital systems also reported that cases tended to be more complex than normal, leading to higher insurance payments.

UPMC accepted $460 million in bailout funds while collecting $2.5 billion more in revenue in 2020 than in 2019. The nonprofit system ended the year with an $836 million operating surplus — providing a 3.6% margin that was triple the prior year's — in part due to the growth of the health insurance plan the system owns.

Other hospitals that sold insurance, including Baylor, persevered because the cause of their financial troubles — fewer surgeries and doctors' visits — meant the health plans paid fewer claims.

UPMC's strong finances went unmentioned in a recent fundraising pitch announcing the launch of its "Healthcare Heroes" campaign. "During the past year, healthcare workers have carried the weight of the world on their shoulders, risking their own health and safety to ensure ours as we navigated the COVID-19 pandemic," the email said. "Now it's our turn to recognize their hard work. … By making a donation, you will help provide training, recognition, and support for our staff initiatives."

Donald Yealy, a senior vice president of UPMC and the chief medical officer of UPMC Health Services, said the fundraising appeal was a way to allow people in the community to show their appreciation.

"The intent of the request and the letter were clear. People are free to ignore or to have an opinion. I don't begrudge that at all. I respect people having a different opinion," he said.

Hospitals can hold on to unspent relief funds until the end of July to defray any further pandemic-related costs. After that, any unspent money must be returned to the U.S. Treasury. UPMC retains $80 million in unspent relief funds, which the health system said it expects to use. "We're still in the process of incurring significant costs related to COVID," said Edward Karlovich, UPMC executive vice president and chief financial officer.

'A Shot in the Arm' Sometimes Unneeded

In April 2020, the Mayo Clinic in Rochester, Minnesota, forecast up to $3 billion in lost revenue because of the pandemic. Instead, Mayo, which received $338 million in federal relief funds, ended the year with revenue that was $202 million higher than in 2019. Mayo recorded a $728 million surplus, which equaled a 5.2% margin.

"It gave us a shot in the arm when we needed it," said Dennis Dahlen, Mayo's chief financial officer. Later, when it seemed likely Mayo would run a surplus, executives debated what to do with the federal funds.

"Honestly, we considered dropping the margin," Dahlen said. After weighing their options, Mayo "landed in a middle-of-the-road decision" by returning $156 million to the federal government.

"We considered it with what everyone else was doing … and we thought about what was good for society," Dahlen said. "'Nonprofit' doesn't really mean no profit. It means tax-exempt. We still have to create earnings so we can reinvest in ourselves."

Mayo ended the year with $14 billion in investments, $3 billion more than it had in 2019, a 29% increase.

The funds were, indeed, a lifesaver for some. Marvin O'Quinn, president and chief operating officer of CommonSpirit Health, said "there was never a thought of turning back the money."

Despite receiving $1.3 billion in relief funds, CommonSpirit, based in Chicago, ended last year with a $75 million deficit, which translated to a 0.2% loss.

"We have been set back by a year," O'Quinn said. "All the things we wanted to do — to renovate, to building new facilities, to expand our service — we've had to slow up to get through the crisis."

Scattershot Relief

The first $50 billion in relief funds "was sent out indiscriminately as a life support," said Ge Bai, an associate professor at Johns Hopkins Bloomberg School of Public Health. HHS tried to target subsequent distributions. It sent $22 billion to 1,090 hospitals with large numbers of COVID patients. It sprinkled an additional $16 billion among hospitals that serve poor populations, Native American tribes, people in rural areas and children.

But even with the targeted aid, recipients included well-endowed academic medical centers and major urban hospitals. Only $14 billion took profitability into consideration, HHS documents show. HHS restricted those payments to hospitals with 3% or lower profit margins.

Wealthy hospitals also benefited because HHS used a broad definition of lost revenue. If a hospital earned less than in the year before, or simply less revenue than it had budgeted for, it could chalk up that difference to the pandemic and apply the relief funds to it. The implications garnered little attention at the time as they were overshadowed by the concerns about how HHS was doling out the money rather than how it could be used.

In September, HHS attempted to tighten its overall limits on how much money the hospitals could keep by basing it on the difference from the previous year's net income rather than overall revenue — a number that in many cases would be much lower. The goal, the department said, was to "prohibit most providers from using PRF [Provider Relief Fund] payments to become more profitable than they were pre-pandemic, to conserve resources to allocate to providers who were less profitable."

The American Hospital Association complained that would punish hospitals that had behaved responsibly by cutting costs and be an "administrative and accounting disaster," as many hospitals had already spent the grant money.

HHS backed down a month later, citing "significant attention and opposition from many stakeholders and Members of Congress." Not fully satisfied, Congress cemented the rollback in a December law.

Some hospital executives attributed their surpluses to their aggressive cost-cutting measures.

NYU Langone Health, for instance, received $461 million in relief funds, which covered about a third of its pandemic-related losses, said Daniel Widawsky, chief financial officer. Another third of Langone's losses was absorbed by the record-high financial performance in the months before the pandemic, he said, and prompt cost control addressed the rest.

Widawsky said that at the beginning of March Langone canceled travel, froze hiring, paused construction and stopped discretionary purchases. "The first three days in March, we locked down spending," he said. "If they wanted to buy a pencil, they had to call me." Langone ended its fiscal year in August with $208 million in net income, and recorded a $136 million surplus in the final quarter of 2020, or 5.5%. Earlier this year, two credit agencies upgraded their outlook on Langone from stable to positive.

Despite accepting $942 million in bailout funds, NewYork-Presbyterian Hospital had a $457 million operating deficit, a 7% loss, at the end of September. It was a sharp turn from September 2019, when the system recorded a $166 million surplus, a 2.5% gain.

The system, which declined to comment, has not yet released its financial metrics for the final three months of 2020, but Fitch projected it would remain in the red. Still, NewYork-Presbyterian remains fiscally solid: Its most recent disclosure reported $3.8 billion in cash and short-term investments, enough to keep operating for more than a year.

Jordan Rau: jrau@kff.org, @JordanRau

The rollout of vaccinations in California, as in many states, has been slow and chaotic. More than 5 million of the 24 million adults in the nation’s most populous state have been at least partially vaccinated, while an additional 5.6 million are fully vaccinated.

This article was published on Friday, April 2, 2021 in Kaiser Health News. This story also ran on Black Voice News.

By Anna Almendrala

Leonor Garcia held her clipboard close to her chest and rapped on the car window with her knuckles. The driver was in one of dozens of cars lined up on a quiet stretch of road in Adelanto, California, a small city near the southwestern edge of the Mojave Desert. He was waiting for the food bank line to start moving and lowered the passenger window just enough to hear what Garcia wanted. Then she launched into her pitch.

“Good morning! We’re here to talk about covid-19 today! Do you have a minute?” she said in Spanish.

After a brief conversation, Garcia learned the man had no internet connection or phone of his own but was 66 years old and wanted to get the covid vaccine. He had tried to visit a pharmacy in person, but the shots were all out for the day. Garcia took down his name and the phone number of a friend, so she could reach the driver later about a mobile vaccine clinic that her organization, El Sol Neighborhood Educational Center, was putting together for the remote desert city sometime in April.

Then it was on to the next car. And the next. As the line started moving, she and fellow health worker Erika Marroquin jogged up and down the sidewalk, taking down names, phone numbers and preexisting conditions. It was the first mild, sunny day the High Desert region had seen in weeks, and the exercise made them sweat.

After 90 minutes, the food bank was done for the day, and Garcia and Marroquin had spoken to people in 54 cars. They had found six people eager for the covid vaccine and eligible for it immediately. Ten more wanted to be put on a waiting list for leftover doses.

The rollout of vaccinations in California, as in many states, has been slow and chaotic. More than 5 million of the 24 million adults in the nation’s most populous state have been at least partially vaccinated, while an additional 5.6 million are fully vaccinated. Come April 15, all adults in California will be eligible to sign up for a vaccine, and by early summer the goal is to have plenty of vaccine for any adult who wants it.

But the country needs to get the vaccination rate to about 75% to keep the virus from easily spreading — a level called herd immunity by experts on infectious diseases. But even that figure assumes the population is homogenous in terms of vaccination. That’s why the state’s ability to stave off another covid surge may rely on people like Garcia and Marroquin — community health workers and organizers doing time-intensive, laborious work — to prevent pockets of the population with low vaccination rates in remote or isolated communities from becoming a tinderbox for a new covid surge.

“When you have geographical or social pockets of unvaccinated people, it really messes up herd immunity,” said Daniel Salmon, director at the Institute for Vaccine Safety at Johns Hopkins University’s Bloomberg School of Public Health.

U.S. measles outbreaks in recent years provide a sobering example. State and national vaccine coverage is quite high, “but then you’d have these communities where a lot of people would refuse vaccines, and then measles would be imported and create an outbreak,” Salmon said. Outbreaks have hit certain Orthodox Jewish communities in New York, Somali immigrants in Minnesota and affluent pockets of Southern California where anti-vaccine parents lived.

The coronavirus is still circulating widely in California, though at much lower levels than two months ago. The virus, especially an increasingly common, more contagious variant, could easily rip through vulnerable communities with low levels of immunity. In Adelanto, where 29% of residents live in poverty, less than 6% of the adult population had been fully vaccinated by March 20.

As of March 26, most of the more than 15.9 million vaccine doses distributed since December had gone to the healthiest, wealthiest places in the state. Community-based organizations like nonprofits and churches are clamoring for more funding — and trust — to carry the vaccine the final mile to the people they’ve been serving for years.

El Sol’s success in getting Black, Latino and other underrepresented populations vaccinated debunks the idea that these groups won’t get the shot, said Juan Carlos Belliard, assistant vice president for community partnerships at Loma Linda University Health in San Bernardino County. Loma Linda is collaborating with El Sol to staff and provide doses for clinics. The people who show up are ready for their vaccine, though some are a bit hesitant, he said.

“They’re not like our middle-class folks who are literally crying for the vaccine,” Belliard said. “These folks are still nervous about it, but you’ve removed almost all of these other barriers for them.”

El Sol’s community workers were supported by a $52.7 million combined effort from state and philanthropic funding that provided grants to 337 organizations considered “trusted messengers” in their communities. The money was pushed out to groups like El Sol that had proven track records of shoe-leather canvassing for voter registration or census surveys.

El Sol received $120,000 from the public-private initiative to support its general outreach and educational efforts for covid vaccination. But the group was in the dark about whether it would get any reimbursement for the mobile vaccination events it has organized in San Bernardino County, said executive director Alex Fajardo.

El Sol held a pop-up vaccination event Feb. 17 at Centro Cristiano Luz y Esperanza, a church located off a two-lane expressway in Adelanto, surrounded by desert scrub. Medical staffers, students and vaccines arrived from Loma Linda University Health, about an hour away, to vaccinate 250 people, and returned a month later to give people their second doses.

Patricia Perez, 47, and Rosa Hernandez, 69, a mother-daughter pair, were among those who got their vaccines at Centro Cristiano.

Perez’s father, who works in a supermarket dairy department, fell ill with covid in June and was unable to return to work for six months. No one else in the seven-member household ended up testing positive, but Rosa Hernandez is a cancer survivor and her daughter was worried about her.

Despite multiple calls to a county phone line, Perez had been unable to line up a vaccine for her mom. The family’s internet connection, in the nearby town of Hesperia, was spotty, and Perez couldn’t really navigate the websites or find any information in Spanish, the language she’s most comfortable with.

She jumped at the chance when she heard about El Sol’s pop-up event through someone at her church. Perez also managed to snag an additional dose for herself after someone didn’t show up for their appointment. Now she and her mom are fully vaccinated, Perez said, and it wouldn’t have happened without El Sol.

The group plans to do three more vaccination pop-ups in the High Desert area. But future support for its clinics, vaccine outreach and education are murky, said Fajardo.

“What is going to happen after?” he said. “When we need you, we pay you. When we don’t need you, ‘Bye-bye.’”

“That’s a very fair assessment,” said Susan Watson, program director for the Together Toward Health initiative of the Public Health Institute, the philanthropic funder behind some of El Sol’s work. “There’s an opportunity here for people to be thinking about the future, and how we do things that doesn’t necessarily leave community groups permanently on the outside, only tapped into when there’s an emergency.”

Community Coalition, a South Los Angeles nonprofit founded in 1990, also received grants from the public-private partnership to raise awareness about covid vaccines, but no additional funding to deliver vaccines to the people. Still, it mobilized staff to knock on doors, text and email eligible people to turn out for a two-week pop-up vaccination event at a neighborhood park in early March — providing 4,487 people with their first vaccine dose, said the group’s chief operating officer, Corey Matthews.

Dr. Mark Ghaly, the state’s secretary for health and human services, promised to provide more money for groups that are getting their communities vaccinated. “This is not a volunteer job,” he told KHN at a news briefing. “This is real work, and I want to be part of the team that makes that a reality for all of them.”

Los Angeles County department of public health Director Barbara Ferrer echoed that sentiment. “They were there before the pandemic started, they’ve been there the entire time during the pandemic, and they’ll be here long after the pandemic,” she said.

Whether or not those promises hold up, community groups say, they want to be part of the vaccination effort.

“Even if they don’t give us money, we’ll keep doing the work,” said Fajardo.

Even though critically ill patients now must travel to hospitals farther away, Fort Scott residents haven't seen that as a pandemic-related problem.

This article was published on Thursday, April 1, 2021 in Kaiser Health News. This story also ran on NPR.

By Sarah Jane Tribble

At 70, Linda Findley has long been active in her small town of Fort Scott, Kansas, which sits more than an hour away from any major city.

Findley, whose husband died in an accident just after the local hospital closed, helps with the Elks and fundraising, and — like many people in this part of the country — doesn’t think covid-19 is that dangerous.

“I don’t even know what I think about it,” Findley said recently. “I don’t know if I trust the testing because it’s so messed up or … I’ve had nieces and nephews, that’ve had it. I’ve lost good friends to it, or supposedly it’s to that.”

Findley said she just isn’t sure that every case reported as the coronavirus really is the virus: “Everything seems to be coronavirus. I mean, it’s just … no matter what somebody has, it’s coronavirus. I don’t know whether it is or isn’t.”

Fort Scott is one of nearly 140 rural communities that have lost a hospital in the past decade. Mercy Hospital Fort Scott closed in December 2018.

Even though critically ill patients now must travel to hospitals farther away, Fort Scott residents haven’t seen that as a pandemic-related problem. Rather, not having a hospital doesn’t really come up when people here talk about covid.

Dave Martin, the former city manager, is pretty sure he caught covid at work last August.

“You know, when I got it, I was in good health and it did take me a while to recover,” Martin said. “I do remember waking up one of my bad nights and thinking, when I was running a temperature and not feeling very well. And I’m thinking, ‘Oh, wow, this could kill me.’”

But Martin also thought that any number of unpredictable events could end a person’s life. “So it didn’t really stick with me,” he said.

After recovering, the 62-year-old Martin went ahead with his retirement. He took his wife to Disney World and then they hiked Yellowstone National Park.

That casual attitude toward the dangers of covid worries health care leaders in Fort Scott. Jason Wesco helps lead the regional health center that took over primary care services when the hospital closed. One clinic occupies part of the same building that used to be Mercy Hospital.

Wesco said his family is careful about wearing masks and not gathering in groups, and he believes they are in the minority in the area.

“I think most people just keep going. They have maybe modified a little bit. Maybe they put on a mask in public,” Wesco said. “I think life here has changed a lot less than it’s changed in D.C. And I think we’re seeing the impact of that, right?”

The pandemic hit the area hard in the fall, peaking in late December.

One in 11 people in Bourbon County, where Fort Scott is the largest community, has been infected by covid, according to national analysis.

Two dozen of the county’s 14,000 residents have died of covid. And most people know someone who had the virus and survived — but residents just seem tired of talking about it.

Community volunteer Findley said she won’t get a vaccine.

“How did they come up with a vaccine that quickly? And how do they even know for sure it’s even working?” Findley wondered.

The three vaccines approved by federal regulators in the U.S. are being given out to millions, and their efficacy has been shown through massive clinical trials in the U.S. and globally.

But Findley’s skepticism is fairly common in southeastern Kansas and across rural America. Nationwide, a smaller share of rural residents say they will definitely get a covid shot compared with their more urban counterparts. More than a third, 35%, of those who live outside big-city borders said they would probably not or definitely not get vaccinated, compared with about a quarter of suburban and urban residents, according to a poll by KFF. (KHN is an editorially independent program of the foundation.) An NPR/PBS NewsHour/Marist Poll found that 47% of Trump supporters said they would not get a vaccine; 75% of Bourbon County residents voted for Trump in 2020.

Factors such as age and occupation also play a role in attitudes toward the vaccines. And — as Findley and others in Fort Scott noted — rural Americans are more likely to think of getting a vaccine as a personal choice and believe the seriousness of covid is exaggerated in the news.

Findley said she believes that there is a very bad virus, but also that the media have brainwashed people. The news has “everybody running scared,” she said. “I don’t know why they want to do that, but that’s what I feel like.”

About 50% of rural residents say the seriousness of the coronavirus is generally exaggerated in the news, according to the KFF poll. And 62% see getting the vaccine as a personal choice — rather than a necessary social obligation.

Wesco, executive vice president of the Community Health Center of Southeast Kansas, said he has hope more area residents will begin to see the vaccines as necessary.

“There’s hesitancy,” Wesco said, adding that he believes hesitancy is declining as vaccines become more abundant.

When residents are directly provided the opportunity to get a vaccine, they consider it more seriously, he said. And the more people they know who have gotten a vaccine, the more likely they will be to get a shot.

The Community Health Center, like other health centers nationwide, is receiving direct federal shipments of vaccines. Currently, the clinic has a waitlist and is giving out as many doses as it can get its hands on.

Sarah Jane Tribble is reporter and host of “Where It Hurts,” a narrative podcast created by KHN and St. Louis Public Radio about the people of Fort Scott and how their health care transformed after the hospital closed. “Where It Hurts” is available wherever you get your podcasts.