College Tuition Sparked a Mental Health Crisis. Then the Hefty Hospital Bill Arrived.

Despite a lifelong struggle with panic attacks, Divya Singh made a brave move across the world last fall from her home in Mumbai, India. She enrolled at Hofstra University in Hempstead, New York, to study physics and explore an interest in standup comedy in Manhattan.

This story also ran on NPR. It can be republished for free.

Arriving in the midst of the covid-19 pandemic and isolated in her dorm room, Singh’s anxiety ballooned when her family had trouble coming up with the money for a $16,000 tuition installment. Hofstra warned her she would have to vacate the dorm after the term ended if she was not paid up. At one point, she ran into obstacles transferring money onto her campus meal card.

“I’m a literally broke college student that didn’t have money for food,” she recalled. “At that moment of panic, I didn’t want to do anything or leave my bed.”

In late October, she called the campus counseling center hotline and met with a psychologist. “All I wanted was someone to listen to me and validate the fact that I wasn’t going crazy,” she said.

Instead, when she mentioned suicidal thoughts, the psychologist insisted on a psychiatric evaluation. Singh was taken by ambulance to Long Island Jewish Medical Center in New Hyde Park, New York, and kept for a week on a psychiatric ward at nearby Zucker Hillside Hospital. Both are part of the Northwell Health system.

The experience — lots of time alone and a few therapy sessions — was of minimal benefit psychologically, she said. Singh emerged facing the same tuition debt as before.

And then another bill came.

The Patient: Divya Singh, a 20-year-old student at Hofstra University.

Medical Service: Seven-day inpatient psychiatric stay at Zucker Hillside Hospital in Glen Oaks, New York.

Service Provider: Northwell Health, a large nonprofit hospital system in New York City and Long Island.

Total Bill: Northwell charged $50,282, which Singh’s insurer, Aetna, reduced to $17,066 under its contract with Northwell. The plan required Singh to pay $3,413.20 of that.

What Gives: Singh had purchased her Aetna insurance plan through Hofstra, paying $1,107 for the fall term. Aetna markets the plan specifically for students. Under its terms, students can be on the hook for up to $7,350 of the costs of medical care during a year, according to plan documents. Singh’s Northwell bill of around $3,413 is the plan’s requirement that she pay for 20% of the costs of her hospital stay.

Although such coinsurance requirements are common in American health plans, they can be financially overwhelming for students with no income and families whose finances are already under the extreme stress of high tuition. Singh’s Hofstra bill for the academic year, including room and board and ancillary fees, totaled $68,275.

As a result, Singh found herself beset by a double whammy of bills from two of the costliest kinds of institutions in America — colleges and hospitals — both with prices that inexorably rise faster than inflation.

For hospitals, there is supposed to be a relief valve. The Internal Revenue Service requires all nonprofit hospitals to have a financial assistance policy that lowers or eliminates bills for people without the financial resources to pay them. Such financial assistance — commonly known as charity care — is a condition for hospitals to maintain their tax-exempt status, shielding them from having to pay property taxes on often expansive campuses.

Northwell’s financial assistance policy limits the hospital from charging more than $150 for individuals who earn $12,880 a year or less. It offers discounts on a sliding scale for individuals earning up to $64,400 a year, although people with savings or other “available assets” above $10,000 might get less or not qualify.

The IRS requires hospitals to “widely publicize” the availability of financial assistance, inform all patients about how they can obtain it and include “a conspicuous written notice” on billing statements.

While the bill Northwell sent Singh includes a reference to “financial difficulties” and a phone number to call, it did not explicitly state that the hospital might reduce or waive the bill. Instead, the letter obliquely said “we can assist you in making budget payment arrangements” — a phrase that conjures installment payments rather than debt relief.

Resolution: In a written statement, Northwell said that although “all eligible patients are offered generous financial payment options … it is not required that providers list the options on the bill.” Northwell stated: “If a patient calls the number provided and expresses financial hardship, the patient is assisted with a financial need application.” However, Northwell lamented, “unfortunately, many patients do not call.”

Indeed, a KHN investigation in 2019 found that, nationwide, 45% of nonprofit hospital organizations were routinely sending medical bills to patients whose incomes were low enough to qualify for charity care. Those bills, which totaled $2.7 billion, were most likely an undercount since they included only the debt hospitals had given up trying to collect.

Singh said the worker who took down her insurance information during her hospital stay never explained that Northwell might reduce her portion of the charge. She said she didn’t realize that was a possibility from the language in the bill they sent.

Northwell said in a statement that after KHN contacted it about Singh’s case, Northwell dispatched a caseworker to contact her. Singh said the caseworker helped Singh enroll in Medicaid, the state-federal health insurance program for low-income people. Foreign students are not generally eligible for Medicaid, but in New York they can get coverage for emergency services. With the addition of Medicaid’s coverage, Singh should end up paying nothing if the stay is retroactively approved, Northwell said.

At the same time the caseworker was helping Singh, Singh received a “final reminder” letter from Northwell about her bill. That letter also mentioned Northwell’s financial assistance, but only within the context of people who completely lack health insurance.

“Send payment or contact us within 21 days to avoid further collection activity,” the letter said.

The Takeaway: Despite stricter requirements from the Affordable Care Act and the IRS to make nonprofit hospitals proactively educate patients about the various forms of financial relief they offer, the onus still remains on patients. If you have trouble paying a bill, call the hospital and ask for a copy of its financial assistance policy and the application to request your bill be discounted or excused.

Be aware that hospitals generally require proof of your financial circumstances such as pay stubs or unemployment checks. Even if you have health insurance that covers much of your medical bill, you may still be eligible to have your bill lowered or get on a government insurance program like Medicaid.

You can also find documentation online: All nonprofit hospitals are required to post financial assistance policies on their websites. They must provide summaries written in plain language and versions translated into foreign languages spoken by significant portions of their communities. Be aware that financial assistance is distinct from paying your full debt off in installments, which is what hospitals sometimes first propose.

Although the IRS rules don’t govern for-profit hospitals, many of those also offer concessions for people with proven financial hardship. The criteria and generosity of charity care vary among hospitals, but many give breaks to families with middle-class incomes: Northwell’s policy, for instance, extends to families of four earning $132,500 a year.

Singh’s family has paid off her fall tuition and half of her spring tuition so far. She still owes $16,565.

Singh said the back and forth over her hospital bill continues to cause anxiety. “The treatment I got in the hospital, after I’ve gotten out, it hasn’t helped,” she said. “I have nightmares about that place.” The biggest benefit of her week there, she said, was bonding with the other patients “because they were also miserable with the way they were being treated.”

Dan Weissmann, host of the “An Arm and a Leg” podcast, contributed the audio portrait that aired on NPR’s “Morning Edition.”

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

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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As Covid Surged, Vaccines Came Too Late for at Least 400 Medical Workers

This story also ran on The Guardian. It can be republished for free.

As health care workers in the U.S. began lining up for their first coronavirus vaccines on Dec. 14, Esmeralda Campos-Loredo was already fighting for oxygen.

The 49-year-old nursing assistant and mother of two started having breathing problems just days earlier. By the time the first of her co-workers were getting shots, she was shivering in a tent in the parking lot of a Los Angeles hospital because no medical beds were available. When she gasped for air, she had to wait all day for relief due to a critical shortage of oxygen tanks.

Campos-Laredo died of covid on Dec. 18, one of at least 400 health workers identified by The Guardian/KHN’s Lost on the Frontline investigation who have died since the vaccine became available in mid-December, narrowly missing the protection that might have saved their lives.

“I told her to hang in there, because they are releasing the vaccine,” said her daughter Joana Campos. “But it was just a little too late.”

In California, which became the epicenter of the national coronavirus surge following Thanksgiving, 40% of all health care worker deaths came after the vaccine was being distributed to medical staff members.

An analysis of The Guardian-KHN’s Lost on the Frontline database indicates that at least 1 in 8 health workers lost in the pandemic died after the vaccine became available. Unlike California, many states do not require a thorough reporting of the deaths of nurses, doctors, first responders and other medical staff members. The analysis did not include federally reported deaths in which the name was not released and may be missing numerous recent deaths that have not yet been detected by The Guardian and KHN.

The vaccine is now widely available to health care workers around the country and since mid-January, and covid-19 cases have been trending downward in the United States.

Sasha Cuttler, a nurse in San Francisco, has been gathering health care data for one of California’s nursing unions. Cuttler was alarmed and disheartened to see the number of deaths still surging weeks after the vaccination became widely available. “We can prevent this. We just need the means to do it,” said Cuttler, who noted that, nearly a year into the pandemic, some hospitals still lack adequate protective gear and proper staffing. “We don’t want to be health care heroes and martyrs. We want a safe workplace.”

Stockton nurse Barbara Clayborne became sick the same week her colleagues started receiving their first doses of the vaccine.

The 22-year staff member and union activist at St. Joseph’s Medical Center had picketed last summer to demand more help for the beleaguered nurses treating covid patients.

Though she worked on what was considered a relatively low-risk postpartum care unit, she was advocating for her colleagues in the intensive care unit, many of whom were overwhelmed by the number of patients they were responsible for.

“We know what it’s like to work a full 12-hour shift and not be able to drink water or sit down or go to the bathroom,” Clayborne told the Stockton Record in August. “It’s been chaos.”

In mid-December, Clayborne, who had asthma, became ill in mid-December. She had been exposed to a patient who hadn’t yet been diagnosed with covid, said her daughter Ariel Bryant. Clayborne died on Jan. 8.

“She was the best mom and grandmother — and she was a great role model for me,” said Bryant, who herself became a nurse. Bryant works in an intensive care unit in Southern California — as the same type of nurse her mother fought so hard to protect.

If the vaccine had come just a few days earlier, it might have saved Tennessee fire chief Ronald “Ronnie” Spitzer and his department’s dispatcher, Timothy Phillips.

Spitzer and his crew from the Rocky Top Fire Department were called to a medical emergency on Dec. 11 but weren’t told until later that the patient had tested positive for covid. Both Spitzer, 65, and the firefighter who accompanied him came down with the virus. A few days later, Phillips became ill as well.

Spitzer, a 47-year firefighting veteran, was already hospitalized when his co-workers got their first doses of the vaccine in January, according to Police Chief Jim Shetterly. He died on Jan. 13, and Phillips, 54, died a few days later.

The state of Tennessee does not publish statistics on health care worker deaths, but 10 of the 22 Tennessee health care worker deaths identified by the Guardian/KHN occurred since the vaccine rollout in December.

Shetterly said his town of 1,800 has been shattered by the losses. “Everyone knows everyone here. It’s tragic when it hits the nation. But, when it’s in your town, it really hits home,” he said.

Gerald Brogan, director of nursing practice for National Nurses United, said many hospitals hadn’t done adequate planning to be ready for the recent surges, which put exhausted health care workers at extra risk.

“When there are more patients in, there’s more chaos in the hospitals and it’s harder for workers to be safe,” he said. During the recent surge, “we had nurses breaking down because of the influx of patients and the emotional and physical toll that took on workers.”

Even once all health care workers are vaccinated, he said, health care administrators would need to remain vigilant on worker safety.

He said that surge preparations, extra safety equipment, contingency staffing plans and facilities like negative-pressure rooms to stop disease from spreading around hospitals should be a regular part of preparing for potential future pandemics.

KHN reporters Shoshana Dubnow and Christina Jewett contributed to this report.

This story is part of “Lost on the Frontline,” an ongoing project from The Guardian and Kaiser Health News that aims to document the lives of health care workers in the U.S. who die from COVID-19, and to investigate why so many are victims of the disease. If you have a colleague or loved one we should include, please share their story.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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‘It Doesn’t Feel Worth It’: Covid Is Pushing New York’s EMTs to the Brink

This story also ran on The Guardian. It can be republished for free.

In his 17 years as an emergency medical provider, Anthony Almojera thought he had seen it all. “Shootings, stabbings, people on fire, you name it,” he said. Then came covid-19.

Before the pandemic, Almojera said it was normal to respond to one or two cardiac arrests calls a week; now he’s grown used to several each shift. One day last spring, responders took more than 6,500 calls — more than any day in his department’s history, including 9/11.

An emergency medical services lieutenant and union leader with the New York City Fire Department, Almojera said he has seen more death in the past year than in his previous decade of work. “We can’t possibly process the traumas, because we’re still in the trauma,” he said.

EMS work has long been grueling and poorly paid. New FDNY hires make just over $35,000 a year, or $200 more than what is considered the poverty threshold for a four-person household in New York City. (That figure is on par with national averages.) Employee turnover is high: In fiscal year 2019, more than 13% of EMTs and paramedics left their jobs.

But covid-19 has added a new layer of precarity to the work. According to Oren Barzilay, the Local 2507 union president, nearly half of its 4,400 emergency medical technicians and paramedics have tested positive for the covid virus. Five have died, though that figure doesn’t account for first responders who worked for private emergency response companies. Nationwide, at least 128 medical first responders have died of covid, according to Lost on the Frontline, an investigation by KHN and The Guardian.

The problem of EMS pay was in the spotlight in December, when the New York Post outed paramedic Lauren Caitlyn Kwei for relying on an OnlyFans page to make extra money. Kwei, who works for a private ambulance company, wrote on Twitter: “My First Responder sisters and brothers are suffering … exhausted for months, reusing months old PPE, being refused hazard pay, and watching our fellow healthcare workers dying in front of our eyes.” She added: “EMS are the lowest paid first responders in NYC which leads to 50+ hour weeks and sometimes three jobs.”

Almojera earns $70,000 annually as a lieutenant, but his paramedic colleagues’ salaries in non-leadership roles are capped at around $65,000 after five years on the job. He earns extra income as a paramedic at area racetracks and conducting defibrillator inspections. He has colleagues who drive for Uber, deliver for GrubHub and stock grocery shelves on the side. “There are certain jobs that deserve all your time and effort,” Almojera said. “This should be your only job.”

For Liana Espinal, a paramedic, union delegate and 13-year veteran of the FDNY, a sense of camaraderie and the opportunity to serve her fellow Brooklynites compensated for low pay and exhausting shifts. For years she was willing to take on overtime and even a second job with a private ambulance company to make ends meet.

But covid changed that. The department switched from eight- to 12-hour shifts last summer, leaving Espinal, a single mother of three, too exhausted to pick up overtime. Like many health care workers, she isolated from her children at the outset of the pandemic to avoid potentially exposing them to the coronavirus, leaving them in the care of her own mother; she described being separated from her 1-year-old son as “devastating.” Despite working round-the-clock to get the city through the early days of the pandemic, she often had to choose between paying rent on time or paying utility bills.

“After working this year, for me personally, it doesn’t feel worth it anymore,” she said. She is two exams shy of finishing a nursing degree she started studying for before the pandemic. She said the last year has only strengthened her resolve to shift careers.

The pandemic has disproportionately claimed Black and brown lives — Black and Hispanic people were significantly more likely than white people to die of covid — and those disparities extend to health care workers. Lost on the Frontline has found that nearly two-thirds of health care workers who have died of covid were non-white.

All five of the department’s EMS employees who died of covid were non-white.

They included Idris Bey, 60, a former Marine and 9/11 first responder who was known to stay cool under pressure. He was an avid reader who bought new books each time he got a paycheck.

Richard Seaberry, 63, was looking forward to retiring to the Atlanta area to be near his young granddaughter.

Evelyn Ford, 58, left behind four children when she died in December, just as the coronavirus vaccine became available to first responders in New York City. According to the City Council’s finance division, 59% of EMS workers are minorities.

Almojera and Espinal see a racial component to pay disparities within the FDNY. Firefighters with five years on the job can make more than $100,000, including overtime and holiday pay, whereas paramedics and EMTs cap out at $65,000 and $50,000, respectively. According to the City Council finance division, 77% of New York firefighters are white.

“My counterpart fire lieutenants make almost $40,000 more than me,” Almojera said. “I’ve delivered 15 babies. I’ve been covered head to toe in blood. I mean, what do you pay for that? You can at least pay us like the other 911 agencies.”

A spokesperson for the FDNY declined to comment on pay.

The last year has also exacted an emotional toll on an already stressed workforce. Three of the FDNY’s EMS workers died by suicide in 2020. John Mondello Jr, 23, a recent EMS academy graduate, died in April. Matthew Keene, 38, a nine-year veteran, died in June. Brandon Dorsa, 36, who had struggled with injuries from a 2015 workplace accident, died in July.

Family and colleagues told local news outlets that Mondello and Keene were struggling with trauma as a result of the pandemic. Last spring, New York Mayor Bill de Blasio and first lady Chirlane McCray announced a partnership between the U.S. Department of Defense and city agencies to help front-line health workers cope with the stress of working through the pandemic. But many EMS workers have said that the program has been difficult to access.

“There aren’t a lot of resources for people, so a lot of EMS internalize what they go through,” Almojera said. “It’s not normal to see the things that we see.”

Issues regarding pay and mental health challenges predate the pandemic: A national survey conducted in 2015 found EMS providers were much more likely than the general population to struggle with stress and contemplate suicide.

Almojera knew Keene and last spoke with him a week before his death. “You can’t say enough nice things about the guy,” he said. “I wish he had mentioned even a hint of [his struggles] on the phone. And I would have shared how I was feeling through all this.”

He said he has felt a mix of pride, exhaustion and resignation over the past year. “I’ve seen the magic that you can do on the job,” Almojera said. “And I’ve seen my brothers and sisters on this job cry after calls.”

Almojera is now representing his union in talks with the city to renegotiate EMS and paramedic contracts. He said he hopes that city officials will think of the hardships he and his fellow first responders endured over the past year when they come to the negotiating table to discuss pay raises. But early talks have not been encouraging.

“After all the sacrifices made by our members,” he said. “I don’t know whether to be angry, flip the table, or just shrug my shoulders and give up.”

This story is part of “Lost on the Frontline,” an ongoing project from The Guardian and Kaiser Health News that aims to document the lives of health care workers in the U.S. who die from COVID-19, and to investigate why so many are victims of the disease. If you have a colleague or loved one we should include, please share their story.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Look Up Your Hospital: Is It Being Penalized By Medicare?

Under programs set up by the Affordable Care Act, the federal government cuts payments to hospitals that have high rates of readmissions and those with the highest numbers of infections and patient injuries. For the readmission penalties, Medicare cuts as much as 3 percent for each patient, although the average is generally much lower. The patient safety penalties cost hospitals 1 percent of Medicare payments over the federal fiscal year, which runs from October through September. Maryland hospitals are exempted from penalties because that state has a separate payment arrangement with Medicare.

Below are look-up tools for each type of penalty. You can search by hospital name or location, look at all hospitals in a particular state and sort penalties by year.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Companies Pan for Marketing Gold in Vaccines

This story also ran on NBC News. It can be republished for free.

For a decade, Jennifer Crow has taken care of her elderly parents, who have multiple sclerosis. After her father had a stroke in December, the family got serious in its conversations with a retirement community — and learned that one service it offered was covid-19 vaccination.

“They mentioned it like it was an amenity, like ‘We have a swimming pool and a vaccination program,’” said Crow, a librarian in southern Maryland. “It was definitely appealing to me.” Vaccines, she felt, would help ease her concerns about whether a congregate living situation would be safe for her parents, and for her to visit them; she has lupus, an autoimmune condition.

As the coronavirus death toll soars and demand for the covid vaccines dwarfs supply, an army of hospitals, clinics, pharmacies and long-term care facilities has been tasked with getting shots into arms. Some are also using that role to attract new business — the latest reminder that health care, even amid a global pandemic, is a commercial endeavor where some see opportunities to be seized.

“Most private sector companies distributing vaccines are motivated by the public health imperative. At some point, their DNA also kicks in,” said Roberta Clarke, associate professor emeritus of marketing at Boston University.

Among senior living facilities — which saw their largest drop in occupancy on record last year — some companies are marketing vaccinations to recruit residents. Sarah Ordover, owner of Assisted Living Locators Los Angeles, a referral agency, said many in her area are offering vaccines “as a sweetener” to prospective residents, sometimes if they agree to move in before a scheduled vaccination clinic.

Oakmont Senior Living, a high-end retirement community chain with 34 locations, primarily in California, has advertised “exclusive access” to the vaccines via social media and email. A call to action on social media reads: “Reserve your apartment home now to schedule your Vaccine Clinic appointment!”

Although the vaccine offer was a selling point for Crow, it wasn’t for her parents, who have not been concerned about contracting covid and didn’t want to forgo their independence, she said. Ultimately, they moved in with her sister, who could arrange home care services.

This marketing approach might sway others. Oakmont Senior Living, based in Irvine, reported 92 move-ins across its communities last month, a 13% increase from January 2020, noting the vaccine is “just one factor among many” in deciding to become a resident.

But some object to facilities using vaccines as a marketing tool. “I think it’s unethical,” said Dr. Michael Carome, director of health research at consumer advocacy group Public Citizen. While he believes that facilities should provide vaccines to residents, he fears attaching strings to a vaccine could coerce seniors, who are particularly vulnerable and desperate for vaccines, into signing a lease.

Tony Chicotel, staff attorney at California Advocates for Nursing Home Reform, worries that seniors and their families could make less informed decisions when incentivized to sign by a certain date. “You’re thinking, ‘I’ve got to get moved in in the next week or otherwise I don’t get this shot. I don’t have time to read everything in this 38-page contract,’” he said.

Oakmont Senior Living responded by email: “Potential residents and their families are always provided with the information they need to be confident in a decision to choose Oakmont.”

Some people say facilities are simply meeting their demand for covid vaccines. “Who is going to put an elderly person in a place without a vaccine? Congregate living has been a hotbed of the virus,” said retired philanthropy consultant Patti Patrizi. She and her son recently chose a retirement community in Los Angeles for her ex-husband for myriad reasons unrelated to the vaccines. However, they accelerated the move by two weeks to coincide with a vaccination clinic.

“It was definitely not a marketing tool to me,” said Patrizi. “It was my insistence that he needs it before he can live there.”

The concept of using vaccines to market a business isn’t new. The 2009 H1N1 pandemic ushered in drugstore flu shots, and pharmacies have since credited flu vaccines with boosting storefront sales and prescriptions. Many offer prospective vaccine recipients coupons, gift cards or rewards points.

A few pharmacies have continued these marketing activities while rolling out covid shots. On its covid vaccine information site, CVS Pharmacy encouraged visitors to sign up for its rewards program to earn credits for vaccinations. Supermarket and pharmacy chain Albertsons and its subsidiaries have a button on their covid vaccine information sites saying, “Transfer your prescription.”

But the pandemic isn’t business as usual, said Alison Taylor, a business ethics professor at New York University. “This is a public health emergency,” she said. Companies distributing covid vaccines should ask themselves “How can we get society to herd immunity faster?” rather than “How many customers can I sign up?” she said.

In an email response, CVS said it had removed the reference to its rewards program from its covid vaccination page. Patients will not earn rewards for receiving a covid shot at its pharmacies, the company said, and its focus remains on administering the vaccines.

Albertsons said via email that its covid vaccine information pages are intended to be a one-stop resource, and information about additional services is at the very bottom of these pages.

Boston University’s Clarke doesn’t see any harm in these marketing activities. “As long as the patient is free to say ‘no, thank you,’ and doesn’t think they’ll be penalized by not getting a vaccine, it’s not a problem,” she said.

At least one health care provider is offering complimentary services to people eligible for covid vaccines. Membership-based primary care provider One Medical — now inoculating people in several states, including California — offers a free 90-day membership to groups, such as people 75 and older, that a local health department has tasked the company with vaccinating, according to an email from a company spokesperson who noted that vaccine supply and eligibility requirements vary by county.

The company said it offers the membership — which entails online vaccine appointment booking, second dose reminders and on-demand telehealth visits for acute questions — because it believes it can and should do so, especially when many are struggling to access care.

While these may very well be the company’s motives, a free trial is also a marketing tactic, said Silicon Valley health technology investor Dr. Bob Kocher. Whether it’s Costco or One Medical, any company offering a free sample hopes recipients buy the product, he said.

Offering free trial memberships could pay off for providers like One Medical, he said; local health departments can refer many patients, and converting a portion of vaccine recipients into members could offer a cheaper way for providers to get new patients than finding them on their own.

“Normally, there’s no free stuff at a provider, and you have to be sick to try health care. This is a pretty unique circumstance,” said Kocher, who doesn’t see boosting public health and taking advantage of an uncommon marketing opportunity as mutually exclusive here. “Vaccination is a super valuable way to help people,” he said. “A free trial is also a great way to market your service.”

One Medical insisted the membership trial is not a marketing ploy, noting that the company is not collecting credit card information during registration or auto-enrolling trial participants into paid memberships. But patients will receive an email notifying them before their trial ends, with an invitation to sign up for membership, said the company.

Health equity advocates say more attention needs to be paid to the people who slip under the radar of marketers — yet are at the highest risk of getting and dying from covid, and the least likely to be vaccinated.

Kathryn Stebner, an elder-abuse attorney in San Francisco, noted that the high cost of many assisted living facilities is often prohibitive for the working class and people of color. “African Americans are dying [from covid] at a rate three times as much as white people,” she said. “Are they getting these vaccine offers?”

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

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Medicare Cuts Payment to 774 Hospitals Over Patient Complications

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The federal government has penalized 774 hospitals for having the highest rates of patient infections or other potentially avoidable medical complications. Those hospitals, which include some of the nation’s marquee medical centers, will lose 1% of their Medicare payments over 12 months.

The penalties, based on patients who stayed in the hospitals anytime between mid-2017 and 2019, before the pandemic, are not related to covid-19. They were levied under a program created by the Affordable Care Act that uses the threat of losing Medicare money to motivate hospitals to protect patients from harm.

On any given day, one in every 31 hospital patients has an infection that was contracted during their stay, according to the Centers for Disease Control and Prevention. Infections and other complications can prolong hospital stays, complicate treatments and, in the worst instances, kill patients.

“Although significant progress has been made in preventing some healthcare-associated infection types, there is much more work to be done,” the CDC says.

Now in its seventh year, the Hospital-Acquired Condition Reduction Program has been greeted with disapproval and resignation by hospitals, which argue that penalties are meted out arbitrarily. Under the law, Medicare each year must punish the quarter of general care hospitals with the highest rates of patient safety issues. The government assesses the rates of infections, blood clots, sepsis cases, bedsores, hip fractures and other complications that occur in hospitals and might have been prevented. The total penalty amount is based on how much Medicare pays each hospital during the federal fiscal year — from last October through September.

Hospitals can be punished even if they have improved over past years — and some have. At times, the difference in infection and complication rates between the hospitals that get punished and those that escape punishment is negligible, but the requirement to penalize one-quarter of hospitals is unbending under the law. Akin Demehin, director of policy at the American Hospital Association, said the penalties were “a game of chance” based on “badly flawed” measures.

Some hospitals insist they received penalties because they were more thorough than others in finding and reporting infections and other complications to the federal Centers for Medicare & Medicaid Services and the CDC.

“The all-or-none penalty is unlike any other in Medicare’s programs,” said Dr. Karl Bilimoria, vice president for quality at Northwestern Medicine, whose flagship Northwestern Memorial Hospital in Chicago was penalized this year. He said Northwestern takes the penalty seriously because of the amount of money at stake, “but, at the same time, we know that we will have some trouble with some of the measures because we do a really good job identifying” complications.

Other renowned hospitals penalized this year include Ronald Reagan UCLA Medical Center and Cedars-Sinai Medical Center in Los Angeles; UCSF Medical Center in San Francisco; Beth Israel Deaconess Medical Center and Tufts Medical Center in Boston; NewYork-Presbyterian Hospital in New York; UPMC Presbyterian Shadyside in Pittsburgh; and Vanderbilt University Medical Center in Nashville, Tennessee.

There were 2,430 hospitals not penalized because their patient complication rates were not among the top quarter. An additional 2,057 hospitals were automatically excluded from the program, either because they solely served children, veterans or psychiatric patients, or because they have special status as a “critical access hospital” for lack of nearby alternatives for people needing inpatient care.

The penalties were not distributed evenly across states, according to a KHN analysis of Medicare data that included all categories of hospitals. Half of Rhode Island’s hospitals were penalized, as were 30% of Nevada’s.

All of Delaware’s hospitals escaped punishment. Medicare excludes all Maryland hospitals from the program because it pays them through a different arrangement than in other states.

Over the course of the program, 1,978 hospitals have been penalized at least once, KHN’s analysis found. Of those, 1,360 hospitals have been punished multiple times and 77 hospitals have been penalized in all seven years, including UPMC Presbyterian Shadyside.

The Medicare Payment Advisory Commission, which reports to Congress, said in a 2019 report that “it is important to drive quality improvement by tying infection rates to payment.” But the commission criticized the program’s use of a “tournament” model comparing hospitals to one another. Instead, it recommended fixed targets that let hospitals know what is expected of them and that don’t artificially limit how many hospitals can succeed.

Although federal officials have altered other ACA-created penalty programs in response to hospital complaints and independent critiques — such as one focused on patient readmissions — they have not made substantial changes to this program because the key elements are embedded in the statute and would require a change by Congress.

Boston’s Beth Israel Deaconess said in a statement that “we employ a broad range of patient care quality efforts and use reports such as those from the Centers for Medicare & Medicaid Services to identify and address opportunities for improvement.”

UCSF Health said its hospital has made “significant improvements” since the period Medicare measured in assessing the penalty.

“UCSF Health believes that many of the measures listed in the report are meaningful to patients, and are also valid standards for health systems to improve upon,” the hospital-health system said in a statement to KHN. “Some of the categories, however, are not risk-adjusted, which results in misleading and inaccurate comparisons.”

Cedars-Sinai said the penalty program disproportionally punishes academic medical centers due to the “high acuity and complexity” of their patients, details that aren’t captured in the Medicare billing data.

“These claims data were not designed for this purpose and are typically not specific enough to reflect the nuances of complex clinical care,” the hospital said. “Cedars-Sinai continually tracks and monitors rates of complications and infections, and updates processes to improve the care we deliver to our patients.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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‘I Wanted to Go in There and Help’: Nursing Schools See Enrollment Bump Amid Pandemic

This story also ran on USA Today. It can be republished for free.

Last December, Mirande Gross graduated from Bellarmine University in Louisville, Kentucky, with a bachelor’s degree in communications. But Gross has changed her mind and is heading back to school in May for a one-year accelerated nursing degree program. The pandemic that has sickened more than 27 million people in the United States and killed nearly 500,000 helped convince her she wanted to become a nurse.

“I was excited about working during the pandemic,” Gross, 22, said. “It didn’t scare me away.”

Enrollment in baccalaureate nursing programs increased nearly 6% in 2020, to 250,856, according to preliminary results from an annual survey of 900 nursing schools by the American Association of Colleges of Nursing.

“In the pandemic we saw an increased visibility of nurses, and I think that’s been inspirational to many people,” said Deb Trautman, president and CEO of the association, whose members represent nursing programs at the bachelor’s, master’s and doctoral levels. “It’s a profession where you can make a difference.”

Two-year associate nursing degree programs seem to be experiencing a similar bump, though hard numbers are unavailable, said Laura Schmidt, president of the Organization for Associate Degree Nursing.

There’s no way to know exactly what is propelling the new applications. But medical schools also saw an 18% boost in applications last year, a jump partly attributed to the pandemic and high profile of key doctors, such as Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, during the crisis.

It’s possible that the media stories, social media accounts and front-line medical workers’ personal accounts of battling the novel coronavirus have played a role. “Nurse” was the No. 1 term that people queried “how to become” on Google in 2020, according to Google trends data.

For Gross, it was a turn back to an initial career choice. When she started college, nursing was her chosen path. But after fainting twice while shadowing a nurse at the hospital, she switched to a major that didn’t involve needles or blood. For the past two years, she’s worked as a newborn photographer at a hospital near her Louisville home, and she no longer gets squeamish at the sight of IVs or injuries.

“When I saw on the news nurses being so overworked, I thought, ‘Gosh, I wish I could be in there helping,’” said Gross.

Demand for nurses was strong even before the pandemic hit. There are about 3 million registered nurses in the United States, but employment is expected to grow 7% between 2019 and 2029, according to the Bureau of Labor Statistics, faster than the 4% average for all occupations. Many hospital medical staffs are stretched to the breaking point as they deal with a surge of covid-19 patients and at the same time cope with staff shortages as medical personnel have become ill with covid or had to quarantine.

Meeting the demand for nurses is hampered by long-standing capacity issues at nursing schools. According to a report by the American Association of Colleges of Nursing, programs at the bachelor’s and graduate degree levels turned away more than 80,000 qualified applicants in 2019. The reasons included not having enough faculty, clinical training sites and supervisors or classroom space, as well as budget constraints, the report found.

“The people who are prepared to teach are at least master’s degree level and frequently have doctorate degrees,” said Beverly Malone, president and CEO of the National League for Nursing. “They can work at hospitals or community care centers for [significantly] more money.”

Malone and others also noted that it can be difficult to ensure access to the clinical training slots that nursing students need. This problem was exacerbated during the pandemic when many hospitals sent nursing students home to avoid their getting sick and to conserve scarce personal protective equipment for staffers treating covid patients.

For some nursing students, the pandemic has opened their eyes to new possibilities for patient care. David Namnath is finishing a two-year associate nursing degree at the College of Marin in Kentfield, California. He learned last spring that his clinical rotation at the local hospital would be canceled because of covid.

Instead, he and other students took on a telenursing project, in which he made regular wellness check-ins and provided health education related to chronic conditions such as diabetes and back pain with eight patients over video and phone.

“It was really helpful for me,” said Namnath, 29, who has a bachelor’s degree in biochemistry and worked in a lab before starting nursing school. “It’s not something you normally learn. I think we became more three-dimensional because of it.”

Some people who got nursing degrees in years past but didn’t practice also may be taking a fresh look at the profession, said David Benton, CEO of the National Council of State Boards of Nursing. More than 222,000 nurses who were educated in the U.S. took the National Council Licensure Examination last year, a figure that was 5% higher than the year before, he said.

The economic downturn that has shuttered thousands of businesses may have made nursing more attractive, he said.

“We know that, nationally, services like the restaurant industry have shut down,” Benton said. “But one thing that hasn’t shut down is demand for health care.”

Nurses who worked in hospitals made $79,400 a year on average in 2019, according to the Bureau of Labor Statistics. But as the covid crisis hit and hospitals scrambled to find staff last year, nurses who were willing to travel to covid hot spots could make many times that amount, in some cases up to $10,000 a week.

There are many paths to becoming a nurse. A growing proportion of nurses get a bachelor of science degree in nursing at four-year colleges. But many still go to community colleges for two-year associate degrees in nursing. These programs are more affordable and may appeal to older students who are parents or going back for a second degree, said Schmidt.

Both types of graduates can take the nurse licensing exam and become registered nurses. But nurses with bachelor’s degrees may be better positioned for higher-level jobs or supervisory roles. They may also earn more money. According to the association of nursing colleges’ annual survey, 41% of hospitals and other health care facilities require new nursing hires to have a bachelor’s degree in nursing.

Many nursing schools have “RN to BSN” programs that enable registered nurses with associate degrees to get the additional training they need for their bachelor of nursing degrees. And numerous accelerated programs, like the one Mirande Gross will start in May, allow people to fill in their nursing education gaps in a compressed time frame.

Not every nursing student sees the pandemic as an opportunity, however. Steven Bemben worked as a paramedic in Uvalde County, Texas, west of San Antonio, during the first frightening months of the pandemic last year. Personal protective equipment was hard to come by, and sometimes the calls to transport very sick covid patients came nonstop.

“It was extremely stressful, and people were getting fatigued and burned out,” said Bemben, 33, who had been on the job for nine years.

Last October, he quit his paramedic job, and in January he started a two-year bachelor’s nursing program at the University of Texas-San Antonio. (He already has an associate degree, although not in nursing.)

When Bemben finishes school, he hopes, the pandemic will be in our collective rearview mirror.

“By the time I graduate, I’m trying to stay optimistic that we’ll be past all this stuff,” he said.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Bay Area Cities Go to War Over Gas Stoves in Homes and Restaurants

This story also ran on U.S. News & World Report. It can be republished for free.

San Francisco restaurant owners, already simmering over covid-19 restrictions, are ready to boil over because of a city ban on natural gas stoves in new buildings that takes effect in June.

The ban, which also affects other gas appliances, is part of a statewide campaign aimed at reducing climate change-feeding carbon emissions as well as health hazards from indoor gas exposure. A similar ban went into effect in Berkeley in 2020; Oakland and San Jose recently passed similar measures, and other California cities are considering them.

Officials championing the bans say they’re responding to evidence that gas stoves emit dangerous levels of toxic gases such as nitrogen oxide, nitrogen dioxide and formaldehyde, which can cause heart and lung problems, aggravate asthma and contribute to early death, according to federally funded research.

Restaurant owners say it’s an outrageous, unnecessary law that will make expansions and opening in new buildings impossible. It puts salt in the wounds of businesses agonizing over covid restrictions, they add.

“If you get rid of the gas element, I don’t think restaurants can do it unless you’re like a coffee shop with a panini press,” said Matthew Dolan, executive chef and partner of restaurant 25 Lusk in San Francisco. “Whoever cooked up this idea should be reprimanded.”

Many are skeptical that properly vented stoves pose any health problems. Restaurants in California are required to have state-of-the-art ventilation systems that remove byproducts of burning natural gas and circulate fresh air, Dolan said. “The average employee isn’t really in contact with those issues,” he said.

The California Restaurant Association sued Berkeley in 2019 over its ban, arguing that it makes it impossible to prepare flame-seared meats, charred vegetables and wok-prepared dishes, putting steakhouses, ethnic restaurants and others out of business.

“You cannot cook with an electric wok,” said Vice Mayor Chin Ho Liao of San Gabriel, a Los Angeles suburb with 200 restaurants, mostly Asian. “You can cook with them, but it won’t taste good.”

Defenders of the law say it’s a long-delayed recognition of the harm of indoor pollution, which isn’t regulated by the Environmental Protection Agency, and is especially important since 87% of the typical person’s life is spent indoors.

Research shows clearly that gas stoves put out potentially dangerous levels of toxic fumes. Electric stoves also pollute, but at lower levels. While it’s difficult to prove gas stoves diminish health, studies have shown correlations between their use and higher rates of illness.

Buildings account for the second-largest percentage of San Francisco’s carbon footprint, next to transportation, and natural gas accounts for more than 75% of that. Roughly half of California homes use natural gas for cooking, according to the California Energy Commission. But health impacts are potentially a more immediate risk than climate change.

A study by UCLA’s Fielding School of Public Health in June found that in modeled scenarios where a gas stove and oven are used simultaneously for one hour, concentrations of nitrogen dioxide usually exceed the pollution levels dictated by national and California air quality standards. Gas appliances also release carbon monoxide and particulates.

“All of those have been shown to be detrimental to human health,” said Yifang Zhu, lead author of the UCLA study and a professor in the school’s department of environmental health sciences.

San Francisco Supervisor Rafael Mandelman, the sponsor of the city’s ban, said in a written release that building electrification is “a critical step in addressing the serious public health and safety hazards of natural gas, and of course the ever-intensifying climate crisis.” He also cited a report by the Rocky Mountain Institute, a clean energy think tank, which found high levels of harmful emissions in homes and businesses with gas stoves.

In November, California’s air regulation agency adopted a resolution to curtail emissions from gas appliances in buildings and said pollution could exacerbate covid-19. Climate activists are urging the California Energy Commission to include a ban on gas hookups in its next building regulations update, a move that would affect the entire state.

There’s been a similar push in Massachusetts. The nation’s oldest medical society last December became the first to recognize the health impacts of gas cooking — though it also noted that ventilation mitigates such effects.

When caring for children with asthma, health care practitioners should ask, “‘What kind of stove do you have?’” said Dr. T. Stephen Jones, a retired former Centers for Disease Control and Prevention official who co-sponsored a resolution on the matter passed by the Massachusetts Medical Society.

Society members were taken aback by the data on how gas stoves could make children sick.

“This is not really out in the general public. It’s not out among providers,” said Dr. Heather Alker, chair of the society’s environmental and occupational health committee.

Low-income people are at particularly high risk because they tend to live in smaller residences where gases can concentrate; may use kitchen appliances for supplemental heat; and cannot easily maintain or replace older equipment, especially if they rent, according to the UCLA study.

A government-funded 2014 study concluded that residents of 62% of the Southern California homes it measured were routinely exposed to nitrogen dioxide through hoodless appliances at levels that exceed health standards. A 2012 study done at the behest of the DOE found particulate matter from indoor gas burning could hurt lungs and reduce life expectancy.

As outdoor air gets cleaner, policymakers are focusing more on indoor air quality, which was “under the radar previously” and generally not regulated by state or federal governments, Zhu said.

Critics of the bans argue that electricity is more expensive than natural gas and will drive prices up, making it especially hard for low-income residents. And not all cities are on board with the move away from gas.

More than 100 California cities, including San Gabriel, have approved resolutions, with language put forward by the Southern California Gas Co., calling for “balanced energy solutions.”

In addition to the near impossibility of properly stir-frying food with electricity, Liao is worried about making residents rely solely on the state’s overworked electrical grid, which was hit with rolling blackouts last year. He is pushing for the development of clean gas derived from methane captured from rotting food, a process called anaerobic digestion. Riverside has such a project. But the approach needs more funding and development to be scalable, the vice mayor acknowledged.

The gas ban could pose an extra burden on restaurants struggling to survive covid strictures, owners and chefs say.

“This is the last thing in the world we need right now,” said Dolan. “It’s an added burden on an already burdened industry.”

But advocates for the change say people need to look at the issue a new way.

“When you actually stop and think about it as ‘This is a gas-guzzling device that’s in the middle of my house,’ it is sort of like a mind shift,” said Brady Seals, a senior associate at the Rocky Mountain Institute. “I don’t think it’s unrealistic to think that, in a generation or two, we’ll come to a place where our kids can’t ever imagine why we would want to burn a fossil fuel in our kitchen that emits some of the same pollutants that come from tailpipes.”

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

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Rural Hospital Remains Entrenched in Covid ‘War’ Even Amid Vaccine Rollout

Editor’s note: KHN wrote about St. James Parish Hospital in April, when it was experiencing its first surge of covid-19 patients. Ten months later, we checked in to see how the hospital and its staff were faring.

This story also ran on The Guardian. It can be republished for free.

The “heroes work here” sign in front of St. James Parish Hospital has been long gone, along with open intensive care unit beds in the state of Louisiana.

Staffers at the rural hospital spent hours each day in January calling larger hospitals in search of the elusive beds for covid-19 patients. They leveraged personal connections and begged nurses elsewhere to take patients they know are beyond their hospital’s care level.

But as patients have waited to be transferred out of the hospital, which is about 45 minutes outside New Orleans, doctors such as Landon Roussel are forced to make unthinkable choices. As recently as Jan. 29, he had to decide between two patients: Which one should get the sole available BiPAP machine to push oxygen into their lungs?

That’s like a “war situation, which is not a situation that I want to be in — in the United States,” he said.

As the nation’s attention shifts to the vaccine rollout, rural hospitals such as St. James Parish Hospital have struggled to handle their communities’ sick following the holiday surge of covid patients.

“We knew it was coming. We saw it coming,” Mary Ellen Pratt, St. James Parish Hospital’s CEO, said by phone. “It really has to happen to their family for them to really go, ‘OK, wow.’”

And even though the vaccines have arrived and caseloads continue to improve after the holiday surge, only about 30% of staffers have opted to get their shots. Disparities in the broader community persist: In the initial rollout, only 9% of those vaccinated were Black in a parish — the Louisiana equivalent of a county — that is nearly 49% Black.

Staff members are burned out from months of handling never-ending covid crises.

“They had been giving 150%, and they’re just getting really tired,” Pratt said. “It’s just exhausting.”

‘Sometimes, Your Best Isn’t Enough’

In mid-January, the closest intensive care bed the staff could find was some 600 miles away in Brownsville, Texas — so far that a plane would have been necessary to transport a patient. After three days, a closer bed was found at a Veterans Affairs hospital about 45 miles away.

Staffers have tried Mississippi and Alabama with mixed luck. One patient they tried to transfer four hours away couldn’t go because the ambulance didn’t have enough oxygen to make it that far. A hospital in Florida even called them looking for ICU beds at St. James Parish Hospital, which has never had any.

More than half of U.S. counties are like St. James Parish and have no intensive care beds, full or empty. Rural hospitals in those communities are designed for step-down care: They often serve as a stopping point to stabilize people before they can be sent to larger hospitals with more specialized staff and equipment.

Across the country, rural residents’ mortality rate from covid has been consistently higher than that of urban residents since August, according to the Rural Policy Research Institute Center for Rural Health Policy Analysis. That has occurred even though covid incidence has been lower among rural populations than urban ones since the middle of December, said Fred Ullrich, who runs the health policy department at the University of Iowa’s College of Public Health and co-authored the study.

But, he said, rural populations are typically older, sicker and poorer than urban populations. And the nation has lost at least 179 rural hospitals over the past 17 years.

“This crisis is just magnifying existing access issues in a rural context,” said Alan Morgan, the head of the National Rural Health Association. “If you don’t have a local hospital, that impacts the diagnosis, the initial treatment, the complex treatment. It has multiple impacts, all leading to what we’re seeing: higher mortality.”

And at the hospitals that remain, such as St. James Parish Hospital, the stress level is palpable, because the level of care needed for such sick patients is higher than what staffers normally handle, said Karley Babin, the hospital’s acute nurse manager.

“It’s just an uncomfortable spot,” she said. “You know you’re doing everything you can and that patient just needs more.”

That’s led to many sleepless nights for Pratt.

“Sometimes your best isn’t enough if you don’t have the right resources,” she said.

‘We Know All These People’

Radiology technologist Brooke Michel lives seven minutes from the hospital, where she works with her husband and five other relatives. Her grandfather, grandmother and aunt were hospitalized there in December with covid.

Her family brought folding chairs to sit outside her 83-year-old grandfather’s hospital window each day, keeping vigil through the glass on Christmas Eve. He died Jan. 3 while family members stood outside, taking turns looking in and praying.

“It gave us a sense of closure,” Michel said. “We were all together. We were with him. We would never have gotten that at a bigger hospital.”

Seeing multiple family members hospitalized at the same time is tough on the staff, said Scott Dantonio, the hospital’s pharmacy director. “We know all these people,” he said.

Dozens of hospital staffers also have battled covid, and three have been hospitalized. A nurse’s aide died last summer after contracting it. One staffer, who was particularly close to that aide, now has a hard time treating covid patients, said Rhonda Zeringue, chief nursing officer.

“It’s a reminder: ‘You took my person,’” she said.

‘It’s Just Exhausting’

St. James Parish Hospital has been running short-staffed, because they haven’t been able to hire more nurses or pay traveling nurses — they’re just too expensive. Amid the pandemic, traveling nurses can command more than double what the staff nurses make.

So Babin’s kids ask often why she works all the time.

Community praise has died down, she said. People aren’t thanking them in grocery stores anymore. One upside? Pratt is happy to have finally lost the “covid 19” — the weight she put on from the community bringing food to the hospital back in the spring.

Pratt and Zeringue have offered staff members counseling, massage sessions, coffee and doughnuts. But it’s not enough.

Zeringue said the stress has gone through the staff in waves: First they were scared to death of being the front line in the spring. Now she sees burnout and sheer exhaustion.

The vaccines were supposed to offer hope. But when Pratt heard they would be distributed through CVS and Walgreens, she knew immediately the logistics of getting the ultra-cold Pfizer vaccine from its cooler into residents’ arms would fall to them. She said the community has no chain pharmacies nearby and the local health department is overloaded.

“We get an email at, like, 4:30 on Friday which says, ‘We’re going to send you another 350 vaccines on Wednesday and you have to respond in the next 10 minutes,’” Pratt said. “There’s not enough planning or time to do it.”

Staff members, who are juggling monoclonal antibody infusions and elective surgeries to deal with the backlog from the spring on top of the surge, must also call members of the community to let them know they have the vaccine available. And then the problems begin.

“People don’t answer the phone or they’re not available,” Dantonio said. “Or they can’t come at that time or they scheduled somewhere else.”

Most of the people coming in following the hospital’s advertising online and on Facebook have been white. So Pratt called on the people she had relied on during the rollout of the Affordable Care Act: Black preachers and well-respected Black local leaders such as Democratic state Rep. Kendricks Brass. After word from the pulpit spread and Brass’ team staffed a phone line, the vaccine distribution the next week jumped to 30% Black residents from the prior week’s 9%.

Even some among the St. James Parish Hospital staff have been reluctant. Many have told Zeringue they’re worried about their fertility. Others just don’t want to be first. So the hospital’s line of defense has many holes.

And the covid patients keep coming.

“This is a nightmare,” said Kassie Roussel, the hospital’s marketing director. “It’s crazy because it’s at the same time we marketed the beginning of the end.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Vaccines Go Mobile to Keep Seniors From Slipping Through the Cracks

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ANTIOCH, Calif. — A mobile “strike team” is bringing vaccines to some of Northern California’s most vulnerable residents along with a message: This is how you avoid dying from covid-19.

So far, that message has been met with both nervous acceptance and outbursts of joy from a population that has been ravaged by the disease. One 68-year-old pastor, who lives in a racially diverse, low-income senior housing complex, rolled down his sleeve after his shot and said he wants to live to see 70 — just to spite the government.

The team of county nurses and nonprofit workers is targeting Contra Costa County residents who are eligible for covid vaccines but have been left out: residents of small assisted-living facilities that haven’t yet been visited by CVS or Walgreens, and occasionally people who live in low-income senior housing. The retail pharmacy giants have a federal government contract to administer vaccines in most long-term care facilities.

Launched a few weeks ago, the strike team moves through each vaccination clinic with practiced choreography. At a small group home in Antioch recently, a nurse filled syringes while another person readied vaccine cards and laid them on a table. An administrative assistant — hired specifically for these clinics — checked everyone’s paperwork and screened them for symptoms and allergies before their shots, logging them into the state’s database afterward. After the shots, a strike team member told each person when their 15 minutes of observation was up.

In a little over an hour, 14 people had a shot in their arm, a card in their hand and their data in the system. Nurses wiped down the chairs and tables and packed up supplies.

As the state vaccination plan moves past long-term care facilities and on to the next group, deploying mobile units will help prevent eligible people in small facilities from being left behind, said Dr. Mike Wasserman, past president of the California Association of Long Term Care Medicine.

“The assisted living side has been our greatest tragedy,” Wasserman said. “It’s February. We’re vaccinating others already and we haven’t finished vaccinating those who need it most.”

California is in the midst of transferring primary control of vaccine distribution from local public health departments to Blue Shield of California. The agreement between the state and the insurance company includes incentives for vaccinating underserved and minority populations, and like Contra Costa, Los Angeles, Kern and other counties are creating mobile clinics to reach vulnerable residents.

But as efficiently as these clinics can run, it’s still slow going to vaccinate a few people at a time in a state that has lost more than 44,500 people to covid.

Small long-term care facilities, usually with no more than six beds, are the strike team’s main target. These “six-beds” are a major source of residential care for older Californians, as well as others who need care and supervision but don’t want to live in nursing homes. Of almost 310,000 long-term care beds in California, about one-third are in nursing homes, according to Nicole Howell, executive director for Ombudsman Services of Contra Costa, Solano and Alameda counties. Two-thirds are in some form of assisted living, mostly six-beds.

These homes are typically in residential areas, with little to distinguish them from other houses on a suburban block. They’re small businesses, often owned by families, that offer a “social” model of care, not a medical one. There is no doctor or director of nursing on staff.

Long-term care residents were in line to be vaccinated right after front-line health workers, starting in nursing homes. Theoretically, residents of small facilities like six-beds should get their shots from the same federal program vaccinating most nursing homes, which is administered through CVS and Walgreens.

But it’s difficult to coordinate with these homes because there are so many, Howell explained, and they often have fewer resources and minimal IT infrastructure. Because these aren’t large corporate chains or 500-bed facilities with everyone’s medical records on hand, it takes time and local knowledge to reach them all, she said.

CVS and Walgreens said they have administered first and second doses to nearly all nursing home residents in the state and have started on assisted living communities. They said they do not have breakdowns of which kinds of assisted living facilities they have visited, but CVS Health spokesperson Joe Goode noted that the pharmacy has completed the first round of doses at nearly 80% of participating assisted living facilities, with hundreds more clinics scheduled.

The state has largely left it up to facilities to call the pharmacies to schedule clinics, though many did not know it was their responsibility until late January, according to Mike Dark, a lawyer with California Advocates for Nursing Home Reform. He had been fielding calls for weeks from families who were told that, if they wanted to get their loved ones in six-bed homes vaccinated, they needed to figure it out themselves, he said.

“Smaller assisted living facilities, the ones least equipped to deal with this virus, still house people with significant impairment and needs,” Dark said. “It’s been a scandal, really, how poorly this process has been going.”

The residents at Above All Care, a six-bed in Orange County, finally got their first shots on Feb. 4, according to owner Nicolas Oudinot. But that came after weeks of confusion and silence.

“From November to mid-January, I had no information,” Oudinot said. “I went from nothing to getting a call every day. They tried to schedule the same facility two or three times.”

In late December, when it became clear that many long-term care facilities wouldn’t get clinics scheduled for months, Contra Costa County decided the federal program needed to be supplemented with local resources, said Dr. Chris Farnitano, the county health officer.

“This is where we’re seeing the most dying happening,” Farnitano said. “These are the most vulnerable people. We’ve got to protect them sooner.”

The mobile vaccine strike team emerged from a collaboration among the county, local home health agencies, advocates for long-term care residents and nonprofit groups. It was created without additional public funding when Choice in Aging, a local nonprofit that provides community-based support to older residents, paid its own administrative workers to staff the clinics alongside county public health nurses.

The team of five or six people heads out several days a week, hauling rolling carts packed with syringes, bandages and a special vaccine cooler. The team might spend one day vaccinating 100 people in six-bed and other small facilities for older people or those with disabilities. The next, it might visit 50 seniors and their caregivers gathered from a few low-income apartments.

The vaccines are treated like a precious resource. Nothing goes to waste and there’s a list of caregivers on standby if the team finds itself with extra shots. Nurses say they can almost always squeeze a sixth dose of what they call “liquid gold” out of the vials, intended to contain five.

When defrosted vials aren’t in the cooler, they’re carried gingerly, sandwiched between two egg cartons so they don’t tip or break. Often, the team’s biggest problem is running too far ahead of schedule.

Its efforts seem to be working: 810 people in 50 facilities had been vaccinated as of Tuesday.

Choice in Aging CEO Debbie Toth said she originally got into this line of work to give people a choice of where to spend their last years. But the pandemic has given her work new urgency: saving lives.

“These are people who would die” if they got covid, she said. “We have an opportunity to make sure they don’t. That’s our north star.”

California Healthline correspondent Angela Hart contributed to this report.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Health Policy Valentines to Warm the Heart

Nothing warms our hearts like a few good Health Policy Valentines ― especially those that are sweet on KHN. Tweeters lit up our timeline in recent days with valentine messages about topics ranging from covid-19 vaccines and mask-wearing to the price of health care. Here are some of our favorites.

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Roses are red Violets are blue Covid-19 is here Imma' Vaccinate You #HealthPolicyValentines @KHNews

— Robert Longyear (@RLLongyear) February 8, 2021

 

Roses are redPlease wear a maskI swear, you'll be fineIt's not too much to ask https://t.co/DXFQbHMBhy

— Chad Sokol (@bychadsokol) February 9, 2021

Roses are redViolets are blueWhat to give moms this year?12 months postpartum coverage, child care & telehealth, to name a few! #HealthPolicyValentines @GeorgetownCCF @KHNews

— Stephanie Rubin (@Steph_Rubin) February 9, 2021

60 days? Nah baby.You deserve a whole year of postpartum coverage under Medicaid. #HealthPolicyValentines

— Emily Eckert (@emilyanneck) February 8, 2021

ACA roses are silverDiscounts are hidden in the sandYou will only find them as you walk On the beaches of Cheyenne#HealthPolicyValentines @TheDaduary @garthbrooks https://t.co/uTRI4S6lpu

— Greg Fann (@greg_fann) February 9, 2021

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In honor of Valentine’s Day, the panelists on the latest episode of KHN’s “What the Health?” chose their favorite #healthpolicyvalentines from Twitter.

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Just like Medicaid I won't terminate your eligibility with me until the end of the PHE. #HealthPolicyValentines

— Dr. Emma Sandoe (@emma_sandoe) February 8, 2021

Will you join my bubble? #HealthPolicyValentines

— Dr. Emma Sandoe (@emma_sandoe) February 8, 2021

Unlike compounded drugsThat caused meningitisOr bad stents that ledTo myocarditis

Our love I do sayIt isnt defectiveData can prove itBut its not prospective

Its based on real dataFrom our world where it cameLike safety examinedFrom using a claim#HealthPolicyValentines

— Ben Moscovitch (@benmoscovitch) February 9, 2021

Roses are redIt can’t be deniedYour mask does no goodWhen your nose is outside#HealthPolicyValentines

— Arielle Levin Becker (@ariellelb) February 8, 2021

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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Counterfeit N95 Scam Widens as Senator Demands FTC Investigation

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A key U.S. senator is calling on the Federal Trade Commission to investigate N95 mask fraud and federal agents announced the seizure of 1.7 million more counterfeit 3M masks in the New York borough of Queens as the breadth of a major scam concerning front-line health workers continues to grow.

Early Thursday, Sen. Maria Cantwell (D-Wash.), on her first day as chair of the Senate Commerce Committee, said she would ask the Federal Trade Commission to look into 1.9 million counterfeits shipped to hospitals in Washington state. The state hospital association announced earlier in the week that law enforcement had notified them that they’d been sold fake N95s branded as 3M products.

“We are looking to our FTC to make sure that there are no fraudulent products and materials out here, like masks, that my state is facing,” Cantwell said in a statement.

KHN reported Thursday that hospitals in Ohio, Minnesota and New Jersey also were sold thousands of fake masks. Later in the day, nurses on a covid-19 unit at Jersey Shore University Medical Center discovered yet another highly suspicious aspect to their 3M-branded respirators: The lot numbers printed on the masks did not match the lot numbers on the boxes they were shipped in.

“Lives are literally at risk because these workers are not protected,” said Debbie White, president of the Health Professionals & Allied Employees union.

KHN also reported that independent tests on masks given to New Jersey nurses — which matched the very lot numbers 3M had warned customers about in a fraud alert — actually showed filtration levels at 95% or above, as would be expected of a genuine N95.

Yet the 3M company said other critical aspects of the devices, such as how consistently and well they fit the face, could not be guaranteed. The Cleveland Clinic, which took purported 3M N95s off the shelves after discovering they were fake in January, said in a statement that their tests revealed “these masks were not effective.”

Federal law enforcement authorities have been tracking down these counterfeits for months. Homeland Security Investigations and its Global Trade Investigations unit have been coordinating with Border Patrol officials to seize more than 14.5 million counterfeit masks, nearly all falsely branded as 3M.

One of their cases made headlines Thursday, when Homeland Security Investigations and Queens District Attorney Melinda Katz announced an arrest and the seizure of nearly 1.8 million fake 3M masks in a warehouse.

Katz’s office got a tip that counterfeit masks were being offered for sale from a warehouse in the Long Island City section of Queens. Investigators posed as undercover buyers and purchased masks on several days to verify their authenticity.

The investigators determined that a health care system in the southern U.S. bought 200,000 of them, at prices that were more than twice what an authorized vendor is advised to charge, which is $1.27 each. Officials arrested the warehouse manager, a 33-year-old from Brooklyn, and said the investigation is ongoing.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.

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